Donor age has no relevant role in biomechanical properties of allografts used in anterior cruciate ligament (ACL) reconstruction: A systematic review.

PURPOSE: Surgeons generally consider the donor age as a factor that negatively influences the quality of allograft used in anterior cruciate ligament (ACL) reconstruction, however, the available evidence does not clearly support this statement. The purpose of the study was to investigate if donor age influences the biomechanical properties of allografts used in ACL reconstruction. METHODS: A comprehensive literature search was conducted for all relevant articles using MEDLINE (PubMed), Scopus, and Cochrane Collaboration Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Studies including the analysis of the correlation between biomechanical properties of the allografts and donor age were selected. The role of donor age was labelled as 'none' if absent, 'higher' or 'lower' if the properties were higher or lower in older specimens with respect to younger. The correlation was defined as 'weak' or 'strong' according to each study definition. RESULTS: No conflicting role of donor age was reported for modulus of elasticity, load to failure, strain, stiffness and displacement. The only parameters where the significant results were consistent were the tensile strength and the stress (low or moderate correlations). When considering the tested samples with a donor's age <65 years, a significant role of age was reported in only four out of 13 groups of graft tested (patellar tendon, fascia lata, anterior tibialis tendon and posterior tibialis tendon). CONCLUSION: The current literature did not allow to state that the donor age negatively influences the biomechanical properties of allografts, making it impossible to identify a clear age cut-off value to exclude them from ACL reconstruction procedures. LEVEL OF EVIDENCE: Level IV, systematic review.

All-Polyethylene Versus Metal-Backed Tibial Components in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: In the literature, there is no evidence suggesting the superiority in clinical performance between all-polyethylene (AP) and metal-backed (MB) tibial implants in total knee arthroplasty. The aim of this study was to systematically review the literature to collect only high-quality studies investigating the differences in terms of clinical and radiostereometric analysis (RSA) outcomes of AP compared to MB implants. METHODS: Only randomized controlled trials (RCTs) reporting either clinical or RSA outcomes have been included. Data sources were Embase, Medline, and the Cochrane Central Register of Controlled Trials. RESULTS: We included eleven RCTs evaluating the outcomes of 1,377 patients. Of the RCTs, 9 of them showed a low risk and 2 showed moderate risk of bias. There was no statistically significant difference in terms of clinical outcomes and survival rate between the AP and MB group; however, a statistically significant lower mean lift-off in the AP group (0.19 mm) compared to the MB group (0.3 mm) was observed on RSA. CONCLUSIONS: The performance of AP total knee arthroplasty in terms of clinical outcomes and 5-year survival was not statistically different when compared to the MB group. However, the RSA showed a statistically significant lower mean lift-off in the AP group.

Long sports career and satisfactory clinical outcomes after Meniscal Allograft Transplantation (MAT) in young professional athletes involved in strenuous sports.

PURPOSE: To assess the return to sport rate of young professional athletes, to analyze their careers in terms of matches played and league participation over a minimum period of 6 years after Meniscal Allograft Transplantation (MAT), as well as to assess the long-term clinical subjective outcomes and satisfaction. METHODS: Thirteen professional athletes (ten soccer and one basketball players, one fencer and one wrestler) with a mean age at surgery of 23.4 ± 4.0 underwent MAT (six medial, seven lateral). The time required to return to sport, post-operative performance level and the number of reoperations were evaluated. At an average follow-up of 9.0 ± 2.8 years, Lysholm, KOOS and Cincinnati scores were administered and collected. RESULTS: Thirteen patients (100%) returned to sports practice after an average period of 11.8 ± 3.8 months. Nine athletes (69%) returned to sports at the same pre-injury level. Overall, 93%, 85%, 62% and 55% were active until the 3rd, the 5th, the 7th and the 9th season after MAT, respectively. Seven patients (54%) underwent a reoperation after MAT, where only two of them (15%) were related to graft problems (one meniscectomy and one graft suture). Of the ten athletes that completed subjective evaluation, the mean Lysholm score was 72 ± 15 (0% "Excellent", 10% "Good", 60% "Fair", 30% "Poor"). Of the athletes with lower scores, one suffered from patellar tendon rupture, one from post-operative infection and one from a previous femoral fracture. The mean Cincinnati knee score was 77 ± 18, while the average KOOS values were 60 ± 34 for sports. CONCLUSION: Meniscal Allograft Transplantation (MAT) in young professional athletes involved in strenuous activities allowed all patients to return to pre-injury sport and in nearly 70% of cases at their pre-injury level. After five seasons following MAT, 85% of patients were still active or playing more than 20-30 matches per season. On the other hand, nearly 50% underwent at least one reoperation and only 70% of patients were rated as "Good", or "Fair" using the Lysholm score. LEVEL OF EVIDENCE: IV.

High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings.

PURPOSE: Anterior cruciate ligament (ACL) ruptures are considered high burden injuries in sports with high pivotal activity, especially for professional footballers. A lack of evidence exists about long-term follow up of professional elite athletes who underwent ACL reconstruction. The purpose of the study is to analyze the return to play and the career of professional footballers who underwent ACL reconstruction with hamstrings, to evaluate re-rupture and reoperation at either indexed and contralateral knee, and to assess the long-term clinical subjective outcomes and satisfaction. METHODS: Twenty-eight professional footballers that underwent 33 ACL reconstructions were retrospectively included in the study. All surgical interventions were performed using hamstring tendons graft and an over the top technique. Inclusion criteria were: inability to compete due to joint instability caused by total or subtotal ACL lesion, patients contracted to a professional football team at time of surgery. Exclusion criteria were: multi-ligament reconstruction or concomitant meniscal allograft transplantation. Patients were contacted by phone and a brief questionnaire about surgery was administered. Subsequently, a Lysholm knee scoring scale was obtained. After that, an online research was performed on publicly available websites in order to retrieve information of the patients included after surgery. RESULTS: In all cases, ACL Reconstruction was performed with hamstring tendons using a non-anatomic Double-Bundle technique in 16 cases (49%), an Over-The-Top Single-Bundle technique in 9 cases (27%), and an Over-The-Top Single-Bundle plus Lateral Plasty technique in 8 cases (24%); moreover, a meniscal lesion was present in 20 cases (61%). Three (9%) of the 33 ACL reconstruction failed (2/16 Double-Bundle, 1/9 Single- Bundle, 0/8 Single-Bundle + Lateral Plasty; p = n.s.), with two of them within 12 months from surgery. Other procedures, mainly arthroscopic meniscectomies, were performed in 10 cases (30%). The first official match was played after an average of 8.0 ± 3.6 (4.6-18.2) months in 31 cases (94%). Patients were evaluated after 12.6 ± 3.3 years (6.7-17.5) from the indexed ACL reconstruction. The average Lysholm score was 94.2 ± 8.3. CONCLUSIONS: In our small case-series, professional soccer players were able to return to play at a competitive level with a hamstrings over the top technique. Patients with long careers had a high percentage of reoperation on the contralateral knee. LEVEL OF EVIDENCE: IV.

High survivorship rate and good clinical outcomes at mid-term follow-up for lateral UKA: a systematic literature review.

PURPOSE: The purpose of this paper is to systematically review the available literature to understand the effectiveness, the survivorship, the clinical outcomes and the complications of lateral UKA. METHODS: A review of the current literature available about lateral UKA was performed in March 2020, according to the PRISMA guidelines. Selection was based on the following inclusion criteria: (1) clinical reports of any level of evidence, (2) written in English language, (3) published from 1996 to 2020, (4) dealing with clinical data on lateral UKA. A total of 47 articles, published between 1996 and 2020, were included in the review. Quality of every article was assessed using the Modified Coleman Methodology Score. RESULTS: A total of 47 studies were included. Mean mCMS was 45.27 (range 30-62). Mean age at surgery was 64.5 years (range 34.1-88.0 years). In 1741 patients (65.5%) a metal back implant was used and in 421 patients (15.8%) an all poly design was used. Several scores were used to evaluate clinical results (OKS, AKSS, IKS, KOOS, WOMAC, VAS). Range of motion improved with an overall mean value of 120.3° (range: 105.9°-143.3°). The mean follow-up was 60.7 months (range, 7-204 months), mean survivorship (absence of a revision) with a minimum 60 months of follow-up was 88.6% (range 74.5-100) and mean satisfaction of patients was 78.5% (range 41.0-97.9). CONCLUSIONS: Lateral UKA seems to be an effective solution to manage lateral osteoarthritis (OA), based on preliminary results, with survivorship and satisfaction rate comparable to medial UKA and total knee arthroplasty (TKA). Nonetheless, this review highlights that the quality of studies available in current literature is low. LEVEL OF EVIDENCE: Systematic review of level IV studies.

Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe.

PURPOSE: This study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery training in Europe by conducting an online survey among orthopaedic trainees. METHODS: The survey was conducted among members of the Federation of Orthopaedic and Trauma Trainees in Europe (FORTE). It consisted of 24 questions (single-answer, multiple-answer, Likert scales). Orthopaedic trainees' demographic data (six questions), clinical role changes (four questions), institutional changes due to the COVID-19 pandemic (nine questions), and personal considerations (five questions) were examined. RESULTS: Three hundred and twenty-seven trainees from 23 European countries completed the survey. Most trainees retained their customary clinical role (59.8%), but a significant number was redeployed to COVID-19 units (20.9%). A drastic workload decrease during the pandemic was reported at most institutions. Only essential activities were performed at 57.1% of institutions and drastic disruptions were reported at 36.0%. Of the respondents, 52.1% stated that faculty-led education was restricted and 46.3% pursued self-guided learning, while 58.6% stated that surgical training was significantly impaired. Concerns about the achievement of annual training goals were expressed by 58.2% of the participants, while 25.0% anticipated the need for an additional year of training. CONCLUSIONS: The SARS-CoV-2 pandemic significantly affected orthopaedic and trauma training in Europe. Most trainees felt the decrease in clinical, surgical, and educational activities would have a detrimental effect on their training. Many of them consulted remote learning options to compensate training impairment, stating that after the COVID-19 pandemic electronic educational approaches may become more relevant in future.

How Reliable Is the Cell Count Analysis in the Diagnosis of Prosthetic Joint Infection?

BACKGROUND: Synovial analysis of joint aspirates is a key diagnostic tool; all major diagnostic algorithms include cell count (CC) and polymorphonuclear percentage (PMN%) as important criteria to make the diagnosis. In this context, we conducted this study to analyze the overall accuracy of CC and PMN%. METHODS: A single-center retrospective analysis was performed with clinical data of included patients, with a total of 524 preoperative joint aspirations (255 hips, 269 knees). From the aspirated synovial fluid, we tested the leukocyte esterase activity, leukocyte CC, and PMN%, and sent specimens for aerobic and anaerobic bacterial culture. Depending on the clinical results in accordance with the Musculoskeletal Infection Society criteria for prosthetic joint infection (PJI), 203 patients were then admitted for aseptic revision and 134 patients for septic exchange. RESULTS: In 337 cases (64.3% of the study patients), it was possible to measure the CC. The best cutoff level for PJI of all study patients was 2582 leukocytes/µL (sensitivity [SE] 80.6%, specificity [SP] 85.2%) and a PMN% of 66.1% (SE 80.6%, SP 83.3%). The chosen cutoff levels for PJI of total knee and total hip arthroplasty were 1630 leukocytes/µL (SE 83.6%, SP 82.2%) and a PMN% of 60.5% (SE 80.3%, SP 77.1%) and 3063 leukocytes/µL (SE 78.1%, SP 80.0%) and a PMN% of 66.1% (SE 82.2%, SP 82.4%), respectively. CONCLUSIONS: CC and PMN% are sensitive methods for diagnosing PJI of total hip and total knee arthroplasty. However, there are differences in cutoff levels between knees and hips. International guidelines and diagnostic criteria need revisions in terms of these parameters.

How Reliable Is the Alpha-defensin Immunoassay Test for Diagnosing Periprosthetic Joint Infection? A Prospective Study.

BACKGROUND: A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation. QUESTIONS/PURPOSES: We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results? METHODS: Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI. RESULTS: The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval [CI], 92%-99%), the specificity was 97% (95% CI, 92%-99%), the positive predictive value was 88% (95% CI, 81%-92%), and the negative predictive value was 99% (95% CI, 96%-99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative. CONCLUSIONS: Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result. LEVEL OF EVIDENCE: Level I, diagnostic study.

Unicompartmental knee arthroplasty in patients over 75 years: a definitive solution?

INTRODUCTION: The purpose of this study was to perform a mid-long-term clinical and radiographic evaluation of the results obtained in patients older than 75 years treated with minimally invasive unicompartmental knee arthroplasty (UKA). The hypothesis was that UKA is a viable solution for the definitive treatment of localized disease in this age group, with good results and a low failure rate. METHODS: An all-poly tibial component UKA was applied with a minimally invasive technique. Sixty-seven knees in patients with a minimum age of 75 years were evaluated at mean 9 years' follow-up. The Oxford knee score, Knee Society Score, WOMAC score, Visual Analogue Scale (VAS) for pain self-assessment and range of motion (ROM) were determined, as well as weight-bearing antero-posterior and laterolateral radiographs. RESULTS: All clinical scores, as well as VAS and ROM, improved significantly at 9-year follow-up, and the outcome was considered good or excellent in 92.6% of the patients. Radiographic results showed that both tibial plateau angle and posterior tibial slope angles were maintained, whereas femoro-tibial angle was significantly changed at follow-up. Further analysis showed no significant correlation between clinical scores and body mass index, whereas the clinical outcome was correlated with the ROM obtained. Only two failures and one major post-operative complication were observed. CONCLUSIONS: UKA is a viable option for treating unicompartmental knee osteoarthritis. With the proper indications and an accurate technique UKA may be indicated also in very elderly patients with reduced complications and morbidity, and excellent survivorship.

Is PLC repair of a peel-off femoral lesion an effective option in a multiligament setting?

PURPOSE: Treatment of posterolateral corner (PLC) injury in the multiligament-injured knee is still controversial. The aim of this study was to investigate the clinical outcome of acute or sub-acute surgical repair of Type 1 and 2 PLC peel-off lesions in a multiligament setting. METHODS: Mini-open direct repair of the PLC was performed in 13 patients. Combined PCL, ACL and MCL injuries were simultaneously managed. Telos valgus and varus stress radiographs at 30° of flexion with 150 N load were used to investigate medial and lateral joint opening. Posterior stress radiograph with 150 N load was used to investigate the function of the PCL. External rotational laxity was assessed with a dial test at 30° of knee flexion, and photographs were taken to measure angles. Anterior displacement was examined using the manual maximum test performed with a KT-1000 arthrometer. RESULTS: A statistically significant reduction between pre- and postoperative laxity values was achieved for every test. Particularly, lateral joint opening side-to-side difference reduced from 10.3 ± 4.0 to 1.0 ± 3.2 mm and external rotation reduced from 15 ± 8° to 0° ± 6° more than that of the contralateral uninjured knee. The medial joint opening side-to-side difference reduced from 11.5 ± 5.6 to 2.6 ± 2.7 mm in the 7 patients surgically managed for MCL lesion. The anterior tibial displacement side-to-side difference reduced from 14.0 ± 5.0 to 3.0 ± 5.0 mm in the 9 patients surgically managed for ACL lesion. The posterior tibial translation side-to-side difference reduced from 11.1 ± 5.1 to 4.4 ± 3.9 mm in the 11 patients treated for PCL lesion. CONCLUSION: The main finding of the current study is that acute repair of Type 1 and 2 PLC peel-off injury proved to be an effective procedure to restore PLC function in a multiligament-injured knee. These data enabled the current literature with an effective treatment option to face such a complex and various scenarios such as multiligament-injured knee. LEVEL OF EVIDENCE: IV.

Long-term clinical outcomes of combined BPTB ACL reconstruction and popliteus tendon plasty.

PURPOSE: A deficiency of posterolateral structures significantly increases the varus load on the ACL, while a chronic ACL lesion, the increased tibial rotation and the repetitive non-physiological knee motion, could affect and damage the integrity of the popliteus tendon. Therefore, the aim of the present study was to report the very long clinical outcomes of a combined single-bundle BPTB ACL reconstruction and popliteus plasty according to Bousquets technique, for the treatment of combined chronic anterior and posterolateral laxities. METHODS: Fifteen patients that underwent combined ACL reconstruction and popliteal plasty according to Bousquets technique were available at mean 26.8 ± 1.0 years (range 25.4-28.0 years). All the patients were evaluated clinically and 13 by means of KT-1000 Arthrometer as well. Subjective evaluation was performed with the subjective IKDC, WOMAC and a 0-10 VAS for pain scales. RESULTS: At clinical evaluation, 10 patients (67 %) presented a negative anterior drawer test; Lachman test was negative in nine patients (60 %); the varus stress test was negative in eight (53 %); and the dial test was negative in all but one patient (93 %). Only two patients (15 %) presented a side-to-side difference >5 mm at the instrumented laxity evaluation. CONCLUSION: The combined single-bundle BPTB ACL reconstruction and popliteal plasty according to Bousquets technique were able to produce very good long-term results, in terms of knee stability, subjective outcomes, functional results and return to sport activity, in case of chronic anterior and posterolateral laxities. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Biomechanical effect of posterolateral corner sectioning after ACL injury and reconstruction.

PURPOSE: Posterolateral corner structures functionally interact with the ACL. The aim of this study was to investigate the capability of an isolated ACL reconstruction control laxity parameters in a knee with combined ACL and PLC and the increase in terms of laxity produced by the resection of the PC in an ACL-deficient knee. METHOD: An in vitro cadaveric study was performed on seven knees. The joints were analysed in the following conditions: intact, after ACL resection, after popliteus complex resection, after ACL reconstruction and after LCL. Testing laxity parameters were recorded with an intra-operative navigation system and defined as: AP displacement at 30° and 90° of flexion (AP30 and AP90) applying a 130 N load and IE at 30° and 90° of knee flexion with a 5 N load. RESULTS: Sectioning the ACL significantly increased the AP30 at 30° and 90° of knee flexion (p < 0.05). At 90° of knee flexion, the resection of the LCL determined a significant increase in terms of AP laxity (p < 0.05). At 90° has been found a significant difference for the IE laxity (p < 0.05) after PC resection. Sectioning the LCL produced a significant increase in IE laxity at 30° and 90° of knee flexion (p < 0.05). CONCLUSION: Isolated ACL reconstruction is able to control the AP laxity with a combined complete lesion of the PLC at 30° of knee flexion, but not at higher angle of knee flexion. Considering the IE rotations, the reconstruction was not sufficient not even to control a partial lesion of the PLC. These findings suggest that additional surgical procedures should be considerate even when facing combined PLC lesion.

MRI evaluation of a collagen meniscus implant: a systematic review.

PURPOSE: Good clinical results have been demonstrated in numerous clinical studies using the collagen meniscus implant (CMI); however, the MRI behaviour of the scaffold, evaluated with Genovese score, is limited to a few cases series. The purpose was to evaluate, using the Genovese score, the MRI behaviour of the CMI at different follow-up periods and investigate possible differences in the behaviour of lateral and medial CMI. METHODS: A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the following keywords: "collagen meniscus implant" or "collagen meniscal implant". All the studies evaluating medial or lateral CMI using Genovese score for MRI were included in the systematic review. RESULTS: Six studies have been included in the systematic review, with no RCT's. The pooled number of patients involved in CMI surgery was 194 (83 % medial and 17 % lateral), with a mean age at surgery of 37.7 years. Concomitant procedures raged from 11 to 52 %. CMI morphology was grade 1 in 0, 2.7, 5.9, 0, 16.7 %, respectively, at 6 months, 1, 2, 5, 10 years. It was grade 2 in 12.5, 60.9, 60.3, 74.4, 75 %, respectively, at 6 months, 1, 2, 5, 10 years and grade 3 in 87.5, 36.4, 33.8, 25.6, 8.3 % at the same time points. CMI signal intensity was grade 1 in 80, 18.2, 25, 11.1, 22.2 %, respectively, at 6 months, 1, 2, 5, 10 years. It was grade 2 in 20, 78.2, 54.7, 55.6, 66.7 %, respectively, at 6 months, 1, 2, 5, 10 years and grade 3 in 0, 3.6, 20.3, 33.3, 11.1 % at the same time points. Slight differences were found between medial and lateral CMI in size and signal intensity. CONCLUSIONS: Higher rates of scaffolds with reduced size and with an MRI signal intensity more similar to normal meniscus were reported at longer follow-up compared with initial evaluations. Correlation between MRI findings and gross CMI appearance has not been reported. LEVEL OF EVIDENCE: IV.

Minimally invasive medial patellofemoral ligament reconstruction with fascia lata allograft: surgical technique.

The present paper describes a new minimally invasive anatomic medial patellofemoral ligament reconstruction, using a fascia lata allograft as graft source and arthroscopy to obtain balanced fixation throughout the range of motion.

Can rotatory knee laxity be predicted in isolated anterior cruciate ligament surgery?

PURPOSE: Despite the overall success of the surgical anterior cruciate ligament (ACL) reconstruction, some patients still present with instability symptoms even after the surgery, mainly due to the presence of associated lesions. At present, the pivot shift test has been reported to be the benchmark to assess rotatory knee laxity. The purpose of this study was to quantitatively evaluate rotatory knee laxity at time-zero in order to determine whether detected post-reconstruction laxity was predictable by its value measured before the reconstruction, which was hypothized to be influenced by the presence of associated lesions. METHODS: Rotatory knee laxity was retrospectively analysed in 42 patients, including two different ACL reconstructions. The maximal anterior displacement and the absolute value of the posterior acceleration reached during the reduction of the tibial lateral compartment were intra-operatively acquired by using a navigation system and identified as discriminating parameters. For each parameter, statistical linear regression analysis (line slope and intercept) was performed between pre- and post-reconstruction values. RESULTS: No statistically significant influence of the initial posterior acceleration on the post-reconstruction outcome was found (line slope, p > 0.05), although a statistically significant line intercept was indeed identified (p < 0.001). A statistically significant influence on the surgery outcome was instead found for the initial value of the anterior tibial displacement (line slope = 0.39, p = 0.004), meaning that, on average, about 40 % of the post-reconstruction lateral compartment displacement could be explained by the corresponding pre-reconstruction value. Both of these findings highlighted the importance of intra-operative quantification of rotatory knee laxity to identify correct indications for the surgery. CONCLUSIONS: This study provided important implications for the future possibility of defining a quantifying tool able to assess rotatory knee laxity during ACL reconstruction. This could allow detection of additional injuries to secondary restraints by easily performing rotatory knee laxity tests, which in turn could reduce post-surgical recurrence of knee instability.

An Innovative Topical Medical Device with Hyaluronic Acid and Polypeptides in Patients with Reduced Knee Function.

A topical medical device, AI500®, constituted of a single-chain polypeptide embedded in hyaluronic acid, was tested and evaluated in patients with reduced knee function due to osteoarthritis and other knee conditions. A total of 35 participants with reduced knee function assessed by the WOMAC Physical Function score were recruited. Four study visits were planned, from the first application at V0 to 1 week follow up at V3. Patient symptomatology was evaluated after 24 h (V1) and after 48 h (V2) through phone contact, and after 1 week from V0, on site (V3). The overall duration of the follow up was one week. An amelioration of 40% in WOMAC Physical Functional scores after 1 week of treatment was recorded, thus achieving the primary endpoint of 20%. Furthermore, a reduction of 29% in Physical Functional scores and of 28% in total WOMAC scores between V0-V2 was registered, together with a decrease of 39% between V0 and V3. The NRS scale showed a 29% and 37% reduction in pain between V0-V1 and V0-V2, respectively. Product safety was confirmed by the very low rate of adverse effects, non-device related, observed in only 2 patients out of 35, resolved spontaneously within 24-48 h. No safety concerns or risks associated with the use of the device were highlighted. There are few the studies on the topical use of HA-based gels for the treatment of knee problems. Compared to invasive intra-articular injections and oral pharmacological therapies used in cases of knee pain, the topical application of AI500® is non-invasive, safe, and appreciated by patients. Good results in terms of functional improvement and symptoms resolution were obtained in less than 1 week.

The Trochlear Bisector as a New Landmark for Kinematic Alignment in Total Knee Arthroplasty: A Radiographic Study.

Background: In recent years, there has been considerable interest in prosthetic alignment techniques for total knee arthroplasty (TKA), particularly in the so-called kinematic alignment, which aims to restore the knee's native alignment. However, implementing this technique requires specialized instruments and procedural steps that can be laborious. This study introduces the bisector of the trochlear groove as a reliable landmark for performing the distal femoral cut while maintaining parallelism with the native femoral joint line. Methods: Three orthopedic specialists assessed 110 X-ray images of full-leg, weight-bearing lower limbs obtained from healthy individuals between January 2021 and December 2022. The bisector of the trochlear groove was identified on the X-ray images, and the angle between this bisector and the femoral joint line was measured. The consistency of these measurements across repeated assessments and different examiners was evaluated. Results: The bisector of the trochlear groove was found to be perpendicular to the femoral joint line, with a mean angle of 89.4°. The inter-rater reliability was 68% within ±1.3° from the mean, while the intra-rater reliability was 82% within ±1.5° from the mean. Conclusions: These results suggest that by performing a femoral cut perpendicular to the bisector of the trochlear groove, surgeons can inherently restore the femoral joint line of the native knee in patients where the native joint line is no longer identifiable due to the effect of osteoarthritis. This method may offer a viable and straightforward alternative to the standard surgical technique currently practiced for kinematic alignment in TKA.

Combined ACL reconstruction and closing-wedge HTO for varus angulated ACL-deficient knees.

PURPOSE: To report the medium-term clinical and radiographic outcomes of a group of patients who underwent anterior cruciate ligament (ACL) surgery combined with high tibial osteotomy (HTO) for varus-related early medial osteoarthritis (OA) and ACL deficiency knee. METHODS: Thirty-two patients underwent single-bundle over-the-top ACL reconstruction or revision surgery and a concomitant closing-wedge lateral HTO. The mean age at surgery was 40.1 ± 8.1 years. Evaluation at a mean of 6.5 ± 2.7 years of follow-up consisted of subjective and objective IKDC, Tegner Activity Level, EQ-5D, VAS for pain and AP laxity assessment with KT-1000 arthrometer. Limb alignment and OA changes were evaluated on radiographs. RESULTS: All scores significantly improved from pre-operative status to final follow-up. KT-1000 evaluation showed a mean side-to-side difference of 2.2 ± 1.0 mm. Two patients were considered as failures. The mean correction of the limb alignment was 5.6° ± 2.8°. Posterior tibial slope decreased at a mean of 1.2° ± 0.9°. At final follow-up, the mechanical axes crossed the medial-lateral length of tibial plateau at a mean of 56 ± 23 %, with only 1 patient (3 %) presenting severe varus alignment. OA progression was recorded only on the medial compartment (p = 0.0230), with severe medial OA in 22 % of the patients. No patients underwent osteotomy revision, ACL revision, UKA or TKA. CONCLUSIONS: The described technique allowed patients with medial OA, varus alignment and chronic ACL deficiency to restore knee laxity, correct alignment and resume a recreational level of activity at 6.5 years of follow-up.

Open versus arthroscopic surgical treatment of chronic proximal patellar tendinopathy. A systematic review.

PURPOSE: A general agreement on the best surgical treatment option of chronic proximal patellar tendinopathy is still lacking. The purpose of this systematic review was to investigate if arthroscopically assisted procedures have been reported better results compared to open surgery and to assess the methodology of studies. METHODS: Twenty-one studies were included in the review. Surgical outcomes were defined referring to the functional classification described by Kelly et al. (Am J Sports Med 12(5):375-380, [11]): return to sport was regarded as the ability of training at the original level before injury with mild or moderate pain and success as the improvement after surgery with symptom reduction. Methodological analysis was performed by two reviewers adopting the Coleman Methodology Score (CMS) (range 0-100, best score 100). RESULTS: Only one randomized controlled trial (RCT) met inclusion criteria; all other included studies were case series. Median sample size 24, range 11-138, mean age at surgery 26.8 ± 3.2 years, mean follow-up 32.5 ± 18.4 (median 31, range 6-60) months. Return to sport rate: global 78.5 %, open group 76.6 % and arthroscopic group 84.2 %. Success rate: global 84.6 %, open group 87.2 % and arthroscopic group 92.4 %. Differences between groups were not statistically significant. CMSs were positively correlated with the year of publication (P < 0.05). CONCLUSIONS: Minimally invasive arthroscopically assisted procedures have not reported better statistically significant results when compared to open surgery in the treatment of chronic proximal patellar tendinopathy. The methodology of studies in this field has improved over the past 15 years, but well-designed RCTs using validated patient-based outcome measures are still lacking. LEVEL OF EVIDENCE: Systematic Review, Level IV.