A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus.

PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

Anterior Cruciate Ligament Revision Plus Lateral Extra-Articular Procedure Results in Superior Stability and Lower Failure Rates Than Does Isolated Anterior Cruciate Ligament Revision but Shows No Difference in Patient-Reported Outcomes or Return to Sports.

PURPOSE: To determine whether comparative clinical studies demonstrate significant advantages of revision anterior cruciate ligament reconstruction (RACLR) combined with a lateral extra-articular procedure (LEAP), with respect to graft rupture rates, knee stability, return to sport rates, and patient-reported outcome measures, compared with isolated RACLR. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews & Meta-Analyses Guidelines. A PubMed search was conducted using the key words "revision anterior cruciate ligament reconstruction" combined with any of the following additional terms, "lateral extra-articular tenodesis" OR "anterolateral ligament reconstruction" OR "Lemaire." All relevant comparative clinical studies were included. Key clinical data were extracted and evaluated. RESULTS: Eight comparative studies (seven Level III studies and a one Level IV study) were identified and included. Most studies reported more favorable outcomes with combined procedures with respect to failure rates (0%-13% following RACLR+LEAP, and 4.4%-21.4% following isolated RACLR), postoperative side-to-side anteroposterior laxity difference (1.3-3.9 mm following RACLR+LEAP and 1.8-5.9 mm following isolated RACLR), and high-grade pivot shift (0%-11.1% following RACLR+LEAP and 10.2%-23.8% in patients following isolated RACLR). There were no consistent differences between isolated and combined procedures with respect to return to sport or patient-reported outcome measures. CONCLUSIONS: This systematic review demonstrates that the addition of a LEAP to RACLR was associated with an advantage with respect to ACL graft failure rates and avoidance of high-grade postoperative knee laxity across almost all included studies. LEVEL OF EVIDENCE: IV, Systematic review of level III to IV studies.

Clinical Outcomes of Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis Procedures in Skeletally Immature Patients: A Systematic Review From the SANTI Study Group.

BACKGROUND: The treatment of anterior cruciate ligament (ACL) tears in the pediatric population has changed significantly in the past few decades. Pediatric patients who underwent ACL reconstruction (ACLR) have a high risk of rerupture of up to 32%. The addition of lateral extra-articular procedures [lateral extra-articular tenodesis (LET)], already shown to be effective in reducing the risk of rerupture in adults, may also be effective in pediatric patients. The purpose of this study was to systematically review the clinical outcomes of ACLR+LET tenodesis in pediatric patients. METHODS: Data were collected from Pubmed, MEDLINE, Cochrane, and Scopus Databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting the clinical outcomes of ACLR+LET in the pediatric population using autograft, return to play, growth disturbances, failure rate, and surgical complications were included. RESULTS: A total of 5 studies comprising 381 pediatric patients were included. Three main surgical techniques with common features were used. The mean age of all pediatric patients in the included studies was 11.73 years (range, 5.6 to 16) with a mean follow-up of 50.1 months. The overall graft failure rate of the included studies was 4.65%. The return to play was 95.11%. The mean Lysholm score was 94.51 and the mean Pediatric International Knee Documentation Committee (Pedi-IKDC) was 93.39. In all, 1.9% of the patients had a coronal plane deformity and 0.8% had a limb length discrepancy. 4.6% of the patients had a contralateral ACL tear. CONCLUSIONS: A combined ACLR+LET in pediatric patients showed a graft failure ranging from 0% to 13.6% at a mean follow-up of 50.1 months. This low graft failure rate is consistent with ACLR+LET in adults. Further investigations are needed to validate these findings and the potential role of LET in reducing graft rupture rates in this population. LEVEL OF EVIDENCE: Level IV-systematic review of level IV studies.

Correlation between Risk Factors and Healing Times in Long Bone Nonunions Treated with Corticoperiosteal Flap from the Medial Femoral Condyle.

BACKGROUND: The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF. METHODS: All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures. RESULTS: The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m2, and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis. CONCLUSION: This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones.

Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition in ACL reconstruction.

PURPOSE: The purpose of this study was to determine whether direct arthroscopic control of femoral buttons can prevent improper deployment and soft tissue interposition in anterior cruciate ligament (ACL) reconstruction. METHODS: A retrospective analysis of prospectively collected data from the SANTI study group database was performed. All patients who underwent ACL reconstruction using suspensive femoral fixation between 01/01/2017 and 31/12/2019 were included. Patient assessment included demographics, sports metrics, reoperations performed and femoral button-related specific complications such as iliotibial band (ITB) irritation and/or septic arthritis. Proper deployment of the button and soft tissue interposition were assessed on postoperative radiographs. RESULTS: A total of 307 patients underwent ACL reconstruction using adjustable femoral button fixation and were analyzed after a mean follow-up of 35.2 ± 11.0 months (14.3-50.2). The mean age was 39.5 ± 10.9-years old (range 13.3-70.6). Postoperative radiographs showed a correctly deployed femoral button without soft tissue interposition for all patients. No septic arthritis was reported. Nine patients (2.9%) suffered from lateral pain related to ITB irritation due to the button. Five of them had their symptoms resolve during rehabilitation. Ultrasound-guided corticosteroid infiltration was necessary for four patients after an average delay of 14.5 ± 4.8 months (11.7-21.7). Three patients were then symptom-free, but one required surgical removal of the implant 27.5 months after the surgery. Regarding unrelated femoral button complications, 15 patients (4.9%) underwent secondary arthroscopic procedures, including meniscectomy (1.6%), surgery for cyclops syndrome (2.6%) and revision ACLR (0.7%). CONCLUSION: Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition without specific complications. LEVEL OF EVIDENCE: Level IV.

Translation, cross-cultural adaptation, and validation of the Italian version of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale and its integration into the K-STARTS test.

BACKGROUND: The timing of a return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) represents a major subject of debate in sports medicine practice. Recently, the Knee Santy Athletic Return to Sport (K-STARTS) composite test was validated. This consists of a battery of physical tests and a psychological evaluation using the anterior cruciate ligament-return to sport after injury scale (ACL-RSI). This study aimed to translate the ACL-RSI and K-STARTS from English to Italian and determine the scale's reliability and validity in an Italian context. METHODS: The translation and cultural adaptation process was performed according to the guidelines for the cross-cultural adaptation of self-report measures. The patients were asked to fill an anonymized online form created for this purpose that included the KOOS, the Lysholm, the IKDC-SKF, and the Italian translation of the ACL-RSI (ACL-RSI-It). After 1 week, the attendees were asked to repeat the ACL-RSI-It to investigate the test-retest reliability. RESULTS: The final study population comprised 115 patients who underwent ACLR, with a mean follow-up of 37.37 ± 26.56 months. The ACL-RSI-It showed axcellent internal consistency (Cronbach's α = 0.963), reliability (test-retest ICC = 0.966), and good construct validity (positive correlations with the other scales were above 75%). CONCLUSIONS: The ACL-RSI-It is valid, reliable, and comparable to the original English version of the questionnaire for Italian-speaking patients. It can be used to assess the psychological readiness of patients for a RTS after primary and unilateral ACLR, and can be integrated into the Italian K-STARTS test. LEVEL OF EVIDENCE: Level II.

The healing potential of an acutely repaired ACL: a sequential MRI study.

BACKGROUND: Recently, there has been renewed interest in primary anterior cruciate ligament (ACL) repair. The aim of this study is to report early clinical and radiological results of a consecutive series of acute ACL tears treated with arthroscopic primary ACL repair within 14 days from injury. PATIENTS AND METHODS: A consecutive series of patients with acute ACL tears were prospectively included in the study. Based on MRI appearance, ACL tears were classified into five types, and tissue quality was graded as good, fair, and poor. Patients with type I, II, and III tears and at least 50% of ACL tibial remnant intact with good tissue quality were ultimately included. Clinical outcomes were measured using the Tegner Lysholm Knee Scoring Scale (TLKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), subjective and objective International Knee Documentation Committee (IKDC) scores, and KT-1000. Patients were also followed up with MRI evaluations at 1, 3, and 6 months postoperatively. ACL appearance was graded based on morphology (normal or abnormal) and signal intensity (isointense, intermediate, and hyperintense). RESULTS: The mean TLKSS was 98.1, the mean subjective IKDC was 97.6, and the mean KOOS was 98.2. The objective IKDC score was A in eight of ten patients and B in two patients. KT-1000 measurements showed a maximum manual side-to-side difference of less than 2 mm in eight of ten patients, whereas two patients showed a difference of 3 mm. The morphology of the repaired ACL was normal (grade 1) at 1 month follow-up in ten of ten cases, and this appearance persisted at 3 and 6 months postoperatively. The signal intensity at 1 month postoperatively was graded as isointense (grade 1) in four of ten patients, intermediate (grade 2) in five of ten patients, and hyperintense (grade 3) in one of ten patients. At both 3 and 6 months postoperatively, the signal intensity was graded as isointense (grade 1) in nine of ten patients and intermediate (grade 2) in one of ten patients. CONCLUSIONS: Arthroscopic primary ACL repair performed acutely in a carefully selected group of patients with proximal ACL tears and good tissue quality showed good early clinical and radiological results. LEVEL OF EVIDENCE: Level 4.

Determination of normal KOOS and WOMAC values in a healthy population.

PURPOSE: The KOOS questionnaire is used to assess the symptoms and function of patients with traumatic or degenerative knee pathology. The WOMAC score has been validated mainly in the context of knee osteoarthritis. The distribution of these scores in a non-diseased population is not known. The hypothesis was that KOOS and WOMAC scores were influenced by patients' age, sex, and BMI. The primary objective of this study was to describe, for the first time, the distribution of KOOS and WOMAC scores in a healthy population based on age, sex, and BMI. METHODS: This was a pilot (innovative), cross-sectional, international, multicenter, descriptive study. Persons accompanying patients to our clinic were invited to participate in this study by filling out the KOOS questionnaire. These data were also used to calculate the WOMAC score. The study was designed according to guidelines on pilot studies and planned to enroll a minimum of 30 subjects in each age, gender, and BMI group. Expected KOOS and WOMAC scores by age, gender, and BMI were determined using a linear regression model. RESULTS: Seven hundred and fourteen subjects were included: 305 men (42.7%) and 409 women (57.3%). For the KOOS score, as age increases, there was a decrease in the "ADL" (p = 0.0001) and "sport" (p = 0.0001) items and an increase in the "symptoms" (p = 0.0025) and "QOL" items (p = 0.0001). Women had lower scores (p < 0.05) than men on all the KOOS items, except "QOL". For the WOMAC, the "pain", "stiffness", and "function" items varied significantly based on age (p = 0.0203) and sex (p = 0.0121). The "stiffness" item varied significantly based on age (p = 0.0005) and sex (p = 0.0477). The "function" item varied significantly based on age (p = 0.0001) and sex (p = 0.0256). The expected value for the KOOS and WOMAC scores in a healthy population without any knee ailments were determined. CONCLUSIONS: The KOOS and WOMAC scores vary significantly based on age, sex, and BMI in a healthy population. This study also provides KOOS and WOMAC values in a population without any knee issue. These scores can be used, in a daily practice, as a reference to assess functional outcomes after a surgical procedure. LEVEL OF EVIDENCE: IV.

Lateral Extra-Articular Tenodesis and Anterolateral Procedures.

The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.

Calipered Kinematically Aligned Medial Unicompartmental Knee Arthroplasty: A Surgical Technique.

This study presents a surgical technique for kinematically aligned medial unicompartmental knee arthroplasty with the MOTO (Medacta Corporate, Switzerland) partial knee implant. This technique aims to replicate the native medial femoral and tibial morphology by providing caliper-verified bone resections and kinematic alignment principles. The paper provides a comprehensive overview of the surgical steps and discusses the implications for implant longevity.

Return to Soccer After Acute Anterior Cruciate Ligament Primary Repair: A 2-Year Minimum Follow-up Study of 50 Amateur Players.

BACKGROUND: Return to sport (RTS) after treatment of an anterior cruciate ligament (ACL) tear is a critical parameter to assess the outcome of a surgical procedure. However, few studies have investigated RTS after ACL repair. PURPOSE: To evaluate RTS of a group of amateur soccer players at a minimum follow-up of 2 years after ACL repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of all patients treated with acute ACL repair was conducted. A total of 50 amateur soccer players were included in the study. Patients were examined clinically or contacted to complete postoperative patient-reported outcome measures, namely the Knee injury and Osteoarthritis Outcome Score, the International Knee Documentation Committee questionnaire, the ACL-Return to Sport After Injury scale, and the Forgotten Joint Score-12. RESULTS: The patients' mean age was 25.8 ± 7.7 years (range, 14-47 years), and the mean follow-up was 34.3 ± 10.7 months (range, 24-51.3 months). The median Tegner Activity Scale score was 9. The ACL repair failure rate was 16% (8/50). The mean time from repair to failure was 23.1 ± 12.7 months (range, 6-44 months), and the mean age of patients who sustained ACL repair failure was 19.9 ± 3.3 years (range, 14-24 years), significantly lower compared with patients who did not experience ACL repair failure (26.9 ± 7.9 years; range, 16-47 years; P = .017). Multivariate analysis showed that age ≤21 years was the only significant risk factor for ACL repair failure (odds ratio, 5.45; confidence interval, 1.24-27.91; P = .041). Excluding the 8 patients who experienced repair failure, 31 of 42 patients (73.8%) returned to soccer after ACL repair, with 29 of the 31 (93.5%) returning at their preinjury level of play. Moreover, patients who played competitive soccer and returned to their preinjury level of play were significantly younger than those who did not return to their preinjury level of play (mean, 21.1 ± 3.4 vs 29.2 ± 9.5 years, respectively; P = .002) and had significantly better ACL-Return to Sport After Injury scores (mean, 96.6 ± 4 vs 87.8 ± 11, respectively; P = .044). CONCLUSION: In this study, 73.8% (n = 31) of patients returned to playing soccer, of whom 93.5% (n = 29) returned to their preinjury level after ACL repair. The failure rate was 16% (n = 8) and mainly involved patients ≤21 years old.

The Influence of Tibial Tubercle-Sparing Slope-Reducing Osteotomy on Patellar Height in Patients Undergoing Revision ACL Reconstruction.

BACKGROUND: A posterior tibial slope (PTS) >12° is an independent risk factor for anterior cruciate ligament (ACL) graft rupture, and a high tibial osteotomy (HTO) for slope correction can help avoid it. Management of patellar height is of major concern when performing HTO. PURPOSE: To evaluate the effect of tibial tubercle-sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstruction (ACLR). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic revision ACLR combined with retro-tibial tubercle anterior closing-wedge HTO (ACW-HTO) between January 1, 2016, and March 31, 2021, were assessed for eligibility. Patellar height was measured on full weightbearing lateral radiographs according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal radiographs using the femoral patellar height index. The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral radiographs. The delta (postoperative - preoperative) and the ratio (preoperative/postoperative) of the 3 patellar height indices and PTS were calculated. Preoperative and postoperative patellar heights were compared using independent t tests for each index. Also investigated was whether patients changed patellar height category (baja, normal, or alta) after slope osteotomy. RESULTS: Among 475 revision ACLRs, 47 tibial tubercle-sparing ACW-HTOs were retained for analysis. No significant difference in patellar height was found between pre- and postoperative radiographs regardless of the index (preoperative - postoperative) (ISI: 1.0 ± 0.2 - 0.9 ± 0.2, P = .1729; CDI: 1.0 ± 0.2 - 1.0 ± 0.2, P = .4034; femoral patellar height index: 1.5 ± 0.2 - 1.5 ± 0.2; P = .5130). Fifteen patients (31.9%) exhibited a postoperative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down one), and 18 patients (38.3%) changed category according to the CDI (10 moved up a category, 8 moved down one). No significant difference was found between pre- and postoperative patellar height among these patients (ISI: P = .2418; CDI: P = .3005). CONCLUSION: Changes in patellar height ratio are common after tibial tubercle-sparing ACW-HTO in patients undergoing revision ACLR. The clinical effect of these changes is unknown, and further study is needed to investigate whether they may result in patellofemoral symptoms.

Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons.

Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.

Evaluating the Reliability of YouTube as a Source of Information for Meniscal Ramp Lesions.

Background: Videos uploaded to YouTube do not go through a review process, and therefore, videos related to medial meniscal ramp lesions may have little educational value. Purpose: To assess the educational quality of YouTube videos regarding ramp lesions of the meniscus. Study Design: Cross-sectional study. Methods: A standard search was performed on the YouTube website using the following terms: "ramp lesion" and "posterior meniscal detachment" and "ramp" and "meniscocapsular" and "meniscotibial detachment," and the top 100 videos based on the number of views were included for analysis. The video duration, publication data, and number of likes and views were retrieved, and the videos were categorized based on video source (health professionals, orthopaedic company, private user), the type of information (anatomy, biomechanics, clinical examination, overview, radiologic, surgical technique), and video content (education, patient support, patient experience/testimony).The content analysis of the information on the videos was evaluated with the use of the DISCERN instrument (score range, 16-80), the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-4), and the Global Quality Score (GQS; score range, 1-5). Results: A total of 74 videos were included. Of these videos, 70 (94.6%) were published by health professionals, while the remaining 4 (5.4%) were published by orthopaedic companies. Most of the videos were about surgical technique (n = 36; 48.6%) and all had an educational aim (n = 74; 100%). The mean length of the videos was 10.35 ± 17.65 minutes, and the mean online period was 18.64 ± 13.85 months. The mean DISCERN score, JAMA benchmark score, and GQS were 31.84 ± 17.14 (range, 16-72), 1.65 ± 0.87 (range, 1-4), and 2.04 ± 1.21 (range, 1-5), respectively. Videos that reported an overview about ramp lesions were the best in terms of quality for DISCERN and JAMA benchmark score, while biomechanics videos were the best according to GQS. The worst category of videos was about surgical technique, with all having lower scores. Conclusion: The educational content of YouTube regarding medial meniscal ramp lesions showed low quality and validity based on DISCERN score, JAMA benchmark score, and GQS.

Effect of Lateral Extra-Articular Procedures Combined With ACL Reconstruction on the Rate of Graft Rupture in Patients Aged Older Than 30 Years: A Matched-Pair Analysis of 1102 Patients From the SANTI Study Group.

BACKGROUND: Clinical studies have demonstrated significant advantages of combined anterior cruciate ligament (ACL) reconstruction (ACLR) and lateral extra-articular procedures (LEAPs) over isolated ACLR in terms of reducing graft rupture and reoperation rates. However, most of the published studies have included young patients, and no studies have focused on patients aged >30 years. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the outcomes of isolated ACLR versus ACLR + LEAP at midterm follow-up in patients aged >30 years. The hypothesis was that patients who underwent combined procedures would experience significantly lower rates of graft rupture. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients >30 years of age who underwent primary ACLR + LEAP between January 2003 and December 2020 were propensity matched at a 1:1 ratio to patients who underwent isolated ACLR. A retrospective analysis of prospectively collected data was performed to determine graft rupture rates, knee stability, reoperation rates, and complications. Graft survivorship was assessed using the Kaplan-Meier method. Risk factors associated with the occurrence of graft failure were analyzed using a Cox proportional hazards model. RESULTS: Two groups of 551 patients each were included in the study, and the mean follow-up was 97.19 ± 47.23 months. The overall mean age was 37.01 ± 6.24 years. The LEAP group consisted of 503 (91.3%) patients who had anterolateral ligament reconstruction and 48 (8.7%) patients who had a Lemaire procedure. Overall, 19 (1.7%) patients had graft failure: 15 (2.7%) in the no-LEAP group and 4 (0.7%) in the LEAP group (P = .0116). The risk of graft failure was significantly associated with the absence of LEAP (31 vs 12; hazard ratio, 3.309; 95% CI, 1.088-10.065; P = .0350) and age between 30 and 35 years (hazard ratio, 4.533; 95% CI, 1.484-13.841; P = .0080). A higher rate of reoperation for secondary meniscectomy was found in the no-LEAP group (5.6% vs 2.2%; P = .0031). CONCLUSION: Patients aged >30 years who underwent combined ACLR and LEAP experienced a >3-fold lower risk of ACL graft failure compared with those who underwent isolated ACLR. Furthermore, the group without LEAP experienced a higher rate of secondary meniscectomy.

Ultrasound-guided electrocoagulation of neovascularisation for persistent patellar tendinopathy in athletes: a cohort study of 25 patients with a mean follow-up of 5 years from the SANTI Study Group.

Background: Patellar tendinopathy (PT) is a common condition characterised by persistent patellar tendon pain and dysfunction, particularly in athletes. Neovascularisation is frequently observed in the PT and is associated with increased pain. Ultrasound-guided electrocoagulation of neovascularisation has emerged as a minimally invasive alternative treatment for recalcitrant PT. Hypothesis/purpose: The purpose of this study was to evaluate the clinical outcomes of ultrasound-guided electrocoagulation of neovascularisation in athletes with persistent PT. Study design: Case series; level of evidence, IV. Methods: A retrospective analysis of prospectively collected data was performed on 25 athletes who underwent ultrasound-guided electrocoagulation of neovascularisation for recalcitrant PT. Clinical outcomes including complications, reinterventions and patient-reported outcome measures were recorded. Comparisons between variables were assessed using χ2 test or Fisher's exact test for categorical variables and Student's t-test or Wilcoxon test for quantitative variables. Results: 25 patients were included in the final analysis. 96% returned to their preoperative activity level at a mean of 3.8 months. At a mean follow-up of 5 years 4% did not receive significant benefit from electrocoagulation therapy. Significant improvements were observed in outcome measures, including the Victorian Institute of Sport Assessment Questionnaire for Patients with Patellar Tendinopathy, Kujala score, modified Blazina score and Visual Analogue Scale for pain. Conclusion: Ultrasound-guided electrocoagulation of neovascularisation for persistent PT in elite athletes resulted in a low complication rate, a high rate and rapid return to sport and a significant improvement in outcome measures.

A slight degree of osteoarthritis appears to be present after anterior cruciate ligament reconstruction compared with contralateral healthy knees at a minimum of 20 years: A systematic review of the literature.

Purpose: The aim of the present systematic review was to quantitatively synthesize the best literature evidence regarding osteoarthritis developing after anterior cruciate ligament reconstruction (ACLR), including only studies with a follow-up duration of at least 20 years. Material and Methods: A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on four electronic databases (PubMed, Scopus, EMBASE and Cochrane Library). The outcome measures extracted from the studies were failure rate, subsequent knee surgery on the same knee, radiographic development of osteoarthritis measured with Kellgren-Lawrence, International Knee Documentation Committee (IKDC) radiographic score and Ahlbäck classification. The health of both the ACLR knee and the contralateral knee was compared. Results: A total of 1552 patients were included in the study, of which 1290 (83.11%) were operated on using a patellar tendon graft, 190 (12.24%) with hamstrings, 27 (1.73%) with an iliotibial band and 45 (2.89%) with patellar tendon plus a ligament augmentation device (LAD). The mean age at the time of surgery was 25.18 ± 1.91 years, and the mean follow-up time was 23.34 ± 2.56 years. Analysing IDKC Score at final follow-up, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 33.2% (324/976) of the patients showed a moderate to severe degree (Grade C or D) of osteoarthritis, while for Kellgren-Lawrence, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 28.9% (196/678) of the patients showed a moderate to severe degree (Grade III or IV) of osteoarthritis. In total, 1552 patients were registered, 155 reruptures (9.98%) and a total of 300 (19.3%) new surgeries, of which 228 meniscectomy (14.69%), 21 (1.35%) knee arthroplasty and 17 (1.09%) hardware removal were recorded. Conclusions: ACL reconstruction appears to result in mild osteoarthritis in the long term in most of the patients and only less than 33.2% develop a moderate to severe degree of knee OA according to IKDC radiographic score. A slight degree of osteoarthritis appears to be present in ACLR knees compared with contralateral healthy knees. Level of Evidence: Level IV.

Spontaneous healing of a ruptured anterior cruciate ligament: a case series and literature review.

PURPOSE: The anterior cruciate ligament is probably one of the ligaments with the lowest healing potential. Many authors have reported cases of spontaneous healing but nowadays it is difficult to predict successful healing of an anterior cruciate ligament rupture and, even more, residual functionality and capability to return to sport. The aim of this study was to investigate cases of spontaneous healing in a population that received non-surgical treatment after anterior cruciate ligament rupture and to perform an updated review of contemporary literature. METHODS: The authors retrospectively reviewed patients who suffered from an acute complete anterior cruciate ligament rupture and underwent non-surgical treatment. No specific rehabilitation protocol was prescribed. A new magnetic resonance imaging study was conducted 6 months after the injury for all patients. A literature review was conducted regarding spontaneous healing of the anterior cruciate ligament. The papers included in the analysis were reports of any level of evidence, written in English, Italian, or French languages; articles were excluded if they reported non-human studies, histological studies, studies conducted without magnetic resonance imaging or arthroscopic second look, or partial anterior cruciate ligament tear. RESULTS: Case series: Six patients were enrolled in the study. All patients had a proximal anterior cruciate ligament lesion. The minimum follow-up was 13 months (range 6-20 months). At the last follow-up the mean score on the Lysholm scale was 97, the mean IKDC score was 94, and the mean KOOS score was 96. All patients returned to their own sport activities; no one reported significant differences. The magnetic resonance imaging study at 6 months revealed an end-to-end continuous anterior cruciate ligament with homogeneous signal. No one had any new knee injury at last follow-up. LITERATURE REVIEW: A search of comprehensive databases retrieved 1057 articles; 8 full-text articles met the eligibility criteria. The studies were heterogeneous regarding the populations analysed, sport activity level, treatment applied, healing definition, and follow-up. The failure rate of non-surgical management ranged among the papers from 0 to 73%. CONCLUSIONS: The study findings show that spontaneous anterior cruciate ligament healing is possible and there are chances of clinical recovery for patients not suitable for surgery. However, there is still a lack of evidence about predictors, clinical outcomes, and adequate rehabilitation protocols.