Assessment of knee instability in ACL-injured knees using weight-bearing computed tomography (WBCT): a novel protocol and preliminary results.

OBJECTIVE: To propose a protocol for assessing knee instability in ACL-injured knees using weight-bearing computed tomography (WBCT). MATERIALS AND METHODS: We enrolled five patients with unilateral chronic ACL tears referred for WBCT. Bilateral images were obtained in four positions: bilateral knee extension, bilateral knee flexion, single-leg stance with knee flexion and external rotation, and single-leg stance with knee flexion and internal rotation. The radiation dose, time for protocol acquisition, and patients' tolerance of the procedure were recorded. A blinded senior radiologist assessed image quality and measured the anterior tibial translation (ATT) and femorotibial rotation (FTR) angle in the ACL-deficient and contralateral healthy knee. RESULTS: All five patients were male, aged 23-30 years old. The protocol resulted in a 16.2 mGy radiation dose and a 15-min acquisition time. The procedure was well-tolerated, and patient positioning was uneventful, providing good-quality images. In all positions, the mean ATT and FTR were greater in ACL-deficient knees versus the healthy knee, with more pronounced differences observed in the bilateral knee flexion position. Mean lateral ATT in the flexion position was 9.1±2.8 cm in the ACL-injured knees versus 4.0±1.8 cm in non-injured knees, and mean FTR angle in the bilateral flexion position was 13.5°±7.7 and 8.6°±4.6 in the injured and non-injured knees, respectively. CONCLUSION: Our protocol quantitatively assesses knee instability with WBCT, measuring ATT and FTR in diverse knee positions. It employs reasonable radiation, is fast, well-tolerated, and yields high-quality images. Preliminary findings suggest ACL-deficient knees show elevated ATT and FTR, particularly in the 30° flexion position.

Recovery of Full Hyperextension After Anterior Cruciate Ligament Reconstruction Is Associated With Better Functional Outcomes but Greater Anterior Cruciate Ligament-Related Laxity After a Minimum 24-Month Follow-Up.

PURPOSE: To evaluate patients who had anterior cruciate ligament (ACL) reconstruction with preoperative hyperextension and compare physical examination (KT-1000 and pivot shift) and patient-reported outcome measures of patients who recovered the entire hyperextension with patients who did not. METHODS: Patients aged 18 to 60 years with more than 5° of knee hyperextension who had anatomic ACL reconstruction with any graft from June 2013 to June 2021 and at least a 24-month follow-up were evaluated retrospectively. Hamstrings and patellar tendon grafts were fixed around 20° to 30° of flexion and in full extension, respectively. Patients who could recover hyperextension were compared with patients who did not. Preoperative, intraoperative, and postoperative data, including physical examination and patient-reported outcome measures, were evaluated. RESULTS: Of the 225 patients evaluated, 48 (21.3%) did not recover hyperextension, and 177 recovered full range of motion. Patients who did not recover hyperextension had a larger graft diameter (8.7 ± 0.7 mm [confidence interval, 8.502-8.898 mm] vs 8.3 ± 0.7 mm [confidence interval, 8.197-8.403 mm]; P = .018). Regarding the postoperative subjective variables, patients who recovered hyperextension showed improvement on all scales (International Knee Documentation Committee, Lysholm, Forgotten Joint Score, and Global Perceived Effect) evaluated compared with patients who did not recover the range of motion. Patients who recovered hyperextension also showed more laxity on physical examination, measured by the KT-1000 (1.8 ± 0.8 vs 1.1 ± 1.0; P = .0006) and the pivot shift (62.1% [grade 0] and 37.9% [grade 1] vs 79.2% [grade 0] and 20.8% [grade 1]; P = .027). CONCLUSIONS: Patients with knee hyperextension who regained range of motion after ACL reconstruction have worse knee laxity than patients who regained full extension but not hyperextension. However, patients who recover full range of motion showed higher scores on subjective function scales, including a greater number of patients who achieved patient acceptable symptom state for the International Knee Documentation Committee score. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Patients With More Than 6.5° of Knee Hyperextension are 14.6 Times More Likely to Have Anterior Cruciate Ligament Hamstring Graft Rupture and Worse Knee Stability and Functional Outcomes.

PURPOSE: To create a cut-off point for hyperextension that best discriminates retear and to verify whether this cut-off point can predict retear regardless of other characteristics after primary anterior cruciate ligament (ACL) reconstruction with hamstrings autograft. METHODS: A cohort of patients submitted to primary isolated ACL reconstruction with hamstrings autografts was retrospectively evaluated. Patients were stratified according to the degree of passive knee hyperextension measured in the normal contralateral knee. The following data were collected: patient age and sex, time from injury to surgery, knee hyperextension, KT-1000 and pivot-shift, associated meniscus injury, intra-articular graft size, follow-up time, graft failure, and postoperative Lysholm and subjective International Knee Documentation Committee scores. RESULTS: Data from 457 patients were evaluated. Median age was 31 years. Thirty-two (7.0%) presented with retear. There was a significant difference in hyperextension between patients with and without retear (P < .001), with the cut-off point established by the receiver operating characteristic curve from 6.5°. Patients with greater hyperextension had a statistically greater frequency of women, longer injury time, greater intra-articular graft diameter, greater postoperative KT-1000, and greater frequency of retear, whereas the subjective International Knee Documentation Committee and Lysholm scores were statistically lower in patients with greater hyperextension. Only hyperextension showed a statistically significant association with re-rupture (P < .001). The odds of retear in patients with hyperextension greater than 6.5 was 14.65 times the odds of patients with hyperextension less than 6.5. CONCLUSIONS: Patients with more than 6.5° of hyperextension are 14.6 times more likely to have a graft rupture than patients with lower hyperextension when submitted to ACL reconstruction with hamstring tendons. Also, they present worse knee stability by the KT-1000 test and worse functional outcomes. Therefore, patients with this degree of hyperextension should not have isolated reconstruction with hamstrings as their first choice. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Patellar Tilt and Patellar Tendon-Trochlear Groove Angle Present the Optimum Magnetic Resonance Imaging Diagnostic Reliability for Patients With Patellar Instability.

PURPOSE: To describe, in controls and in a population with patellar instability, magnetic resonance imaging values of measurements representing major associated factors for patellar instability (patellar height, trochlear dysplasia, and extensor mechanism alignment), as well as their cutoff values. METHODS: In total, 323 knee magnetic resonance imaging scans, 142 with patellar instability and 181 controls without patellofemoral complaints (anterior cruciate, medial collateral ligament, meniscus ruptures or normal) were evaluated. Means, normality values in the control population, ideal cutoff values through receiver operating characteristic curves analysis, and interobserver reliability (intraclass correlation coefficient) were described for a series of measurements. RESULTS: All measurements were statistically different in control and instability patients, except for the patellotrochlear index and tibial tuberosity to posterior cruciate ligament distance. The interobserver intraclass correlation coefficient was good or excellent (above 0.75) only for the patellotrochlear index, patellar tendon-trochlear groove (PTTG) angle, and patellar tilt. The optimal cutoff value for each measurement was: PTTG angle ≥25.3o with sensitivity (S) of 70% and specificity (E) of 89%, patellar tilt ≥16o (S: 69% and E: 84%), trochlear sulcus angle ≥153o (S: 75% and E: 76%), Carrillon ≤12.8o (S: 62% and E: 87%), PTTG distance ≥11mm (S: 71% and E: 78%), Caton-Deschamps index ≥1.23 (S: 72% and E: 76%) and trochlear bump ≥3.95 mm (S: 76% and E: 65%). CONCLUSIONS: Caton-Deschamps index (≥1.23), trochlear sulcus angle (≥153o), ventral prominence of the trochlea (≥3.95 mm), PTTG distance (≥11 mm), PTTG angle (≥25.3o), Carrillon angle (≤12.8o), and patellar tilt (≥16o) presented better diagnostic performance for patellar instability. Patellotrochlear index and tibial tuberosity to posterior cruciate ligament distance were not related to patellar instability. The interobserver reliability of the factors related to patellar instability was excellent only for the PTTG angle and lateral patellar tilt. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Small Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction Combined With Anterolateral Ligament Reconstruction Results in the Same Failure Rate as Larger Hamstring Tendon Graft Reconstruction Alone.

PURPOSE: To compare patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring grafts 7 mm or less in diameter combined with anterolateral ligament (ALL) reconstruction versus isolated ACL reconstruction with grafts greater than 7 mm in diameter. METHODS: We retrospectively evaluated the descriptive data and clinical outcomes of patients who underwent primary ACL reconstruction with hamstring grafts from June 2013 to January 2020 and had a minimum follow-up period of 2 years. Patients with quadrupled or quintupled semitendinosus and gracilis autograft 7 mm or less in diameter combined with single-strand ALL reconstruction (ACL-ALL group) were matched in a 1:2 propensity ratio to patients who underwent isolated single-bundle ACL reconstruction with hamstring grafts greater than 7 mm (ACL group). RESULTS: We identified 30 patients in our database who met the criteria for the ACL-ALL group. The patients in this group were matched to 60 patients comprising the ACL group. Both groups were similar regarding all preoperative matched and unmatched variables. The mean ACL graft diameter was 6.8 ± 0.4 mm in the ACL-ALL group and 8.6 ± 0.6 mm in the ACL group (P < .001). The ACL-ALL group presented 1 failure (3.3%), and the ACL group presented 3 failures (5%) (P = .717). Postoperative KT-1000 measurements were similar between the groups (2.1 ± 1.1 mm vs 1.9 ± 1.2 mm, P = .114), as were postoperative pivot-shift grades (P = .652). Subjective International Knee Documentation Committee scores and Lysholm scores did not present any differences between the groups (P = .058 and P = .280, respectively). CONCLUSIONS: Patients who undergo combined ACL-ALL reconstruction with an ACL graft diameter of 7 mm or less can achieve similar results to patients who undergo isolated ACL reconstruction with a graft diameter greater than 7 mm. An associated ALL reconstruction can be performed to increase knee stability in patients with small-diameter hamstring grafts. LEVEL OF EVIDENCE: Level III, retrospective, comparative therapeutic trial.

The Addition of Either an Anterolateral Ligament Reconstruction or an Iliotibial Band Tenodesis Is Associated With a Lower Failure Rate After Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Comparative Trial.

PURPOSE: To compare the failure rate in patients who underwent revision anterior cruciate ligament (ACL) reconstruction alone or associated with an extra-articular procedure. Secondary objectives were to compare ACL laxity, patient-reported outcome measures, and complication rates in these patients and, subsequently, to compare the outcomes of patients who underwent revision ACL reconstruction associated with anatomical anterolateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET). METHODS: This was a retrospective comparative study. Patients were classified into 2 groups, according to whether (group 2) or not (group 1) an extra-articular reconstruction was performed. Patients who underwent an extra-articular procedure were further divided into ALL reconstruction (group 2A) and LET (group 2B). Baseline demographic variables, operative data and postoperative data were evaluated. RESULTS: The groups with (86 patients) and without (88 patients) an associated extra-articular reconstruction had similar preoperative data. Group 2 had a lower failure rate (4.6% vs 14.7%; P = .038), better KT-1000, better pivot-shift, and better Lysholm. There was no difference regarding complications, except more lateral pain in group 2. Regarding the groups who underwent ALL reconstruction (41 patients) and LET (46 patients), group 2A showed better Lysholm scores. Both groups had similar failure rates and complications. CONCLUSIONS: Patients who underwent revision ACL reconstruction with a laterally based augmentation procedure had a lower failure rate than patients who underwent isolated revision ACL reconstruction. KT-1000 and pivot-shift examination were also significantly better when a lateral augmentation was performed. Complications were similar except for an increase in lateral pain in the augmented group. No clinically important differences were found when comparing the LET group to the ALL group other than a statistical improvement in the Lysholm functional scale, likely not clinically meaningful, favoring the ALL group and an increased duration of post-operative lateral pain in the LET group. LEVEL OF EVIDENCE: III, retrospective comparative therapeutic trial.

Magnetic resonance imaging overestimates patellar height compared with radiographs.

PURPOSE: To evaluate the inter-observer and inter-method reliability for patellar height measurements between conventional radiographs (CR) and magnetic resonance imaging (MRI) using one or two slices. METHODS: This was a reliability study, with 60 patients divided in two groups: 30 patients with patellar instability (patella group) and 30 patients with anterior cruciate ligament or meniscus injury (control group). CR and MRI were evaluated by two independent observers. Insall-Salvati index (IS) and Caton-Deschamps index (CD) were measured using three different methods: CR, one-slice MRI or two-slice MRI. Intra-class correlation coefficients (ICC) were calculated for inter-observer reliability and inter-method reliability. Bland-Altman agreement was also calculated. RESULTS: The inter-observer reliability was very good for the IS with ICCs of 0.93, 0.84 and 0.82, for the CR, one-slice MRI and two-slice MRI, respectively. Similarly, for the CD the ICCs were good, 0.76, 0.80 and 0.75 for the CR, one-slice MRI and two-slice MRI, respectively. No differences were found between the patella and the control group. The inter-method analysis results were: ICCs for IS (0.83, 0.86, 0.93) and CD (0.72, 0.82, 0.83), for the comparisons of CR/one-slice MR, CR/two-slice MRI and one-slice MRI/two-slice MRI, respectively. The Bland-Altman mean differences showed an 8% and a 7% increase on IS values with one-slice MRI and two-slice MRI compared to CR results, while the increase was of 9% and 1% in CD for the respective comparisons with CR. CONCLUSION: MRI can overestimate patellar height compared to CR, as much as an 8% increase in Insall-Salvati values when using one- or two-slice MRI measurements, and up to a 9% increase in Caton-Deschamps value when using the one-slice MRI method. It is recommended to use the CR as the preferred method when measuring patellar height. LEVEL OF EVIDENCE: III.

Sleep medicine in otolaryngology units: an international survey.

PURPOSE: No study to date has described the overall landscape of sleep disorders management and training in otolaryngology departments of different countries. The aim of our study was to investigate and compare settings, diagnostic and therapeutic approaches and training programmes. METHODS: An international online survey was developed with the collaboration of the YO-IFOS (Young Otolaryngologists-International Federation of Otorhinolaryngological Societies) to assess the current practice of otolaryngologists in the management of sleep disorders. The survey also included a session dedicated to training. RESULTS: A total of 126 otolaryngologists completed the survey. The larger part of responses was collected from Central/South America and Europe. The majority of responders from South/Central America (97%) declared to be certified as sleep specialist while 49% of Europeans stated the opposite. Of responders 83% perform a drug-induced sleep endoscopy (DISE) before planning a possible surgical intervention. Soft palate and base of tongue interventions were the most common procedure, respectively performed in 94% and 79% of the cases. Residents were allowed to perform soft palate surgery in 77% of the cases. Upper airway stimulation (26% vs 10%), trans-oral robotic surgery (36% vs 11%) and radiofrequency of the base of the tongue (58% vs 25%) were preferred more frequently by European responders. The highest caseloads of soft palate surgery and bi-maxillary advancement were registered in the academic institutions. CONCLUSION: Significant concordance and few interesting divergences in diagnosis and treatment of sleep disorders were observed between nationalities and types of institution. Economic resources might have played a significant role in the therapeutic choice. Trainees' lack of exposure to certain interventions and to a sufficient caseload appeared to be the main burden to overcome.

Surgical Timing Does Not Interfere on Clinical Outcomes in Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament: A Comparative Study With Minimum 2-Year Follow-Up.

PURPOSE: To compare the functional outcomes, knee stability, failure rate and complication rates of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with hamstrings grafts between acute and chronic cases. METHODS: Consecutive patients who underwent combined ACL and ALL reconstruction with hamstrings grafts were evaluated. Patients operated on less than 8 weeks after injury were allocated to group 1, and the others were allocated to group 2. Demographic data, knee stability, and functional outcomes of the 2 groups were evaluated. RESULTS: Thirty-four patients in the acute group and 96 in the chronic group were evaluated. The follow-up time was similar between the groups (28.7 ± 5.2 [24-43] months vs 29.4 ± 7.2 [24-58] months; P = 0.696). No differences were found between the groups in age, sex, trauma mechanism, presence of knee hyperextension, graft diameter, and meniscal injuries. There was no difference between the groups in the postoperative KT-1000 and in the pre- or postoperative pivot shift. The preoperative KT-1000 was higher in group 2 (7.9 ± 1.1 vs 7.4 ± 1.2; P = 0.031). There were no differences in the International Knee Documentation Committee or Lysholm. Three (2.3%) patients developed failure, 1 (2.9%) in group 1 and 2 (2.1%) in group 2. The total complication rate was 10% and did not differ between the groups. CONCLUSIONS: Combined ACL and ALL reconstruction has similar outcomes in patients undergoing surgery in the acute and chronic phases. Patients with chronic injury have similar knee stability, functional scores, and failure rates as acute-injury patients, and patients with acute injury have no more complications than chronic patients. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Degenerative Medial Meniscus Tear With a Displaced Flap Into the Meniscotibial Recess and Tibial Peripheral Reactive Bone Edema Presents Good Results With Arthroscopic Surgical Treatment.

PURPOSE: To report the arthroscopic treatment results of a degenerative medial meniscus tear with a displaced flap into the meniscotibial recess, tibial peripheral reactive bone edema, and focal knee medial pain. As a secondary objective, we propose to identify possible factors associated with a good or poor prognosis of the surgical treatment of this lesion. METHODS: From 2012 to 2018, patients who had this specific meniscus pathology and underwent arthroscopic surgical treatment were retrospectively evaluated. Patients with Kellgren-Lawrence (KL) classification greater than 2 were excluded. KL classification, the presence of an Outerbridge grade III/V chondral lesion of the medial compartment, limb alignment, body mass index, and smoking were evaluated. The subjective outcomes included the International Knee Documentation Committee score, improvement in the pain reported by patients, and the Global Perceived Effect (GPE) scale score. RESULTS: A total of 69 patients were evaluated. The mean age was 58.6 ± 7.1 years. The follow-up time was 48.7 ± 20.8 months. Fifty-five (79.7%) patients reported pain improvement. The postoperative International Knee Documentation Committee was 62.6 ± 15.4, and the mean GPE was 2.3 ± 2.6. Fourteen patients (20.3%) showed no improvement in pain, and 7 patients (10.2%) presented complications. Groups that improved (GPE > 0) and did not improve (GPE < 0) did not present differences regarding age, sex, follow-up time, chondral lesions, or body mass index. Patients without improvement had a greater incidence of smoking (P = .001), varus alignment (P = .008), and more advanced KL classification (P < .001). In the multivariate analysis based on the GPE score, KL classification (P = .038) and smoking (P = .003) were significant. CONCLUSIONS: Arthroscopic surgical treatment of degenerative medial meniscal tears with a meniscal flap displaced into the meniscotibial recess and adjacent focal bone edema in the tibia shows good results in approximately 80% of cases. Smoking and KL grade 2 were factors associated with poor prognosis of surgical treatment. LEVEL OF EVIDENCE: Level IV (case series).

Olfactory function in patients with obstructive sleep apnea: a meta-analysis study.

PURPOSE: This meta-analysis study was designed to analyze the olfactory function in obstructive sleep apnea patients (OSA). METHODS: A comprehensive review of the English language literature regarding OSA patients and olfactory function/dysfunction was performed. The papers assessing olfactory dysfunction with Sniffin' Sticks test were taken into consideration. RESULTS: A total of 420 OSA patients were judged eligible for the study. The average TDI score was found to be 24.3 ± 5.6. The olfactory identification (OD), the olfactory discrimination (OD), and the olfactory threshold (OT) average values were calculated resulting 9.9 ± 2.1, 9.8 ± 1.5, and 5.3 ± 2, respectively. There were 161 healthy control subjects in this meta-analysis. The average TDI of the control group was 30.7 ± 6.0 showing a statistical difference with the group of OSA patients (p = 0.03). A linear correlation between Apnea-Hypopnea Index (AHI) increase and TDI decrease (R2 = 0.1, p = 0.05) was detected. Finally, the average values of TDI of 151 patients classified as mild-moderate OSA and 159 patients considered as severe OSA were calculated. The difference between these two groups resulted not statistically significant (p = 0.3). CONCLUSION: The comparison between OSA patients and healthy subjects using Sniffin' Sticks test showed lower values of the various olfactory parameters. Although a linear correlation between AHI increase and olfactory dysfunction was observed, no statistical difference between mild-moderate and severe OSA patients in terms of the severity of olfactory dysfunction could be proved.

Effectiveness of barbed repositioning pharyngoplasty for the treatment of obstructive sleep apnea (OSA): a prospective randomized trial.

PURPOSE: The aim of our randomized clinical trial is to produce stronger evidence supporting barbed repositioning pharyngoplasty (BRP) as a therapeutic option for the treatment of obstructive sleep apnea (OSA). METHODS: The trial was a single-center prospective controlled trial with two parallel arms (group A: BRP; group B: observation) and randomization. Baseline and 6-month polygraphy evaluating the apnea hypopnea index (AHI), oxygen desaturation index (ODI), and lowest oxygen saturation (LOS) were performed. To test the differences among groups of Student's t test, the role of each factor (univariate analysis) and their independent effect (multivariate analysis) was explored using logistic regression model as appropriate. Linear regression was also conducted. RESULTS: A significant reduction of AHI, ODI, LOS, and Epworth Sleepiness Scale (ESS) values was recorded in the BRP group. BRP showed to be more effective than observation. Logistic regression showed that preoperative AHI is related significantly to postoperative AHI within the BRP group. A linear regression showed that higher baseline AHI predicts more significant postoperative absolute AHI reduction. CONCLUSIONS: BRP appears to be a promising technique and might be included within the surgical armamentarium of a sleep surgeon. Patients affected by severe OSA may benefit from this surgery with more significant reduction of AHI values.

The use of negative-pressure wound therapy after total knee arthroplasty is effective for reducing complications and the need for reintervention.

BACKGROUND: Wound healing complications are causal factors of prosthesis infection and poor postoperative evolution of patients after total knee arthroplasty (TKA). Negative-pressure wound therapy (NPWT) can be an option to minimize these complications. The aim of this study is to compare the complications of patients undergoing TKA who used a portable NPWT device in the immediate postoperative period with those of a control group. METHODS: A total of 296 patients were evaluated. Patients were divided into two groups: those who used NPWT for seven days in the postoperative period (Group 1 - prospective evaluated) and those who used conventional dressings (Group 2 - historical control group). Epidemiological data, comorbidities, local parameters related to the surgical wound and complications were evaluated. RESULTS: The groups did not differ in regard to sex, age and clinical comorbidities. Overall, 153 (51.7%) patients had at least one risk factor for wound complications. Patients who used NPWT had a lower rate of complications (28.5% vs. 45.7%, p = 0.001) and a lower rate of reintervention in the operating room (2% vs. 8.5%, p = 0.001). Patients in group 1 had a lower incidence of hyperaemia (14.7% vs. 40.2%, p = 0.01), skin necrosis (2.1% vs. 8.5%, p = 0.04) and wound dehiscence (3.1% vs 10.1%, p = 0.03). The use of NPWT was a protective factor for the presence of complications, with an odds ratio of 0.36 (95% CI 0.206-0.629). CONCLUSION: The number of complications related to the wound after TKA is high; however, most of them are minor and have no impact on the treatment and clinical evolution of patients. The use of NPWT decreased the number of surgical wound complications, especially hyperaemia, dehiscence and necrosis, and reduced the need for reintervention.

Clinical results of pulsed signal therapy on patellofemoral syndrome with patellar chondropathy.

This study was designed to evaluate the effect of pulsed signal therapy (PST) on patellofemoral pain syndrome associated with patellar chondropathy. A prospective randomized double-blind placebo controlled trial included 25 patients (41 knees) between 20 and 50 years with pain due to isolated patellofemoral syndrome with chondropathy. PST group received nine 60-min daily sessions of PST treatment. Control group received the same protocol of blinded placebo treatment. The main outcome was change from baseline Kujala score at 3 months. After 3 months, patients in the control group received effective treatment (placebo post-treatment). All patients were then followed, for up to 12 months. Seventeen knees (5 males and 12 females, mean age 36.7 ± 7.9) received placebo and 24 knees (8 males and 16 females, mean age 35.5 ± 8.9) received PST. By the third month, PST group exhibited a mean change from baseline of 9.63 ± 7.5 Kujala points, compared to 0.53 ± 1.8 in the placebo group (P < 0.001). A significant progressive improvement was seen in the PST group between the 3rd and 6th and between the 6th and 12th month (P < 0.016). Patients initially allocated in the control group also improved at 3 months (P < 0.001) and 6 months (P = 0.005) post-effective treatment. In conclusion, PST in patellofemoral pain syndrome with chondropathy was effective compared to placebo at 3 months, showing an important improvement of Kujala score. The improvement was progressive and maintained up to 12 months. PST is safe and should be considered as a non-invasive option for management of this condition. Bioelectromagnetics. 40:83-90, 2019. © 2019 Bioelectromagnetics Society.

Aging effect on sleepiness and apneas severity in patients with obstructive sleep apnea syndrome: a meta-analysis study.

PURPOSE: Different authors have reported that aging could be associated with changes in obstructive sleep apnea (OSA) related parameters (apnea/hypopnea index, SpO2, reduction of daytime sleepiness, etc.), type of sleep and pattern of collapse. Regarding OSA severity in elderly patients, it is commonly believed that the AHI score tends to increase with aging. METHODS: In this paper, we reviewed the literature regarding the studies which compared older (> 65 years old) and young (< 65 years old) OSA patients regarding the effect of aging on daytime sleepiness (ESS evaluation) and OSA severity (AHI evaluation). A meta-analysis to evaluate the effect of age on daytime sleepiness and OSAS severity was also performed to corroborate previously reported experience. RESULTS: Meta-analysis showed no statistical (p = 0.8) differences regarding AHI differences emerged from the comparison of the two groups of patients. Elderly patients (> 65 years old) showed less daytime sleepiness, showing a statistical difference in the meta-analysis of data (p = 0.004) CONCLUSION: Although a direct correlation between aging and AHI values would seem to be present, no significant differences in baseline AHI between young (< 65-years-old) and elderly (> 65-years-old) patients emerged in this meta-analysis study. The effects of OSAS on daytime sleepiness seem to be much more prominent in young or middle-aged patients than in elderly patients.

Phenotyping the pathophysiology of obstructive sleep apnea using polygraphy/polysomnography: a review of the literature.

Continuous positive airway pressure (CPAP) is the first-line treatment for the majority of patients affected by obstructive sleep apnea syndrome (OSA). However, long-term compliance with CPAP therapy may result limited and alternatives to CPAP therapy are required to address the increasing need to provide tailored therapeutic options. Understanding the pathophysiological traits (PTs) of OSA patients [upper airway (UA) anatomical collapsibility, loop gain (LG), arousal threshold (AT), and UA gain (UAG)] lies at the heart of the customized OSA treatment. However, sleep research laboratories capable to phenotype OSA patients are sparse and the diagnostic procedures time-consuming, costly, and requiring significant expertise. The question arises whether the use of routine clinical polysomnography or nocturnal portable multi-channel monitoring (PSG/PM) can provide sufficient information to characterize the above traits. The aim of the present review is to deduce if the information obtainable from the clinical PSG/PM analysis, independently of the scope and context of the original studies, is clinically useful to define qualitatively the PTs of individual OSA patients. In summary, it is possible to identify four patterns using PSG/PM that are consistent with an altered UA collapsibility, three that are consistent with altered LG, two with altered AT, and three consistent with flow limitation/UA muscle response. Furthermore, some PSG/PM indexes and patterns, useful for the suitable management of OSA patient, have been discussed. The delivery of this clinical approach to phenotype pathophysiological traits will allow patients to benefit in a wider range of sleep services by facilitating tailored therapeutic options.

Laryngopharyngeal reflux in obstructive sleep apnoea patients: Literature review and meta-analysis.

PURPOSE: Laryngopharyngeal reflux (LPR) is a frequent condition in Obstructive Sleep Apnoea (OSA) patients and different studies have been published in the last years about this topic. A review of the published literature regarding LPR in OSA patients has been reported. A meta-analysis to evaluate the incidence of LPR in OSA patients and correlate LPR positivity with OSA patients' characteristics has been performed. METHODS: A comprehensive review of the English language literature about LPR in OSA patients was performed using the most important electronic databases (PubMed, EMBASE, the Cochrane Library etc.). A total of 10 papers studying LPR in OSA were assessed and considered eligible for the meta-analysis. RESULTS: The data analysis regarding 870 identified OSA patients showed that 394 patients were LPR +, while 476 were LPR-. The meta-analysis showed no statistical difference regarding the AHI value between LPR + patients and LPR- patients (p = 0,3). Mean BMI was more higher in LPR + patients than in the patients without LPR, showing a significant statistical difference (p = 0.001). CONCLUSION: Current international literature demonstrates a high incidence of LPR (45.2%) in OSA patients. The severity of AHI in OSA patients would not seem to correlate with the presence of laryngopharyngeal reflux. The OSA patients with LPR showed a higher BMI compared with LPR- patients.

Let's know from our patients: PPOPS score for palate surgery evaluation/a pilot study.

AIM: To introduce a questionnaire that can be used to assess the post-operative perception of the patients after palatal surgery. The questionnaire was named: Palate Post-Operative Problems Score (PPOPS). STUDY DESIGN: Pilot study. PATIENTS AND METHODS: The study was performed at Morgagni-Pierantoni hospital, Forli. Forty patients suffering from obstructive sleep apnea (OSA) who performed either expansion sphincter pharyngoplasty (ESP) or barbed reposition pharyngoplasty (BRP) in our hospital were divided into two groups, 20 patients per group. The patients' answers to the PPOPS questionnaire were recorded and their total scores were compared in addition to each item separately. PPOPS questionnaire consists of 12 items scored from 0 to 3 with a total score from 0 to 36. RESULTS: The overall average scores between both groups were similar being 4.05 for the BRP and 4.35 for the ESP with P value 0.4. From the results of the questionnaire, the patients favoured choosing BRP than ESP although some items showed better results among ESP patients and the difference between both techniques is not statistically significant. Every item score was separately compared and described in details later in the results. CONCLUSION: PPOPS questionnaire can be an additional useful tool for the assessment of any kind of palatal surgery through detailed analysis of the patients' perception for their surgery. BRP and ESP are similar procedures in the idea and results.

The aging effect on upper airways collapse of patients with obstructive sleep apnea syndrome.

PURPOSE: To evaluate, using drug-induced sleep endoscopy (DISE), sites of upper airway obstruction and pattern of collapse in patients over 65 years old affected by obstructive sleep apnea. To compare sites and pattern of collapse of elderly patients with a group of patients younger than 65 years. METHODS: A group of 55 patients aged over 65 years were enrolled in this prospective study. Fifty patients under 65 years old were collected in the control group. Polysomnographic data and clinical parameters such as the daytime sleepiness, and body mass index were evaluated for both groups of patients. All patients underwent DISE examination with VOTE classification. RESULTS: The AHI value increased with aging whereas elderly patients presented a reduction in daytime sleepiness. Elderly patients showed a higher incidence of total collapse in the velum region compared to younger patients (90.9% vs 70%;); the older patients showed a lower degree of total oropharyngeal lateral wall collapse with respect to younger patients, (20% vs 50%). No difference in tongue base collapse emerged between the two subgroups of patients. CONCLUSION: Elderly patients showed a higher incidence of total collapse in the velum and a lower incidence in the oropharyngeal lateral wall compared to younger patients.

Medial patellotibial ligament and medial patellomeniscal ligament: anatomy, imaging, biomechanics, and clinical review.

PURPOSE: The purpose of this article is to review anatomical, biomechanical, and clinical data of the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML), as well as studies focusing on the medial patellofemoral ligament (MPFL) but with relevant data about the MPTL and MPML. METHODS: A literature search of articles specifically addressing the MPTL and/or MPML was included along with studies focusing on the MPFL but with relevant data about the MPTL and MPML. RESULTS: The medial patellar ligaments responsible for maintaining the stability of the patellofemoral (PF) joint include the MPFL, the MPTL, and the MPML. The MPFL is considered the primary restraint to lateral patellar translation, while the latter two are considered secondary restraints. There is robust literature on the anatomical, imaging, and biomechanical characteristics of the MPFL, and also the clinical outcome of its injury and surgical reconstruction; much less is known about the MPTL and MPML. Isolated MPFL reconstruction has good clinical and functional outcomes, with a low failure rate when defined as frank re-dislocation. Complications, including continued episodes of patellar apprehension and subluxation, remain present in most series. In addition, the current literature primarily includes a homogeneous population with few excessive anatomic dysplastic factors. There is lack of knowledge on the role of MPTL and MPML in (potentially) aiding patella stabilization and improving clinical outcomes. Understanding the role of the medial-sided patellar ligaments, in particular the role of the secondary stabilizers, in PF function and injury will aid in this goal. CONCLUSION: MPTL and MPML have consistent basic science literature, as well as favorable clinical outcomes of surgical patellar stabilization with reconstruction of the MPTL. However, there is much heterogeneity among clinical case series and lack of comparative studies to allow clear indication for the role of isolated or combined surgical reconstruction in patellar stabilization. Therefore, this comprehensive review helps understand the current knowledge and the possible applications in the orthopedic clinical practice. LEVEL OF EVIDENCE: V.