Meniscal allograft transplantation (MAT) combined with revision ACL reconstruction and lateral extra-articular tenodesis results in significantly improved outcomes, but patient-reported knee function is inferior compared to an isolated MAT.

PURPOSE: Meniscal allograft transplantation (MAT) is a valuable option for postmeniscectomy syndrome in young and active patients, which can successfully improve symptoms, function and quality of life. This study aimed to report outcomes and complications in patients treated with isolated MAT or MAT combined with revision anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular tenodesis (LET). METHODS: In total, 18 patients who were treated with MAT using a soft tissue fixation technique were retrospectively analysed. Patients were allocated into two groups, the isolated MAT group and the MAT plus revision ACLR + LET group (MAT+ group). Both groups were assessed using the following Patient-Reported Outcome Measures (PROMs): Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), Tegner Activity Scale, Lysholm score, EuroQol 5-Dimension 5-level (EQ-5D-5L) questionnaire and a patient acceptable symptom state (PASS) statement. RESULTS: The mean follow-up was 3.2 years and the mean age of patients was 29 (±7.6) years. Ten patients were treated with isolated MAT and eight patients were treated with MAT combined with revision ACLR and LET. No complications and no reoperations were reported. In both groups, all PROMs significantly improved postoperatively (p < 0.05), except for the Tegner score in the MAT+ group, which did not reach statistical significance (not significant [n.s.]). No significant difference was found postoperatively in PROMs between the MAT and the MAT+ group; however, differences in the KOOS Symptoms, Sports and Quality-of-life subscales reached the minimal clinically important threshold. Mean values were: IKDC 61.2 (±13.9) versus 64.7 (±23.2), KOOS Total 72.8 (±14.9) versus 68.0 (±16.7), Lysholm score 83.2 (±11) versus 84.2 (±8.7) and EQ-5D-5L 71.8 (±14.9) versus 72.2 (±22.4). Median values for the Tegner Activity Scale were 4 versus 3. PASS statement was negative in 37.5% of the MAT+ group in comparison to 20% of the MAT group (n.s.). CONCLUSION: In terms of patient-reported outcomes, MAT is an effective and safe procedure, even when combined with revision ACLR + LET. Compared to the preoperative assessment, a significant improvement of the postoperative PROMs can be expected either when MAT is performed isolated or in combination with ACLR + LET. However, clinically important differences between the two groups can be noted in favour of the isolated MAT procedure, especially regarding symptoms and sporting activity. LEVEL OF EVIDENCE: Level III.

Tibial tubercle fractures are sports injuries in male adolescents with a considerable risk of complications and reoperations: a systematic review.

PURPOSE: There is growing interest in tibial tubercle fractures in pediatric and adolescent population within the last decade. However, there is limited evidence in the existing literature. Therefore, the purpose of this systematic review was to analyze and provide up-to-date data that may prove valuable in decision making and management of these injuries in the general as well as the athletic population. METHODS: A systematic review of the literature in PubMed, Cochrane library and Virtual Health Library was conducted using the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" (PRISMA) guidelines. Articles published in English or Spanish, during the past 20 years, reporting outcomes of tibial tubercle fracture management in patients younger than 18 years old, with a mean follow-up of at least 6 months reporting outcomes, type of management and classification were included. RESULTS: A total of 919 patients with 956 fractures in 25 retrospective cohort studies were included. The mean age was 14.4 ± 0.6 years while 766 [83%] were males and 740 [81%] of the injuries were sports-related. Associated injuries were reported in 91[10%] cases, most common being patellar tendon avulsion. Surgical management was chosen for 845[88%] of the cases, the vast majority being open reduction internal fixation (ORIF) with screws. Union was achieved in 954 [99.8%] cases. Complications and re-operations rate stood at 172[18%] and 161 [19% of the operations], respectively. Return to play (RTP) was reported in 11 [44%] of the studies standing at an average of 98.9% ± 3.6. CONCLUSION: Essentially, this is an adolescent sports knee injury that needs careful planning before decision making because it may affect both RTP and joint preservation. Although union was achieved in almost all patients, there is a high risk of associated injuries, complications and reoperations. The surgeon should be confident to perform fracture fixation as well as addressing associated knee soft tissue injuries to achieve optimal outcomes. LEVEL OF EVIDENCE: Level IV.

Satisfactory patient-reported outcomes in patients treated with impaction bone grafting and autologous matrix-induced chondrogenesis for osteochondral knee defects.

PURPOSE: Osteochondral knee defects usually affect young, active patients and may alter knee biomechanics and progressively lead to joint degeneration. Various treatment options exist with autologous, impaction bone grafting in combination with autologous matrix-induced chondrogenesis (BG-AMIC) being a less-expensive, one-step, promising option. The purpose of this study is to evaluate the clinical and radiological mid-term outcomes of large osteochondral lesions treated with BG-AMIC, identify a possible correlation between the two and report postoperative complications and reoperation rate. METHODS: A retrospective analysis of 25 patients treated with the BG-AMIC technique for knee osteochondral lesions was performed. Patients were assessed using the following PROMs: the IKDC, the KOOS and the Lysholm score, the Tegner activity scale and a patient acceptable symptom state (PASS). The EQ-5D-5L score was used to assess health-related quality of life. Radiological assessment was performed using the MOCART 2.0 score on a 3 T MRI. RESULTS: At a mean of 3.8 (± 0.8)-year follow-up, all functional scores increased significantly (p < 0.005) when compared to the preoperative baseline. IKDC increased from 44.5 (± 15.9) to 81.4 (± 14.7), KOOS from 41.5 (± 16.1) to 91.6 (± 11.6) and Lysholm from 54.4 (± 23) to 95.2 (± 5.5) (p < 0.005). The EQ-5D-5L score also revealed a significant improvement [59.9 (± 25) to 93.4 (± 10.2), p < 0.005]. Mean Tegner score reached pre-injury levels. The PASS was positive in 100% of patients. The minimum clinically important difference was reached in all PROMs except for the KOOS Sports subscale. There were no re-operations. Morphological evaluation of the repair tissue using the MOCART 2.0 score revealed a mean total score of 52.8 (± 30.5). A statistically significant, positive correlation was found between the MOCART 2.0 score and the IKDC score, the KOOS ADL subscale and the EQ-5D-5L (p < 0.05). CONCLUSION: BG-AMIC is a safe and reliable option for treating deep, knee osteochondral lesions, providing a statistically significant and clinically important improvement in patient-reported outcomes. No complications were noticed, and no re-operations were performed after the procedure. A moderate positive correlation between the MOCART 2.0 score and the IKDC, KOOS ADL and EQ-5D-5L was noticed. However, this correlation is not necessarily clinically relevant, and excellent clinical results can be expected even in patients with low MOCART scores. LEVEL OF EVIDENCE: III.

Patellar tendinopathy: an overview of prevalence, risk factors, screening, diagnosis, treatment and prevention.

Patellar tendinopathy (PT), or jumper's knee, is an overuse injury that occurs in professional, as well as recreational, athletes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical; however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport, playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic performance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition, especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treatment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy, platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic techniques, as well as screening and prevention methods, are expected to emerge in the near future.

No difference in mobile and fixed bearing partial knee arthroplasty in octogenarians: a clinical trial.

BACKGROUND: A clinical trial comparing MB (mobile-bearing) versus FB (fixed-bearing) in medial partial knee arthroplasty (PKA) in octagenarians has been conducted. The focus of the present study was on PROMs, range of motion (ROM), implant positioning and implants survivorship. The hypothesis of the present study was that MB implants performed better than FB in PKA in octogenarians. METHODS: The first group received FB PKA-PPK®; the second received MB PKA-Oxford. Patients were not randomly allocated. The following PROMs were administered at T0 (pre-operatively), T1 (1 year after surgery), and T2 (3 years after surgery): visual analogue scale (VAS), Knee Society Score (KSS) and Oxford Knee Score (OKS). Data regarding the implant survivorship and ROM were also collected. Furthermore, the following radiographic parameters were measured: Femoral component varus/valgus; Tibial component varus/valgus; Anteroposterior slope. RESULTS: At T0, 28 patients were included in the FB and 33 in the MB group. The surgical time was shorter in the FB group (p < 0.001). No difference between FB and MB in ROM, VAS, KSS, and OKS at each follow-up (p > 0.05). No difference was found in implant positioning (p > 0.05). At last follow-up, FB group reported three failures caused by aseptic loosening. Four failures were observed in the MB cohort: two for bearing dislocation and two for aseptic loosening. The Kaplan-Meier Curve found no differences in implant survivorship. CONCLUSIONS: According to the main findings of the present clinical trial, MB implants performed similar to FB in PKA in octogenarians. The FB group demonstrated shorted surgical time. No difference was found in patient reported outcome measures, ROM, implant positioning, and survivorship. LEVEL OF EVIDENCE: Level II, prospective study.

Long-term follow-up of bucket-handle meniscal repairs: chondroprotective effect outweighs high failure risk.

PURPOSE: Outcomes after repair of bucket-handle meniscal tears tend to be satisfying in the short-term follow-up. However, the literature is scarce regarding long-term data following repair of bucket-handle meniscal tears. The aim of this study was to assess long-term follow-up outcomes, focusing on knee osteoarthritis (OA) development and failure rate, and determine risk factors associated with failure. METHODS: This is a retrospective cohort study, including all patients with bucket-handle tears within 4 mm of the menisco-synovial junction, who underwent meniscal repair, either isolated or combined with anterior cruciate ligament reconstruction (ACLR) between 2004 and 2015. A combination of all-inside, outside-in, and inside-out repair technique was used in all patients. Patients over 40 years old, concomitant multi-ligamentous injuries, and severe cartilage lesions documented intraoperatively were excluded. During the follow-up, a meniscus was considered healed using Barrett's criteria, while knee OA evaluation was performed according to Kellgren-Lawrence (KL) classification using standing knee radiographs. Patients were assessed preoperatively as well as postoperatively in terms of knee function using International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: In total, the inclusion criteria were met by 66 patients. Median age at the time of operation was 21.9 years (13-39). Median follow-up was 114 (62-176) months. Total failure rate was approximately 33% at median time of 19 (6-39) months. Osteoarthritis was statistically significantly more prevalent in patients with failed repairs (mean KL score: 2.09) in comparison to patients with successful repairs (mean KL score: 0.54) p = 0.001. In addition, successful repairs were associated with higher KOOS score as compared with failed repairs (mean ± SD, 89.6 ± 4.6 vs 77.8 ± 4.9 p < 0.001), higher IKDC score (mean ± SD, 88.2 ± 5.1 vs 79.2 ± 5.2 p < 0.001), and Lysholm score (mean ± SD, 90.3 ± 5.3 vs 78.4 ± 7.8 p < 0.001). Patients with medial meniscus repair had 4.8 higher relative likelihood of failure compared to lateral meniscus [p = 0 .014, OR = 4.8 (95% Cl 1.2, 18.6)]. Patients over 16 years old had 5.7 higher relative likelihood of failure [p = 0 .016, OR = 5.7 (95% Cl 0.04, 0.85)]. Concurrent ACLR did not have a significant effect on the postoperative outcomes. CONCLUSION: A high rate of clinical failure was observed after meniscal repair of bucket-handle tears. However, successful treatment led to lower rates of knee OA development and better knee function, approximately 10 years postoperatively. Meniscal repair of bucket-handle tears is recommended to improve knee function and prevent knee OA in young patients. LEVEL OF EVIDENCE: III.

Soaking of autografts with vancomycin is highly effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts.

PURPOSE: To evaluate the impact of local soaking of the autografts with vancomycin during anterior cruciate ligament (ACL) reconstruction on postoperative infection rates. METHODS: Between 2003 and 2014 (first study period), 1,242 patients underwent ACL reconstruction using autografts, without soaking them in vancomycin solution, while between 2014 and 2019 (second study period) all ACL autografts in 593 patients were soaked in a 5-mg/ml vancomycin solution, in a territory University Hospital. The same standard treatment of perioperative IV antibiotics was applied in both groups. RESULTS: Postoperative septic arthritis occurred in seven out of 1,242 patients (0.56%) during the first study period. Bone patellar tendon bone autograft was used in 311 (25%) patients, and hamstring tendon autograft was used in the rest 931 (75%) of the study population during this period. All infected cases were male and had a hamstrings graft implanted. There were no postoperative infections (0%) in 593 ACL reconstructions during the second study period. Bone patellar tendon bone autograft was used in 178 (30%) patients while hamstring tendon autograft was used in the rest 415 (70%) of the study population, during this period. Statistical analysis revealed a significantly reduced postoperative infection rate (p = 0.018) between the two reported periods, with the main impact referring to the use of hamstrings autograft (p = 0.031) for the first study period. CONCLUSIONS: Septic arthritis following ACL reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting of hamstring tendon autograft use, since the risk of postoperative knee infection is significantly higher when this type of graft is used.

Successful return to sport in patients with symptomatic borderline dysplasia following hip arthroscopy and T-shaped capsular plication.

PURPOSE: This study aims to evaluate the return to sport and correlations of patients with symptomatic borderline hip dysplasia (BHD) after hip arthroscopy and T-shaped capsular plication at a minimum follow-up of 24 months. METHODS: Twenty-five patients who underwent hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All the patients were evaluated clinically prior to surgery (T0) and at two consecutive follow-ups (T1:15 ± 1.2 months and T2: 53.9 ± 23.2 months) using the visual analogue scale (VAS) pain score, whereas sports activity was assessed by the Hip Outcome Score Sport Specific Subscale (HOS-SSS), the University of California, Los Angeles (UCLA) activity scale, the Tegner score and the physical component (PCS) of the Short Form-12 (SF-12). Furthermore, the presence of correlations and the possible differences between subgroups were evaluated and analysed. RESULTS: A significant difference was found for HOS-SSS, VAS, Tegner, UCLA and PCS with the Friedman test for repeated measures through time points (p < 0.0001). Moreover, all the scores reported significant improvement compared to the previous time point (p < 0.0001) except the HOS-SSS between T1 and T2 (n.s.). Body Mass Index (BMI) was negatively correlated with HOS-SSS at T0 (rho = - 0.526 p = 0.006) and T1 (rho = - 0.425; p = 0.034), with Tegner at each follow-up (T0: rho = - 0470 p = 0.017; T1: rho = - 0.450; p = 0.024; T2: rho = - 0.448; p = 0.024), with UCLA at T1 (rho = - 0.396 p = 0.049), with pre-operative PCS (rho = - 0.413 p = 0.0401), and positively correlated with pre-operative VAS (rho = 0.436 p = 0.0291). CONCLUSIONS: Hip arthroscopy and T-shaped capsular plication in young patients with symptomatic BHD demonstrates a significant increase in return to sport and physical activity and low risk of complications. T-shaped capsular plication procedure may be considered in young and active patients for whom non-operative treatment failed and who have a significant limitation in sports activity; in these patterns of patients, the ideal treatment should reliably allow fast recovery in combination with very low invasiveness which will prevent osteoarthritis. The results of this study provide more accurate information regarding return to sport in patients with BHD after hip arthroscopy and T-shaped capsular plication. LEVEL OF EVIDENCE: Level IV.

Biomechanical evaluation of three patellar fixation techniques for MPFL reconstruction: Load to failure did not differ but interference screw stabilization was stiffer than suture anchor and suture-knot fixation.

PURPOSE: The purpose of this study was to compare the maximum load to failure and stiffness of three medial patella-femoral ligament (MPFL) reconstruction techniques: (i) suture anchor fixation (SA), (ii) interference screw fixation (SF), and (iii) suture knot (SK) patellar fixation. The null hypothesis was that the comparison between these three different patella fixation techniques would show no difference in the ultimate failure load and stiffness. METHODS: Reconstruction of the MPFL with gracilis tendon autograft was performed in 12 pairs of fresh-frozen cadaveric knees (24 knees total; mean age, 63.6 [Formula: see text] 8.0 years). The specimens were randomly distributed into 3 groups of 8 specimens; SA reconstruction was completed with two 3.0-mm metal suture anchors; (SF) fixation was accomplished by two 6-mm bio-composite interference screws; SK fixation at the lateral side of the patella was accomplished after drilling two semi-patellar tunnels with a diameter of 4.5 mm. The reconstructions were subjected to cyclic loading for 10 cycles to 30 N and tested to failure at a constant displacement rate of 15 mm/min using a materials-testing machine (MTS 810 Universal Testing System). The final load of failure (N), stiffness (N / mm) and failure mode was recorded in each specimen and followed by statistical analysis. RESULTS: There was no significant difference in mean ultimate failure load among the three groups. The SK group failed at a mean ([Formula: see text] SD) ultimate load of 253.5 [Formula: see text] 38.2 N, the SA group failed at 243 [Formula: see text] 41.9 N and the SF group at 263.2 [Formula: see text] 9.06 N. The SF group had a mean stiffness of 37.8 [Formula: see text] 5.7 N/mm. This was significantly higher (p < 0.05) than the mean stiffness value achieved for the SK group 21.4 [Formula: see text] 9.5 N/mm and the SA group 18.7 [Formula: see text] 3.4 N/mm. The most common mode of failure in the SA group was anchor pullout, and in the SK group was failure at the graft-suture interface. All the reconstructions in the SF group failed due to tendon graft slippage from the tunnel. CONCLUSION: Load to failure was not significantly different between the 3 techniques. However, screw fixation was found to be significantly stronger than the anchor and the suture knot fixation in terms of rigidity of the reconstruction. From a clinical point of view, all methods of fixation can be used reliably for MPFL reconstruction, since they were found to be stronger than the native MPFL.

The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. METHODS: A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. RESULTS: Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. CONCLUSION: A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. LEVEL OF EVIDENCE: Level V.

Evaluating the "Patella-Friendly" Concept in Total Knee Arthroplasty: A Minimum 15-Year Follow-Up Outcome Study Comparing Constant Radius, Multiradius Cruciate-Retaining, and Nonanatomical Cruciate-Retaining Implants.

BACKGROUND: Patella-friendly femoral components were developed in order to reduce anterior knee pain and patellofemoral complications in total knee arthroplasty (TKA), but their effect on long-term outcome is still unclear. METHODS: We retrospectively evaluated prospectively collected data from 3 groups consisting of 100 patients (100 knees in each). In group A, the constant radius a-MP, in group B the multiradius cruciate-retaining Genesis II, and in group C the nonanatomic, multiradius, cruciate-retaining AGC TKA was implanted. Patients of all groups were matched for age, gender, side, body mass index, and length of follow-up. Preoperative and postoperative clinical outcome data in the form of Knee Society System (KSS), Short Form-12, Western Ontario and McMaster University Osteoarthritis Index, and Oxford Knee Score were available at regular intervals for groups A and B. For patients of group C, KSS score data were available at the same time intervals. In all groups, the patellofemoral compartment was assessed using the Clinical Patella Score scale. Anterior knee pain, secondary patella resurfacing, implant failure, and radiological outcome were assessed in patients of all groups. RESULTS: At 10-year and 15-year follow-up, patients of group A showed statistically significant (s.s.) higher (all P = .000) KSS values as compared to those of groups B and C. At 15-year follow-up, patients of group B showed s.s. higher (P = .001) KSS values as compared to those of group C. At 10-year and 15-year follow up, patients of group A showed s.s. higher (all P = .00) Western Ontario and McMaster University Osteoarthritis Index and Oxford Knee Score values as compared to those of group B. At 15-year follow-up only, patients of group A showed s.s. higher (P = .00) Short Form-12 (physical) values as compared to those of group B. In terms of Clinical Patella Score, patients in group A had s.s. higher values (P = .05) when compared to those of groups B and C. Anterior knee pain was recorded in 4.4% of TKAs in group A, 7.5% in group B, and 17.2% in group C. One (1.1%) patient in group A, 3 (3.25%) in group B, and 7 (8%) in group C underwent secondary resurfacing. CONCLUSION: Anatomical, patella-friendly, constant radius femoral components outperform others in reducing anterior knee pain and patella complications in TKA in which the patellae are left nonresurfaced.

Return to physical activity and change in body mass index after hypoallergenic medial mobile-bearing unicompartmental knee arthroplasty.

BACKGROUND: The primary purpose of the present prospective study was to consecutively analyse the outcomes of the return to sports activity of patients with positive patch tests undergoing a medial mobile-bearing titanium niobium nitride (TiNbN) unicompartmental knee arthroplasty (UKA). The secondary purpose was to ascertain if a higher grade of physical activity leads to a reduction in the body mass index (BMI) of the patients. MATERIAL AND METHODS: Forty-one patients with positive skin patch tests were included in this prospective study. The clinical evaluation consisted of the University of California, Los Angeles (UCLA) activity scale and the High-Activity Arthroplasty Score (HAAS). Each patient was evaluated the day before surgery (T0), after 12.37 ± 0.70 months (T1), and on the day of the final follow-up, after 67.03 ± 18.2 months (T2). Furthermore, the BMI of each patient was analysed before surgery and during the final follow-up. RESULTS: The UCLA and HAAS mean preoperative values ranged from 3.68 ± 1.1.7 and 6.15 ± 0.76 to 6.1 ± 0.76 and 10.34 ± 1.3, respectively, at T1 (p < 0.0001) and to the final values of 6.34 ± 0.62 and 11.0 ± 8.9, respectively, at T2 (UCLA: T2 versus T1: p = 0.132; T2 versus T0: p < 0.0001; HAAS: T2 versus T1: p = 0.0027; T2 versus T0: p < 0.001). BMI ranged from a preoperative value of 27.97 ± 3.63 to a final value of 26.84 ± 3.11 (p < 0.0001). The only differences within the subgroups concerned patients with BMI ≥ 28, showing a superior HAAS at each follow-up (p < 0.05). A positive correlation was found between BMI and HAAS at T0 and T2 (p < 0.05). CONCLUSIONS: This is the first study to evaluate the rate of the return to sports activities and change in BMI following hypoallergenic UKA. The majority of patients reduced their weight following UKA and improved their physical activity, showing outcomes that were comparable to the standard cobalt-chrome (CoCr) prostheses, regardless of gender, age, BMI and implant size. LEVEL OF EVIDENCE: IV - Prospective Cohort Study. Trial registration researchregistry5978-Research Registry www.researchregistry.com.

Failure in diagnosis and under-treatment of osteoporosis in elderly patients with fragility fractures.

We evaluated whether osteoporosis is adequately managed and treated in patients suffering from fragility fractures. Factors that influenced osteoporosis diagnosis and treatment rates were also assessed. To this end, patients with the principal diagnosis of low-energy hip, vertebral, or distal radius fractures were recruited for the study. Collected data included risk factors for osteoporosis, history of previous fractures, known history of osteoporosis, and osteoporosis treatment at the time of admission. The patients' prefracture risk profile was also assessed to determine whether osteoporosis could have been identified prior to the index fracture. We identified 308 patients with fragility fractures, including 214 hip, 41 vertebral, and 53 distal radius fractures. Overall, 238 patients (77.3%) had at least one risk factor for osteoporosis. Eighty-eight patients (28.6%) had sustained ≥ 1 prior fragility fractures in the past. However, only 79 patients (25.6%) were aware that they had osteoporosis and even fewer (66 patients, 21.4%) had been receiving osteoporosis treatment preceding the current admission. Anti-osteoporotic agents were more commonly prescribed in patients 66-75 years old (p = 0.008), with a family history of osteoporosis (p = 0.009) or history of a prior fragility fracture (p = 0.012). The treatment rate was higher in women than men (p = 0.026) and in patients with vertebral or multiple prior fractures compared to patients with prior hip fractures. The current study provides evidence that individuals who experience fragility fractures are not adequately managed for osteoporosis. Only few of the historically known risk factors for osteoporosis were adequately recognized and associated with osteoporosis evaluation and treatment.

Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To develop a statement on the diagnosis, classification, treatment, and rehabilitation concepts of posterolateral corner (PLC) injuries of the knee using a modified Delphi technique. METHODS: A working group of three individuals generated a list of statements relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries to form the basis of an initial survey for rating by an international group of experts. The PLC expert group (composed of 27 experts throughout the world) was surveyed on three occasions to establish consensus on the inclusion/exclusion of each item. In addition to rating agreement, experts were invited to propose further items for inclusion or to suggest modifications of existing items at each round. Pre-defined criteria were used to refine item lists after each survey. Statements reaching consensus in round three were included within the final consensus document. RESULTS: Twenty-seven experts (100% response rate) completed three rounds of surveys. After three rounds, 29 items achieved consensus with over 75% agreement and less than 5% disagreement. Consensus was reached in 92% of the statements relating to diagnosis of PLC injuries, 100% relating to classification, 70% relating to treatment and in 88% of items relating to rehabilitation statements, with an overall consensus of 81%. CONCLUSIONS: This study has established a consensus statement relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries. Further research is needed to develop updated classification systems, and better understand the role of non-invasive and minimally invasive approaches along with standardized rehabilitation protocols. LEVEL OF EVIDENCE: Consensus of expert opinion, Level V.

Superior perioperative analgesia with combined femoral-obturator-sciatic nerve block in comparison with posterior lumbar plexus and sciatic nerve block for ACL reconstructive surgery.

PURPOSE: The purpose of this randomized controlled study is to compare and evaluate the intraoperative and post-operative outcome of PLPS nerve block and that of femoral, obturator and sciatic (FOS) nerve block as a method of anaesthesia, in performing ACL reconstruction. METHODS: Patients referred for elective arthroscopic ACL reconstruction using hamstring autograft were divided in two groups. The first group received combined femoral-obturator-sciatic nerve block (FOS Group) under dual guidance, whereas the second group received posterior lumbar plexus block under neurostimulation and sciatic nerve block (PLPS Group) under dual guidance. RESULTS: The two groups were comparable in terms of age, sex, BMI and athletic activity. The time needed to perform the nerve blocks was significantly shorter for the FOS group (p < 0.005). Similarly, VAS scores during tourniquet inflation and autograft harvesting were significantly higher (p < 0.005) in the PLPS group and this is also reflected in the intraoperative fentanyl consumption and conversion to general anaesthesia. Finally, patients in this group also reported higher post-operative VAS scores and consumed more morphine. CONCLUSIONS: Peripheral nerve blockade of FOS nerve block under dual guidance for arthroscopic ACL reconstructive surgery is a safe and tempting anaesthetic choice. The success rate of this technique is higher in comparison with PLPS and results in less peri- and post-operative pain with less opioid consumption. This study provides support for the use of peripheral nerve blocks as an exclusive method for ACL reconstructive surgery in an ambulatory setting with almost no complications. LEVEL OF EVIDENCE: I.

Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up.

PURPOSE: To report the long-term outcomes of medial open wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis in patients younger than 45 years old. It was hypothesized that the correction of knee alignment would result in preservation of knee function in a long-term follow-up. METHODS: Patients under 45 years old, who underwent MOWHTO for symptomatic medial compartment knee osteoarthritis between 2001 and 2005 were retrospectively reviewed after a minimum of 10 years. The osteotomy was performed utilizing a locking plate without the use of bone graft. Patients were evaluated pre- and postoperatively using the International Knee Documentation Committee Score, the Oxford Knee Score, the Knee injury Osteoarthritis Outcome Score and the Short Form-12 Score. Standardized standing whole-limb radiographs were also obtained to assess mechanical tibiofemoral angle (mTFA) and the grade of osteoarthritis. RESULTS: A total of 20 patients (18 males, 2 females, mean age 35.4 years) with a mean follow-up of 12.3 years were included in the study. During the follow-up period, one patient required conversion to total knee replacement (95% survival rate). All clinical outcome scores (IKDC, KOOS, OKS, and SF-12) significantly improved postoperatively (p < 0.05), with no significant deterioration over time. Preoperative varus alignment with an mTFA of - 5.8 ± 2.4° was corrected to 2.5 ± 1.9° immediately after surgery (p < 0.05), and remained 2.2 ± 1.7° at the last follow-up. Furthermore, no significant radiographic progression of osteoarthritis was observed. CONCLUSIONS: MWOHTO with a locking plate is an effective joint preservation method to treat medial compartment OA in active patients less than 45 years. Clinical and radiological results are satisfactory and the survival rate is 95%, 12 years after the procedure. LEVEL OF EVIDENCE: Level IV therapeutic, retrospective, cohort study.

Magnetic resonance morphometry of the adult normal lumbar intervertebral space.

PURPOSE: This study aims to: (a) quantify and evaluate normal relationships between neighboring spinal units using MR imaging indices, (b) propose an easy-to-apply-and-reproduce method of estimating the correct amount of distraction when surgically restoring a collapsed intervertebral disc, based on individualized measurements. METHODS: This is a retrospective cross-sectional MR imaging study of 119 adult subjects, aged 18-54, asymptomatic for low back pain. Each of the examinees should demonstrate two or more consecutive intervertebral discs classified as Pfirrmann grade I or II to be included. We measured and studied the relationships of disc height index, Dabbs index, Farfan index, disc convexity index and mean and posterior disc height per spinal level using multiple regression analysis. All measurements were tested for intra- and interobserver agreement by two raters. RESULTS: DHI, Dabbs, Farfan, and mean disc height had a statistically significant correlation with the spinal level and age. Our results were highly reproducible, with excellent inter- and intraobserver agreement and reliability between two raters (ICC = 0.992 and 0.994, respectively). Furthermore, we expressed each intervertebral space as a percentage of its adjacent space, introducing the coefficient α factor for every intervertebral space. CONCLUSIONS: Our results suggest that a normal values' database to refer during preoperative planning of correction of a degenerated intervertebral disc is feasible. Our study offers new anatomical and radiological insight in terms of spinal measurements and their potential correlation with current surgical techniques. A new approach for calculating disc space as an expression of its adjacent disc has been introduced with various potential applications.

Anatomical variations of the foramen transversarium in cervical vertebrae: findings, review of the literature, and clinical significance during cervical spine surgery.

PURPOSE: To describe certain anatomical variations of the foramen transversarium, in spine cervical vertebrae in a contemporary specimen of an Indo-European population and approach their clinical importance during cervical spine surgery. METHODS: 102 cervical vertebrae (C2-C7) from 17 different skeletons, intact without any degenerative or traumatic disorders, which belonged to the collection of the Department of Anatomy, were examined. The age of specimens at the time of their death was between 25 and 65 years. All foramina were measured with a digital caliper. RESULTS: The average size of the normal foramina was: 6.49 mm × 5.74 mm on the right side and 6.65 mm × 5.76 mm on the left side. Regarding the variations, we found two cervical vertebrae (1.96 %), one C3 and one C6, in which the right foramen transversarium is clearly smaller than the left. The exact dimensions of these foramina are: 2.3 mm × 2.5 mm on the right side and 6.54 mm × 8 mm on the left side in the first vertebra and 2.8 mm × 3.74 mm on the right side and 6 mm × 7.5 mm on the left side, in the second one. We also observed double foramina in 14 vertebrae (13.72 %). In seven vertebrae, the duplication was bilateral (6.86 %). We finally found one vertebra (0.98 %) with triplication of the foramen transversarium on the left side. CONCLUSIONS: Summarizing, 10 out of our 17 skeletons were presented with variations (extremely narrow or multiple foramina). This finding of hypoplastic, duplicated and triplicated foramina transversaria in unexpectedly high rates raises questions about the integrity of the contained structures, the possibility of a different path for them. These variations may induce an extra-osseous position of the vertebra artery, and the ignorance of such an event may have catastrophic consequences during a surgery in the cervical spine.

Molecular changes indicative of cartilage degeneration and osteoarthritis development in patients with anterior cruciate ligament injury.

BACKGROUND: Anterior cruciate ligament (ACL) tear is considered a risk factor for osteoarthritis development. The purpose of our study was to investigate the expression levels of the apoptotic enzyme caspase 3, pro-inflammatory cytokines interleukin-1ß (IL-1ß) and interleukin-6 (IL-6) and degrading enzyme matrix metalloproteinase 13 (MMP-13), all indicative of cartilage degeneration and osteoarthritis development in patients' chondrocytes after ACL rupture. METHODS: We investigated the correlation between grade of cartilage degradation and time from injury or patients' age. IL-1ß, IL-6 and MMP-13 mRNA expression levels were investigated in normal (n = 4) and chondrocytes from patients with ACL rupture (n = 33) using real-time polymerase chain reaction (PCR). Moreover, MMP-13 and caspase-3 protein expression levels were evaluated by western blot analysis. Trend analysis and correlation coefficient were performed to derive the relations between gene expression (MMP13, IL-6, IL-1ß) and grading of cartilage defects and between gene expression (MMP13, IL-6, IL-1ß) and patients' age, respectively. RESULTS: Correlations were established between grade of cartilage degradation and time from injury. MMP-13, IL-6, IL-1ß and caspase 3 expression levels were significantly upregulated in chondrocytes from ACL-deficient knee compared to normal. Among the patients with ACL-deficient knees, a significant upregulation of MMP-13 was observed in patients with ACL-rupture > 18 months from the time of injury to arthroscopy compared to patients with ACL-injury up to 18 months, whereas IL-6 and IL-1ß expression was higher in chondrocytes from patients with more than 10 months ACL injury compared to those that underwent surgery within the first 10 months after injury. Νο association was observed between IL-1ß, IL-6 and MMP-13 expression levels and cartilage defects or patients' age. CONCLUSION: Our results showed that increased levels of apoptotic, inflammatory and catabolic factors in chondrocytes are associated with time from injury and could contribute to cartilage degradation and osteoarthritis development after ACL rupture.

Dynamic Effect of Quadriceps Muscle Activation on Anterior Tibial Translation After Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstruction.

PURPOSE: To examine differences in anterior tibial translation in 3 groups: single-bundle anterior cruciate ligament (ACL)-reconstructed, double-bundle ACL-reconstructed, and ACL-intact knees under gradual dynamic quadriceps muscle activation. METHODS: Thirty male patients underwent successful single-bundle (n = 15) and double-bundle (n = 15) ACL reconstructions; 15 healthy controls were included in the study. Anterior tibial translation was assessed at 30° of knee flexion in the resting position (0% quadriceps activation) and under 50% and 100% of maximum quadriceps concentric contraction using an isokinetic dynamometer with the KT-2000 arthrometer securely attached to the participants' knees. RESULTS: The 2 ACL-reconstructed groups were similar regarding International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Score (KOOS), Tegner, and Lysholm scores and preliminary isokinetic evaluation (P = .38). Quadriceps activation significantly affected anterior tibial translation (P = .001, α = 0.98). In all 3 study groups, anterior tibial translation was significantly higher under 100% quadriceps activation compared with 0% contraction (P = .01) and 50% quadriceps activation (P = .047). There were no between-group differences in anterior tibial translation with 0%, 50%, or 100% quadriceps activation (P = .46). CONCLUSIONS: Under quadriceps muscle activation, anteroposterior knee laxity in ACL-intact and ACL-reconstructed knees is gradually increased. Single-bundle and double-bundle ACL-reconstructed knees show a similar increase in anterior tibial translation under gradual quadriceps contraction. When comparing different ACL reconstruction techniques in the experimental setting, dynamic, in addition to static, testing is advised to reach a comprehensive assessment of anteroposterior knee stability. LEVEL OF EVIDENCE: Level III, retrospective comparative study.