Unicompartmental osteoarthritis: High survival rate with a combined mechanical and biological salvage approach as alternative to metal resurfacing: Results at minimum 10 years of follow-up.

PURPOSE: The aim of this study was to prospectively evaluate the long-term clinical results and failure rate of patients treated with complex salvage procedures using a combined mechanical and biological approach to address unicompartmental knee osteoarthritis (OA) and postpone the need for joint replacement. METHODS: Thirty-nine patients (40.3 ± 10.9 years old) affected by unicompartmental OA (Kellgren-Lawrence 3) in stable joints underwent a personalized surgical treatment depending on the specific requirements of the affected compartment, including high tibial osteotomy, osteochondral scaffold, meniscal scaffold and meniscal allograft transplantation. Patients were evaluated with the International Knee Documentation Committee (IKDC), Visual Analogue Scale (VAS) and Tegner scores before surgery, at 3 years and a minimum of 10 years of follow-up. RESULTS: A significant improvement was observed over time in all scores but worsened at the final follow-up. The IKDC subjective score improved from 46.9 ± 16.2 to 79.8 ± 16.4 at 3 years (p < 0.0005) and then decreased to 64.5 ± 21.4 (p = 0.001) at 12 years. A similar trend was confirmed for VAS and Tegner scores. Only two patients subsequently underwent knee arthroplasty, and nine more patients were considered clinical failure, for a cumulative surgical and clinical failure rate of 28.2% at the final follow-up. CONCLUSION: A personalized, joint-preserving, combined mechanical and biological approach, addressing alignment as well as meniscal and cartilage lesions, is safe and effective, providing a clinical benefit and delaying the need for arthroplasty in young patients affected by unicompartmental knee OA. At the final evaluation, the clinical improvement decreased, but more than two-thirds of the patients still benefited from this treatment at a long-term follow-up. LEVEL OF EVIDENCE: Level IV case series.

Medial meniscal lesions increase antero-posterior laxity in knees with anterior cruciate ligament injury.

PURPOSE: The aim of this study was to quantify the impact of concomitant meniscal lesions on knee laxity using a triaxial accelerometer in a large population of patients affected by anterior cruciate ligament (ACL) injury. METHODS: A total of 326 consecutive patients (261 men and 65 women, mean age 31.3 ± 11.3) undergoing primary ACL reconstruction, were preoperatively evaluated through Lachman and pivot shift tests using a triaxial accelerometer to quantify knee laxity. An analysis based on the presence of meniscal tears assessed during surgery was performed to evaluate the impact of meniscal lesions on knee laxity. RESULTS: The anterior tibial translation (Lachman test) presented significantly higher values in patients with medial meniscal lesions (7.3 ± 1.7 mm, p = 0.049) and both medial and lateral meniscal lesions (7.7 ± 1.6 mm, p = 0.001) compared to patients without concomitant meniscal lesions (6.7 ± 1.3 mm). Moreover, patients with both medial and lateral meniscal lesions presented significantly higher values of anterior tibial translation compared to patients with lateral meniscal lesions (p = 0.049). No statistically significant differences were found between the groups in terms of tibial acceleration (pivot shift test). CONCLUSION: This study demonstrated that the contribution of concomitant meniscal lesions to knee laxity can be objectively quantified using a triaxial accelerometer in ACL-injured knees. In particular, medial meniscus lesions, alone or in association with lateral meniscus lesions, determine a significant increase of the anterior tibial translation compared to knees without meniscus tears. LEVEL OF EVIDENCE: Level IV.

Almost 79% survival rate at 10-year follow-up for the patellofemoral joint arthroplasty: An Italian prosthetic registry study.

PURPOSE: The aims of the present study were (1) to evaluate the survival of patellofemoral joint (PFJ) arthroplasty in a large cohort of patients using data obtained from an Italian regional arthroplasty registry and (2) to collect clinical outcomes of a subgroup of patients, with a minimum follow-up of 4 years. The hypotheses were that PFJ arthroplasty is a procedure that had good survival and clinical outcomes, not inferior to those reported in the literature for primary total knee arthroplasty (TKA). METHODS: The Register of Orthopaedic Prosthetic Implants (RIPO) of Emilia-Romagna (ER) (Italy) database was searched for the inclusion of all PFJ arthroplasties implanted between 2003 and 2019. PFJ arthroplasties were excluded if they were implanted in patients who lived outside of the ER. The survival information was extrapolated from the RIPO considering the partial or total revision of the implant as failure; moreover, a subgroup of patients was contacted and interviewed by telephone to collect clinical outcomes. Descriptive statistics were used to summarise the data. The survival curve was calculated and plotted using the Kaplan-Meier method. RESULTS: A total of 126 arthroplasties in 114 patients were included in the final analysis (mean age at surgery 60.1 ± 11.5 years old). The main causes of patellofemoral arthroplasty were primary osteoarthritis (88%) and posttraumatic arthritis (7%). The survival was 90.4 ± 30.6 and 78.8 ± 51.5 at 5 and 10 years of follow-up, respectively. At the latest follow-up, 23 implants failed (18.3%). The main cause of revision was osteoarthrosis progression (34.8%). A total of 44 patients were contacted by telephone to collect clinical outcomes: Western Ontario and McMaster Universities Osteoarthritis Index, functional Knee Society Score, Forgotten Joint Score and Oxford Knee Score. These patients reported good to excellent scores at a medium follow-up of 10.3 ± 4.7 years. CONCLUSIONS: The PFJ showed good survival and clinical outcomes and could be considered a valuable option for patients affected by isolated patellofemoral osteoarthritis. LEVEL OF EVIDENCE: Level IV.

Meniscal allograft transplantation: A matched-pair analysis reveals worse sport activity level but similar clinical improvement and survival in women compared to men.

PURPOSE: The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT). METHODS: A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside' stitches. RESULTS: Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscales and Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030), Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructions and a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score (p = 0.024) and Tegner score (p = 0.007) and a lower clinical survival rate (p = 0.03) (67.5% vs. 82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, age and concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences. CONCLUSION: While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesions and a lower activity level, all factors contributing towards a lower clinical success after MAT. LEVEL OF EVIDENCE: Level III, comparative study.

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.

Kinematics of 90° change of direction in young football players: Insights for ACL injury prevention from the CUTtheACL study on 6008 trials.

PURPOSE: To investigate the 90° change of direction (COD) task in an extensive cohort of competitive healthy football players within the CUTtheACL study and to provide normative values and differences between males and females for full-body kinematics based on two-dimensional (2D) video analysis and scoring system. METHODS: One-thousand-and-two competitive football (soccer) players (age 16.3 ± 2.8 years, 264 females) were prospectively enroled. Each player performed three preplanned 90° COD tasks per limb. The 2D evaluation was performed through objective measures (collected through three high-speed cameras) of frontal and sagittal plane joint kinematics at the cut initial foot contact (IC) and maximum knee flexion angle. A previously published scoring system was adopted to measure the movement quality of the COD task. The scoring system included five criteria (limb stability [LS], pelvis stability [PS], trunk stability [TS], shock absorption [SA], movement strategy [MS]) ranked from 0/2 (nonadequate) to 2/2 (adequate) with a maximum score of 10/10. Normative data were provided for all the variables; statistical differences between male and female players were investigated (p < 0.05). RESULTS: A total of 6008 valid attempts were included. Frontal plane knee projection angle (FPKPA) at initial contact was 24.4 ± 9.8° (95th percentile: FPKPA > 40°). The total score was ≤4/10 in 71.2% of the trials, the lowest subscores were LS and PS. Female players showed different movement patterns with lower hip and trunk flexion both at IC and maximum knee flexion angle (p < 0.01, ES = 0.41-0.64). Female players also showed worse scores than males in SA, MS and total score (p < 0.01). CONCLUSION: Female players seem more prone to stiffer lower limb strategy and greater pelvis-trunk frontal plane instability than males. Clinicians could adopt normative data and sex-specific differences in players' movement techniques to improve ACL injury risk mitigation protocols. LEVEL OF EVIDENCE: Level IV.

High survivorship rate and good clinical outcomes after high tibial osteotomy in patients with radiological advanced medial knee osteoarthritis: a systematic review.

INTRODUCTION: The role of valgus producing high tibial osteotomy (HTO) for the treatment of advanced knee osteoarthritis (OA) is still controversial. The aim of the current systematic review was to assess survivorship and patient-reported outcomes (PROMs) of high tibial osteotomy in patients with radiological advanced medial knee OA. METHODS: A systematic search of PubMed, Cochrane and EMBASE database was performed in July 2023 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. Inclusion and exclusion criteria were applied to identify studies investigating the survivorship rate and PROMs of valgus-producing high tibial osteotomy in patients with advanced knee OA at x-ray assessment in the medial compartment at minimum-two-years follow up. Advanced radiological OA was defined as Kellgren Lawrence (K-L) ≥ 3 or Ahlbäch ≥ 2. Survivorship was defined as percentage of patients free of total knee arthroplasty (TKA) at follow-up. Clinical interpretation of provided PROMs were performed according to minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) target values reported in literature. Survivorship data and PROMs scores were extracted, and studies were stratified based on selected study features. The quality of included studies was assessed with modified Coleman score. RESULTS: A total of 18 studies, totalling 1296 knees with a mean age between 46.9 and 67 years old, were included. Average survivorship was of 74.6% (range 60 - 98.1%) at 10-years follow up. The subjective scoring systems showed good results according to MCID and PASS, and postoperative improvements were partially maintained until final follow-up. CONCLUSION: HTO is worth considering as treatment choice even in patients affected by radiological advanced medial knee osteoarthritis. Long term survivorship and good patient reported clinical outcomes could be expected in this population. LEVEL OF EVIDENCE: IV; systematic review of level III-IV studies.

3D visualization of the human anterior cruciate ligament combining micro-CT and histological analysis.

PURPOSE: The study aimed to obtain a comprehensive 3D visualization of knee specimens, including the cruciate ligaments and corresponding femoral and tibial bone insertions using a non-destructive micro-CT method. METHODS: Knee specimens were fixed in anatomical positions and chemically dehydrated before being scanned using micro-CT with a voxel size of 17.5 µm. RGBA (red, green, blue, alpha) transfer functions were applied to virtually colorize each structure. Following micro-CT scanning, the samples were rehydrated, decalcified, and trimmed based on micro-CT 3D reconstructions as references. Histological evaluations were performed on the trimmed samples. Histological and micro-CT images were registered to morphologically and densitometrically assess the 4-layer insertion of the ACL into the bone. RESULTS: The output of the micro-CT images of the knee in extension and flexion allowed a clear differentiation of the morphologies of both soft and hard tissues, such as the ACL, femoral and tibial bones, and cartilage, and the subsequent creation of 3D composite models useful for accurately tracing the entire morphology of the ligament, including its fiber and bundle components, the trajectory between the femur and tibia, and the size, extension, and morphology of its insertions into the bones. CONCLUSION: The implementation of the non-destructive micro-CT method allowed complete visualization of all the different components of the knee specimens. This allowed correlative imaging by micro-CT and histology, accurate planning of histological sections, and virtual anatomical and microstructural analysis. The micro-CT approach provided an unprecedented 3D level of detail, offering a viable means to study ACL anatomy.

High promiscuity among females of the invasive pest species Drosophila suzukii.

Drosophila suzukii (Matsumura, 1931), the spotted-wing drosophila, is a highly invasive fruit fly that spread from Southern Asia across most regions of Asia and, in the last 15 years, has invaded Europe and the Americas. It is an economically important pest of small fruits such as berries and stone fruits. Drosophila suzukii speciated by adapting to cooler, mountainous, and forest environments. In temperate regions, it evolved seasonal polyphenism traits which enhanced its survival during stressful winter population bottlenecks. Consequently, in these temperate regions, the populations undergo seasonal reproductive dynamics. Despite its economic importance, no data are available on the behavioural reproductive strategies of this fly. The presence of polyandry, for example, has not been determined despite the important role it might play in the reproductive dynamics of populations. We explored the presence of polyandry in an established population in Trentino, a region in northern Italy. In this area, D. suzukii overcomes the winter bottleneck and undergoes a seasonal reproductive fluctuation. We observed a high remating frequency in females during the late spring demographic explosion that led to the abundant summer population. The presence of a high degree of polyandry and shared paternity associated with the post-winter population increase raises the question of the possible evolutionary adaptive role of this reproductive behaviour in D. suzukii.

Identifying patient subgroups with different trends of patient-reported outcomes (PROMs) after elective knee arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly being used to assess the effectiveness of elective total knee arthroplasty (TKA). However, little is known about how PROMs scores change over time in these patients. The aim of this study was to identify the trajectories of quality of life and joint functioning, and their associated demographic and clinical features in patients undergoing elective TKA. METHODS: A prospective, cohort study was conducted, in which PROMs questionnaires (Euro Quality 5 Dimensions 3L, EQ-5D-3L, and Knee injury and Osteoarthritis Outcome Score Patient Satisfaction, KOOS-PS) were administered to patients at a single center undergoing elective TKA before surgery, and at 6 and 12 months after surgery. Latent class growth mixture models were used to analyze the patterns of change in PROMs scores over time. Multinomial logistic regression was used to investigate the association between patient characteristics and PROMs trajectories. RESULTS: A total of 564 patients were included in the study. The analysis highlighted differential patterns of improvement after TKA. Three distinct PROMs trajectories were identified for each PROMs questionnaire, with one trajectory indicating the most favorable outcome. Female gender appears to be associated with a presentation to surgery with worse perceived quality of life and joint function than males, but also more rapid improvement after surgery. Having an ASA score greater than 3 is instead associated with a worse functional recovery after TKA. CONCLUSION: The results suggest three main PROMs trajectories in patients undergoing elective TKA. Most patients reported improved quality of life and joint functioning at 6 months, which then stabilized. However, other subgroups showed more varied trajectories. Further research is needed to confirm these findings and to explore the potential clinical implications of these results.

Double-bundle non-anatomic ACL revision reconstruction with allograft resulted in a low revision rate at 10 years.

PURPOSE: This study aimed at reporting the long-term second revision rate and subjective clinical outcomes from a cohort of patients who underwent a double-bundle (DB) ACLR first revision with allograft at a single institution. METHODS: The Institutional database was searched according to the following inclusion criteria: (1) patients that underwent DB-ACL first revision with Achilles tendon allograft, (2) surgery performed between January 2000 and December 2012, (3) age at revision ≥ 18 y/o. Patients' general information, history, surgical data, and personal contacts were extracted from charts. An online survey platform was implemented to collect responses via email. The survey questions included: date of surgeries, surgical data, date of graft failure and subsequent second ACL revision surgery, any other surgery of the index knee, contralateral ACLR, KOOS score, and Tegner scores. RESULTS: Eighty-one patients were included in the survival analysis, mean age at revision 32 ± 9.2 y/o, 71 males, mean BMI 24.7 ± 2.7, mean time from ACL to revision 6.8 ± 5.4 years, mean follow-up time 10.7 ± 1.4 years. There were 12 (15%) second ACL revisions during the follow-up period, three females and nine males, at a mean of 4.5 ± 3 years after the index surgery. The overall survival rates were 85% from a second ACL revision and 68% from all reoperations of the index knee. Considering only the successful procedures (61 patients), at final follow-up, the mean values for the KOOS subscales were 84 ± 15.5 for Pain, 88.1 ± 13.6 for Symptoms, 93 ± 11.6 for ADL, 75 ± 24.5 for Sport, and 71 ± 19.6 for Qol. Twenty-nine (48%) patients performed sports activity at the same level as before ACLR failure. CONCLUSIONS: Double-bundle ACL revision with fresh-frozen Achilles allograft yields satisfactory results at long-term follow-up, with an 85% survival rate from a second ACL revision at mean 10 years' follow-up and good patient-reported clinical scores. LEVEL OF EVIDENCE: Level IV.

International cooperation needed to improve national anterior cruciate ligament registries.

PURPOSE: The aim of this study is to illustrate an overview of the registries currently operative in many countries to support the introduction of new prospective registries in other countries. METHODS: The authors carried out a systematic web research in July 2021 to identify national ACL registries' annual reports and scientific literature on national ACL registries. The latest annual public registry reports were collected and analyzed in this study. RESULTS: There are currently established national ACL registries in Norway, Denmark, Sweden, Luxembourg, New Zealand, the United Kingdom (UK), and the Kaiser Permanente National Anterior Cruciate Ligament Reconstruction Registry in the United States (US). Some differences can be found among the various registries due to the local healthcare system structure, data management rules, and general national laws. CONCLUSION: It is possible to develop accessible, cost-effective and entirely web-based ACL registries-as demonstrated by the Danish and Swedish registries-respecting the national legislation of different countries. This study supports the introduction of new ACL prospective registries in other countries to obtain valuable information for implementing daily clinical practice. LEVEL OF EVIDENCE: IV.

The injury mechanism correlation between MRI and video-analysis in professional football players with an acute ACL knee injury reveals consistent bone bruise patterns.

PURPOSE: To analyze the MRI features, in particular bone bruises pattern, of Anterior Cruciate Ligament (ACL) injured footballers, and to correlate them with the characteristics of injury mechanism and situation obtained from direct video footage. METHODS: Nineteen professional football (soccer) players that sustained ACL injury while playing during an official match of First League Championship were included in the study. The video of injury was obtained from the Television broadcast. Knee Magnetic Resonance (MRI) was obtained within 7 days from the injury. BB and meniscal lesions were analyzed on MRI, while a video-analysis of mechanisms of ACL injury and injury dynamic were assessed from the videos. RESULTS: The most commonly involved Bone Bruise areas in the knee were the Posterior Lateral Tibial Plateau (LTp) in 16 cases (84%) and the Central Lateral Femoral Condyle (LFc) in 11 cases (58%). Three patients (16%) had bone bruise in the Posterior Medial Tibial Plateau (MTp) while none (0%) had bone bruise in the Medial Femoral Condyle. Based on the bone bruise pattern, 11 (58%) had simultaneous LFc and LTp and were defined "Typical" while 8 (42%) had other locations or no bone bruise and were defined "Atypical". 9 out of 11 injuries (82%) of athletes with "Typical" pattern occurred with a "Pivoting" action", in contrast to only 1 case (12%) in those with "Atypical" bone bruise pattern (p = 0.0055). The most common situational mechanism pattern on video analysis was "pressing" (n = 7) accounting for the 47% of the "indirect" ACL injuries. In terms of movement pattern, ten injuries (52%) occurred during a "Pivoting" movement (7 pressing, 1 dribbling, 1 tackled, 1 goalkeeping), whereas the remaining were classified as "Planting" in four cases, "Direct Blow" in four cases and "Landing". CONCLUSION: A well-defined and consistent bone bruise pattern involving the posterior tibial plateau and central femoral condyle of lateral compartment is present in footballers that sustained non-contact and indirect ACL injuries during pivoting with sudden change of direction/deceleration, while heterogeneous patterns were present in those with direct contact or injury mechanisms involving high horizontal velocity. LEVEL OF EVIDENCE: Level IV.

Good long-term patients reported outcomes, return-to-work and return-to-sport rate and survivorship after posterior cruciate ligament (PCL)-based multiligament knee injuries (MLKI) with posteromedial corner tears as significant risk factor for failure.

PURPOSE: To assess the survival rate and associated risk factors of a wide cohort of patient's underwent surgical treatment for posterior cruciate ligament (PCL)-based multiligament knee injury (MLKI) at long-term follow-up and to investigate the long-term patient's reported outcomes (PROMS) and functional activity. METHODS: All cases of PCL-based MLKI performed at one single sport-medicine institution were extracted and patient's with a minimum 2 years of follow-up included. VAS, Lysholm, KOOS, Tegner Activity level scores, the incidence and time of return to sport (RTS) and return to work (RTW) were collected before, after surgery and at final follow-up. A multivariate logistic regression was performed to investigate the outcomes associated with the patient's acceptable symptoms state (PASS) for each sub-score of the KOOS. The Kaplan-Meier method with surgical failure (re-operation to one of the reconstructed ligaments) as endpoint was used to perform the survivorship analysis for the entire cohort. RESULTS: Forty-two patients were included and evaluated at an average of 10 years. All PROMS significantly improved from pre- to post-surgery (range ηp2 0.21-0.43, p < 0.05) except for the Tegner score which significantly improved from pre-surgery and to final follow-up (ηp2 = 0.67, p < 0.001). RTW was achieved in the 95.2% after 2.4 ± 1.9 months. RTS was achieved in 78.6% after 6.7 ± 5.0 months. The higher number of surgeries were the significant negative predictors of PASS for the KOOS sub-scales Sport (p = 0.040) and Quality of Life (p = 0.046), while the presence of meniscal lesions was a significant negative predictor of PASS only for the KOOS sub-scale of Sport (p = 0.003). Six patients (14.3%) underwent reoperation and were considered as surgical failures. The global survivorship was 95.2%, 92.6%, 87.1%, and 74.7% at 2, 5, 12, and 15 years, respectively. The survivorship in patient undergoing PMC reconstruction surgery was significantly lower (p = 0.004; HR 7.1) compared to patients without a PMC lesion. CONCLUSION: Good-to-excellent PROMS could be obtained and maintained at long-term follow-up after surgery, with the higher number of surgeries and meniscal lesions as significant negative predictors of the PASS. Moreover, the presence of a PMC lesion significantly increases the risk of the PCL reconstruction failure. LEVEL OF EVIDENCE: III.

Satisfactory long-term outcomes for combined anterior cruciate ligament reconstruction and lateral closing wedge high tibial osteotomy.

PURPOSE: A combined anterior cruciate ligament (ACL) reconstruction and high tibial osteotomy (HTO) is considered a valuable treatment in young patients affected by symptomatic medial osteoarthritis and ACL deficiency. However, only a few studies have investigated the outcomes of this procedure, especially in the long term. Therefore, the aim of this study is to report clinical and radiographic outcomes of ACL reconstruction and lateral closing wedge HTO at a mean of 14 years of follow-up. METHODS: Patients were prospectively evaluated pre-operatively, after 6.5 ± 2.7 years and 14.3 ± 2.2 years. Patient-reported outcome measures (PROMs) were collected, knee laxity was assessed through KT-1000 arthrometer, and limb alignment and knee osteoarthritis were evaluated on long-cassette radiographs. Survivorship of the surgical procedure was calculated through the Kaplan-Meier method. RESULTS: 32 patients were initially enrolled and completed the mid-term evaluation (6.5 ± 2.7 years), and 23 patients (72%) were available for the final evaluation at 14.3 ± 2.2 years after surgery. Statistically significant improvement was found for all the clinical scores (VAS, WOMAC, Tegner, subjective IKDC, objective IKDC) between the pre-operative status and the mid-term follow-up (p < .001). VAS, subjective IKDC and objective IKDC showed no statistically significant differences (p > .05) between the mid-term and the final follow-up; a significant decrease of WOMAC (p < .05) and Tegner (p < .001) was found from mid-term to final follow-up. Significant progression of osteoarthritis was found for all the knee compartments. The survivorship was 95.7% at 5 years, 82.6% at 10 years, and 72.8% at 15 years. CONCLUSIONS: Combined ACL reconstruction and lateral closing wedge HTO showed satisfactory clinical outcomes and survivorship at a mean of 14 years follow-up. LEVEL OF EVIDENCE: IV.

Good stability and mid-term subjective outcomes after repeated anterior cruciate ligament (ACL) revision surgery using allografts.

PURPOSE: To evaluate the mid-term clinical outcomes of a cohort of patients who underwent multiple ACL revision reconstructions. The hypothesis was that patients with pre-existing meniscal deficiency conditions, malalignment and cartilage degeneration would have obtained lower results. METHODS: All cases of multiple ACL revisions performed with allograft tissue at one single sport-medicine institution were extracted and patients with a minimum 2 years of follow-up were included. WOMAC, Lhysolm, IKDC, and Tegner activity level before the injury and at last follow-up was collected and laxity evaluated with KT-1000 arthrometer and KiRA triaxial accelerometer. RESULTS: From a cohort of 241 ACL revisions, 28 patients (12%) with Repeated ACL Revision reconstructions were included. Fourteen cases (50%) were considered "Complex" due to the addition of meniscal allograft transplantation (8) or meniscal scaffold (3) or high tibial osteotomy (3). The remaining 14 cases (50%) were considered as "Isolate". The mean WOMAC score was 84.6 ± 11.4, Lysholm 81.7 ± 12.3, subjective IKDC 77.2 ± 12.1, and median Tegner score 6 (IQR 5-6) at pre-injury and at final follow-up. Statistically significant inferior values of WOMAC (p = 0.008), Lysholm (p = 0.02) and Subjective IKDC (p = 0.0193) were detected between "Complex" and "Isolate" revision groups. Higher average values of anterior translation at KT-1000 at both 125 N (p = 0.03) and manual maximum displacement test (p = 0.03) were reported in "Complex" with respect to "Isolate" revisions. Four patients were considered as failures and occurred in patients with "Complex" revisions, none occurred in the "Isolate" (30% vs 0%; p = 0.04). CONCLUSION: Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients who experienced multiple failures; however, those who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results. LEVEL OF EVIDENCE: III.

No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis.

PURPOSE: The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft. METHODS: A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score. RESULTS: Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052). CONCLUSION: The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction. LEVEL OF EVIDENCE: Level IV.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision. METHODS: The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document. RESULTS: The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below. CONCLUSION: ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance. LEVEL OF EVIDENCE: II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision. METHODS: Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document. RESULTS: The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article. CONCLUSION: ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults. LEVEL OF EVIDENCE: Level II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method.

PURPOSE: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). METHODS: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate'). RESULTS: The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). CONCLUSION: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. LEVEL OF EVIDENCE: II.