Clinical Outcomes After Polyurethane Meniscal Scaffolds Implantation Remain Stable Despite a Joint Space Narrowing at 10-Year Follow-Up.

PURPOSE: To report the clinical outcomes, radiologic evolution, and survivorship of a series of patients affected by the postmeniscectomy syndrome and treated with a polyurethane scaffold at a minimum 10-year follow-up. In addition, the radiologic evolution of these patients was also assessed. METHODS: All the patients operated on with a polyurethane meniscal scaffold implantation to treat postmeniscectomy syndrome from 2008 to 2011 were prospectively followed. Clinical evaluations and radiologic studies were assessed at the preoperative period, at 5-year follow-up, and at minimum 10-year follow-up. Clinical outcomes were based on patient-reported outcomes (e.g., the Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm, and Tegner). Radiographical evaluation of the joint-space narrowing was done in the Rosenberg view. Failure was defined as patients who required surgery to remove the scaffold or those patients who needed surgery for a total or partial knee replacement. RESULTS: Twenty-one of 27 patients, with a mean age of 56 ± 9.8 years, were available for the final follow-up. The mean follow-up was 11.8 (range, 10-12.7) years. Six patients were lost to follow-up. All functional scores showed a significant improvement (P < .001) at the 5- and 10-year follow-up. The exception was the Tegner score, which remained stable. The joint-space width was maintained from the preoperative period (1.9 ± 1.2 mm) up to the 5-year follow-up (1.3 ± 1.5 mm, P = .3) and decreased by the last evaluation (0.6 ± 1.2 mm, P = .001) at the last follow-up. Two (9.5%) of 21 patients were converted to a total knee replacement during the study period. None of the other patients needed revision surgery during the study period. CONCLUSIONS: The polyurethane meniscal scaffold provides significant and stable pain relief over time and improved functional outcomes at a minimum of 10 years after surgery. However, degenerative changes progressed in the treated compartment, with a joint-space narrowing over the 10-year period. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The distal tibiofibular syndesmosis is a reliable landmark for 3° varus tibial resection in total knee arthroplasty: a radiological evaluation on 1296 cases.

PURPOSE: The purpose of this study was to evaluate the reproducibility and the accuracy of distal tibiofibular syndesmosis (DTFS) as landmark to perform controlled varus tibial resections during total knee arthroplasty (TKA). The hypothesis was that DTFS can be used to perform an accurate 3° varus tibial cut. METHODS: A retrospective analysis on a consecutive series of standard weightbearing full-length anteroposterior views of the lower limbs radiographic images was conducted. For each radiograph, the hip-knee-ankle (HKA) angle, the angle between the tibial mechanical axis and the line connecting the centre of the tibial spines and the DTFS (tibiofibular angle, TFA) and the medial proximal tibial angle (MPTA) were calculated. Each measurement was carried out twice by three independent observers, and intra- and inter-observer measurement reliability were assessed using the intraclass correlation coefficient (ICC) analysis. RESULTS: A total of 1296 lower limbs were analysed from a series of 648 weightbearing full-length anteroposterior radiographs. The ICC were > 90% for all measurements. The mean TFA value was 2.94 ± 0.68 (range 2.38-3.51). No differences were detected comparing the mean TFA value on the right and left limb (p = 0.795) as well as comparing the values in male and female patients (p = 0.691). Linear regression analysis did not find statistically significant correlation between TFA and MPTA, or TFA and HKA angles, respectively. CONCLUSION: The distal tibiofibular syndesmosis is a reliable and easy reproducible radiographic landmark that can be used when planning a 3° varus tibial cut. Future studies are needed to confirm the validity of this method also in clinical settings. LEVEL OF EVIDENCE: IV, retrospective case series.

Good clinical outcomes can be expected after meniscal allograft transplantation at 15 years of follow-up.

PURPOSE: The aim of this study was to evaluate graft survivorship and report the functional and radiographic results of Meniscal allograft transplantation (MAT) throughout a minimum 15-year follow-up period. METHODS: Fifty-one patients that had undergone an isolated MAT procedure during the period studied were included. The results were assessed with the Lysholm and Tegner scores as well as the Visual Analog Scale. Magnetic resonance imaging and a complete radiographic series were carried out to determine the degree of meniscal extrusion and joint space narrowing. A comparison was made between the radiological findings of the last follow-up, the 5-year mid-term follow-up and those from the preoperative period. RESULTS: Thirty-eight patients were available for the final follow-up. The mean follow-up was 17.4 years. There were 23 (60.5%) medial menisci and 15 lateral menisci (39.4%). Meniscal extrusion increased from the 29.7% ± 14.9 obtained at the 5-year follow-up to the 72.5% ± 22.5 seen at the end of the follow-up (p = 0.0001). The joint space distance was almost unchanged from the initial evaluation (3.3 ± 1.5 mm) to the 5-year follow-up measurement (3.1 ± 1.7 mm, n.s.). However, it did decrease at the last follow-up (1.9 ± 1.5 mm, p < 0.05). The functional outcomes improved from the preoperative period to the mid-term follow-up and later worsened at the final follow-up. The mean preoperative Lysholm score at the initial follow-up was 61.5 ± 9.6, 86.9 ± 10.9 for the 5-year evaluation and stood at 77.4 ± 11.5 (p = 0.0001) at the final follow-up. Regarding the Tegner score, those pre-operative scores were compared to the ones at the last follow-up (median: 3; range 0-6 vs. 5.5; 3-6, respectively; p = 0.0001). The VAS went down from 6.6 ± 1.7 at the initial evaluation to 2.5 ± 1.9 at the final follow-up (p = 0.0001). The joint-space width remained unchanged from the initial evaluation (3.35 ± 1.5 mm) up to the 5-year follow-up measurement (3.1 ± 1.7 mm, n.s.). However, this joint-space distance had decreased by the last evaluation in the long-term follow-up (1.9 ± 1.4 mm, p < 0.05). Five patients (13.1%) presented with a MAT failure at 5 years, which was followed by extirpation of the meniscal graft. At the final follow-up, a total of 16 patients (42.1%) presented with a failure. At that time, there were 4 more MAT removals and seven patients that required a total knee replacement. The mean time to failure of the meniscal graft was 206.2 months ± 13.4 (18.0 years). CONCLUSIONS: Meniscal allograft transplantation produces good functional results at a minimum 15-year follow-up. However, degenerative arthritis in the affected compartment progressed during that period. LEVEL OF EVIDENCE: III.

Systematic lateral retinacular release does not reduce anterior knee pain after total knee arthroplasty with patellar resurfacing.

PURPOSE: The aim of this study was to assess the effect of systematic lateral retinacular release (LRR) on anterior knee pain (AKP), as well as its impact on the functional and radiological outcomes after total knee arthroplasty (TKA) with patellar resurfacing. METHODS: A prospective randomized study was designed. It included patients scheduled for a TKA procedure with patellar resurfacing, who were recruited and randomized into either the LRR group or the non-release group. 198 patients were included in the final analysis. The pressure pain threshold (PPT) assessed by pressure algometry (PA), the visual analogue scale (VAS), Feller's patellar score, the Knee Society Score (KSS), patellar height, and patellar tilt were recorded both preoperatively and at the 1-year follow-up. The Mann-Whitney U test was performed to determine comparisons between both groups as well as to determine differences' intragroup. RESULTS: Relative to the clinical variables and scores, no difference was detected between the two groups at the 1-year follow-up (p = n.s.). However, there was a slight difference in patellar tilt (0.1º vs. 1.4º, p = 0.044), with higher tilt values in the non-release group. There was no difference in terms of improvement in the clinical and radiological scores and variables recorded between the two groups (p = n.s.). CONCLUSION: LRR in primary TKA with patellar resurfacing does not show an improvement in AKP and functional outcomes over patellar resurfacing without release. LEVEL OF EVIDENCE: I.

Isolated lateral extra-articular tenodesis in ACL-deficient knees: in vivo knee kinematics and clinical outcomes.

PURPOSE: To carry out an in vivo kinematic analysis of isolated modified Lemaire lateral extra-articular tenodesis (LET) to explore its ability to modify the stability of anterior cruciate ligament (ACL) deficient knees. The secondary aim was to look at the clinical outcomes of the isolated LET to analyze whether biomechanical changes have an influence on clinical improvement or not. METHODS: A total of 52 patients who underwent an isolated modified Lemaire LET were prospectively studied. Twenty-two were over 55-year-old patients with ACL rupture and subjective instability (group 1). They were followed up for 2 years postoperatively. Thirty were patients underwent a two-stage ACL revision (group 2). They were followed up for 4 months postoperatively (up to the second stage of the ACL revision). Preoperative, intraoperative, and postoperative kinematic analyses were carried out using the KiRA accelerometer and KT1000 arthrometer to look for residual anterolateral rotational instability and residual anteroposterior instability. Functional outcomes were measured with the single-leg vertical jump test (SLVJT) and the single-leg hop test (SLHT). Clinical outcomes were evaluated using the IKDC 2000, Lysholm, and Tegner scores. RESULTS: A significant reduction of both rotational and anteroposterior instability was detected. It was present both with the patient under anesthesia (p < 0.001 and p = 0.007 respectively) as well as with the patient awake (p = 0.008 and p = 0.018 respectively). Postoperative analysis of knee laxity did not show any significant variation from the first to the last follow-up. Both the SLVJT and SLHT improved significantly at the last follow-up (p < 0.001 and p = 0.011 respectively). The mean values of both the IKDC and Lysholm and Tegner scores showed an improvement (p = 0.008; p = 0.012; p < 0.001). CONCLUSION: The modified Lemaire LET improves the kinematics of ACL-deficient knees. The improvement in the kinematics leads to an improvement in subjective stability as well as in the function of the knee and in the clinical outcomes. At the 2-year follow-up, these improvements were maintained in a cohort of patients over 55 years. Following our findings, to reduce knee instability, an isolated LET in ACL-deficient knees may be used when ACL reconstruction in patients over 55 years is not indicated. LEVEL OF EVIDENCE: Level IV.

Lateral extraarticular tenodesis improves stability in non-anatomic ACL reconstructed knees: in vivo kinematic analysis.

PURPOSE: To carry out an in vivo kinematic analysis to determine whether adding a lateral extraarticular tenodesis (LET) for those patients with subjective instability and objective residual laxity after a transtibial (TT) anterior cruciate ligament reconstruction (ACLR) reduces anteroposterior and rotational laxity and to evaluate the 2-year follow-up clinical outcomes to analyze whether biomechanical changes determine clinical improvement or not. METHODS: A total of 19 patients with residual knee instability after TT ACLR who underwent a modified Lemaire LET were prospectively evaluated for at least 2-year follow-up. Preoperative, intraoperative, and 6 and 24-month postoperative kinematic analyses were carried out using the KiRA accelerometer and KT1000 arthrometer to look for residual anterolateral rotational instability and residual anteroposterior instability. Functional outcomes were measured with the single-leg vertical jump test and the single-leg hop test. Clinical outcomes were evaluated using the IKDC 2000, Lysholm, and Tegner scores. RESULTS: A significant reduction in anterolateral rotational instability was detected with the patient under anesthesia (from 3 ± 1.2 to 1.1 ± 1.1 m/s2; p < 0.05) as well as with the patient awake (from 2.1 ± 0.8 to 0.7 ± 1.4 m/s2; p < 0.05). A significant reduction in anteroposterior instability was only present under anesthesia (from 3.4 ± 1.9 to 2.1 ± 1.1 mm; p < 0.05), while no difference was present without anesthesia (from 2.3 ± 1.1 to 1.6 ± 1 mm; n.s.). Postoperative analysis of knee laxity did not show any significant variation from the first to the last follow-up. Both the single-leg vertical jump test and single-leg hop test improved significantly at the last follow-up (both p < 0.05). The mean values of both the IKDC and Tegner scores showed an improvement (p < 0.05 and p < 0.05, respectively), whereas that was not the case with the Lysholm score (n.s.). CONCLUSIONS: The modified Lemaire LET can improve the kinematics of a non-anatomic ACL reconstructed knee with residual subjective and objective instability. These kinematic changes were able to lead to an improvement in subjective stability as well as the function of the knee in a small cohort of recreationally active patients. At 2-year follow-up, the kinematic changes as well as the level of activity of the patients and the IKDC score show their improvement sustained. LEVEL OF EVIDENCE: Level IV.

The morphology of the femoral footprint of the anterior cruciate ligament changes with aging from a large semicircular shape to a small flat ribbon-like shape.

PURPOSE: Compare the differences in the morphology of the ACL femoral footprint between the cadavers of the young and elderly in consideration of the degenerative physiological process that occurs with aging. METHODS: The femoral footprint of the ACL was dissected in 81 knees of known gender and age (45 male/36 female). They were divided into four groups by age and gender, establishing 50 years as the cut-off point to divide patients by age. Three observers analyzed the femoral footprint dissections, and the shapes were described and classified. The area and morphometric characteristics of the femoral insertion of the ACL were determined and these were compared between genders and age groups. RESULTS: The femoral footprint of the ACL from the cadavers of males younger than 50 years of age presented a semicircular morphology in 90% of the cases. In males aged more than 50 years, a ribbon-like morphology was found in 96% of the cases. In women less than 50 years old, the semicircular morphology was observed in 93.7% of the cases. In women aged over 50 years old, the ribbon-like morphology was found in 95% of the cases. A significant difference was observed between the prevalence rates of the morphologies, area size and measurements of the younger and older groups (p < 0.001 for both genders). CONCLUSIONS: The femoral insertion of the ACL presents variations in its morphology, area and morphometric characteristics over time. It goes from a large semicircular shape that almost contacts the posterior articular cartilage to a smaller, flattened ribbon-like shape that moves away from the edge of the articular cartilage. It is bounded anteriorly by the lateral intercondylar ridge. These findings should be considered to avoid employing reconstruction techniques in which femoral tunnels with oval or rectangular shapes are used in patients under 50 years of age because they do not correspond to the morphology of the femoral insertion of the ACL in this age group.

Fixed-bearing unicompartmental knee arthroplasty provides a lower failure rate than mobile-bearing unicompartimental knee arthroplasty when used after a failed high tibial osteotomy: a systematic review and meta-analysis.

Despite the fact that the choice of bearing design has been thought to influence the functional outcomes and longevity of unicompartimental knee arthroplasty (UKA), there is a lack of clinical evidence supporting the decision-making process in patients who have undergone high tibial osteotomy (HTO). A systematic review of studies was carried out that reported the outcomes of fixed-bearing (FB) or mobile-bearing (MB) medial UKA in patients with a previous HTO. A random effect meta-analysis using a generalized linear mixed-effects model to calculate revision rates was done. Seven retrospective cohort studies were included for this study. Regarding the fixation method, 40 were the FB-UKA and 47 were MB-UKA. For both groups, the mean post-operative follow-up was 5.8 years. The survival rates were 92% for the FB-UKA with a mean follow-up of 10 years. For the MB-UKA, it ranged from 35.7 to 93%, with a mean follow-up of 4.2 years. For the FB, the time to revision was reported as 9.3 years, while 1.2, 2.5 and 2.91 years was reported for the MB. The results of the meta-analysis showed that the revision rate for the patients receiving a FB-UKA after failed HTO was 8%, compared to 17% in those who received an MB-UKA. The results of the review suggest that the use of the FB-UKA is associated with lower revision rates and a longer survival time than the MB-UKA and have similar functional ability scores.Level of evidence: III (systematic review of level-III studies).

MRI evaluation of the peripheral attachments of the lateral meniscal body: the menisco-tibio-popliteus-fibular complex.

PURPOSE: To determine, identify and measure the structures of the menisco-tibio-popliteus-fibular complex (MTPFC) with magnetic resonance imaging (MRI) in knees without structural abnormalities or a history of knee surgery. METHODS: One-hundred-and-five knees without prior injury or antecedent surgery were analyzed by means of MRI. The average age was 50.1 years ± 14.8. All the measurements were performed by three observers. The peripherical structures of the lateral meniscus body were identified to determine the location, size, and thickness of the entire MTPFC. The distance to other "key areas" in the lateral compartment was also studied and compared by gender and age. RESULTS: The lateral meniscotibial ligament (LMTL) was found in 97.1% of the MRIs, the popliteofibular ligament (PFL) in 93.3%, the popliteomeniscal ligaments (PML) in 90.4% and the meniscofibular ligament (MFL) in 39%. The anteroposterior distance of the LMTL in an axial view was 20.7 mm ± 3.9, the anterior thickness of the LMTL was 1.1 mm ± 0.3, and the posterior thickness of the LMTL 1.2 mm ± 0.1 and the height in a coronal view was 10.8 mm ± 1.9. The length of the PFL in a coronal view was 8.7 mm ± 2.5, the thickness was 1.4 mm ± 0.4 and the width in an axial view was 7.8 mm ± 2.2. CONCLUSIONS: The MTPFC has a constant morphological and anatomical pattern for three of its main ligaments and can be easily identified and measured in an MRI; the MFL has a lower prevalence, considering a structure difficult to identify by 1.5 T MRI.

Isolated reconstruction of medial patellofemoral ligament with an elastic femoral fixation leads to excellent clinical results.

PURPOSE: The primary objective was to compare the functional outcomes after an isolated MPFL reconstruction using either a quasi-anatomical technique (group A) or an anatomical MPFL reconstruction (group B). The secondary objectives were to compare the rates of redislocation, range-of-motion and subjective patellar instability (Smillie test). METHODS: A multicenter longitudinal prospective comparative study was performed. Group A had 29 patients and 28 were included in Group B. Patients with trochlear dysplasia types C and D and patients who had undergone a trochleoplasty, a distal realignment or patella distalization concurrently with MPFL reconstruction were excluded. The main evaluation criterion was the Kujala functional score. RESULTS: The mean postoperative Kujala was 90.4 (89.4 in group A and 92.1 in group B). Upon comparing the mean difference between pre- and post-operative values, no differences were detected between the two groups (n.s). CONCLUSIONS: Isolated quasi-anatomical MPFL reconstruction using a gracilis tendon autograft for recurrent patellar dislocation provides outcomes as good as the isolated anatomical MPFL reconstruction in patients with no trochlear dysplasia up to those with trochlear dysplasia type A and B at the 2-5 years follow-up. LEVEL OF EVIDENCE: Level IV.

The morphology of the tibial footprint of the anterior cruciate ligament changes with ageing from oval/elliptical to C-shaped.

PURPOSE: To further the current understanding of the modifications of the morphology of the ACL tibial footprint in healthy knees during the ageing process. The hypothesis is that there are differences in the morphology of the ACL tibial footprint between the cadavers of the young and elderly due to a degenerative physiological process that occurs over time. METHODS: The tibial footprint of the ACL was dissected in 64 knee specimens of known gender and age. They were divided into four groups by age and gender, setting 50 years of age as the cut-off point. Three observers analyzed the tibial footprint dissections and the shape was described and classified. RESULTS: The knees from the cadavers of males older than 50 years of age presented a "C" morphology in 85% of the cases. In the group of males aged less than 50 years, an oval/elliptical morphology was found in 85.7% of the cases. In the group of women over 50 years-old, the "C" morphology was observed in 82.3% of the cases. In women under the age of 50, the oval/elliptical morphology was found in 84.6% of the cases. A significant difference was observed between the prevalence rates of the morphologies of the younger and older groups (p < 0.001 for both genders). However, no differences were observed between males and females of the same age group (n.s.). CONCLUSIONS: The morphology of the tibial footprint of the ACL presents significant variations with ageing. It can go from an oval/elliptical shape to a "C" shaped morphology. The results of this work make for an advance in the individualization of ACL reconstruction based on the age and the specific morphology of the tibial footprint.

The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study.

PURPOSE: The main aim of this study was to evaluate the re-rupture risk after an anterior cruciate ligament reconstruction (ACL-R) using the vancomycin soaking technique and to compare it with the re-rupture risk in patients on whom this technique was not utilized. The secondary purpose was to compare the functional outcomes of those two subsets of patients operated on for ACL-R. The hypotheses are that the vancomycin soaking technique does not affect the re-rupture risk or the functional outcomes. MATERIAL AND METHODS: A retrospective historical cohort study was conducted. Two groups were compared in terms of the re-rupture rate (traumatic or atraumatic) and functional outcomes (International Knee Documentation Committee (IKDC), Tegner, and Lysholm). Group 1 consisted of patients that received pre-operative IV antibiotics. In group 2, the patients received pre-operative IV antibiotics along with a graft that had been presoaked in a vancomycin solution. A minimum follow-up of five years was required. RESULTS: There were 17 patients that suffered a re-rupture in group 1 (4.7%) and 15 in group 2 (3.9%) (n.s.). IKDC was 82.0 in group 1 and 83.9 in group 2 (p = 0.049); Tegner scored 4 in both groups (n.s.) and Lysholm was 90.3 in group 1 and 92.0 in group 2 (p = 0.015). CONCLUSION: The vancomycin soaking technique for ACL autografts is a safe procedure for the daily clinical practice, in terms of re-ruptures. Moreover, it does not impair functional outcomes after an ACL-R.

The Menisco-Tibio-Popliteus-Fibular Complex: Anatomic Description of the Structures That Could Avoid Lateral Meniscal Extrusion.

PURPOSE: To analyze, quantify, and redefine the anatomy of the peripheral attachments of the lateral meniscal body to further understand how the structures might play a part in preventing meniscal extrusion and how it might be applied to surgical techniques. METHODS: Ten nonpaired fresh-frozen cadaveric knees without prior injury, a surgical history, or gross anatomic abnormality were included. There were 5 right and 5 left knees, and 50% were from male donors and 50% were from female donors. All the dissections were performed by a group of 3 experts in knee surgery (2 knee surgeons and 1 anatomy professor who oversaw the design of the dissection protocol and guided this protocol). The main peripheral structures associated with the lateral meniscus body were dissected to determine the insertion, size, thickness, and location of the lateral meniscotibial ligament (LMTL), popliteofibular ligament (PFL), and popliteomeniscal ligament (PML). The distance to various landmarks in the lateral compartment was also determined using an electronic caliper. Moreover, a histopathologic study was carried out. RESULTS: The average thickness of the LMTL was 0.62 ± 0.18 mm (95% confidence interval [CI], 0.49-0.75 mm); that of the PFL-PML area was 1.05 ± 0.27 mm (95% CI, 0.85-1.24 mm). The anteroposterior distance measured 15.80 ± 4.80 mm (95% CI, 12.40-19.30 mm) for the LMTL and 10.40 ± 1.70 mm (95% CI, 9.21-11.63 mm) for the PFL-PML area. The anteroposterior distance of the whole menisco-tibio-popliteus-fibular complex (MTPFC) was 28.20 ± 4.95 mm (95% CI, 24.70-31.70 mm). The average distance from the MTPFC to the posterior horn of the lateral meniscal root was 29.30 ± 2.29 mm (95% CI, 27.60-30.90 mm), whereas that to the anterior horn was 32.00 ± 4.80 mm (95% CI, 28.60-35.50 mm). The average distance from the tibial insertion of the LMTL to the articular surface was 5.59 ± 1.22 mm (95% CI, 4.72-6.46 mm). In all the anatomic components of the knee, a consistent morphologic and histologic pattern was observed between the fibers of the LMTL, PFL, and PML and those of the lateral meniscal body, making up the proposed MTPFC. CONCLUSIONS: A consistent anatomic pattern has been identified between the lateral meniscal body and the LMTL, PFL, and PML, forming an interconnected complex that would seem appropriate to denominate the MTPFC. A precise study of this region and appropriate nomenclature for it could contribute to a better understanding of the mechanism of lateral meniscal injuries at this level, as well as the development of surgical techniques to treat these lesions and prevent extrusion. CLINICAL RELEVANCE: This study contributes to the understanding of the lateral meniscal body attachments and the functions they serve. This will lead to improvements in the treatment of lesions in this region, including the development of surgical techniques.

Evaluating for Tunnel Convergence in Anterior Cruciate Ligament Reconstruction With Modified Lemaire Tenodesis: What Is the Best Tunnel Angle to Decrease Risk?

PURPOSE: The purpose of this study was to analyze postoperative computed tomography (CT) scan evaluations of patients who had undergone a combined anterior cruciate ligament (ACL) reconstruction and modified Lemaire anterolateral tenodesis (ALT) with femoral fixation through a bony tunnel. METHODS: Postoperative CT scans of 52 patients who had undergone combined ACL and ALT were prospectively evaluated. ACL femoral tunnels were drilled through an anteromedial portal in the center of the native footprint. An ALT fixation tunnel was drilled 5 mm proximal to the lateral epicondyle, aiming at an inclination of 30° proximally and 30° anteriorly. Two independent observers evaluated the CT scans measuring any degree of collision, the shortest distance between the tunnels, and the inclination of the ALT tunnels. Measurements were carried out at both the cortical level and on a plane passing 1 cm deeper in the lateral condyle. RESULTS: At the level of the cortex, no convergence of the tunnels was identified. In 14 of 52 cases (26.9%), the shortest distance between the tunnels was less than 5 mm. Tunnel collision occurred in 8 of 52 cases (15.4%), and the bone bridge between the tunnels was less than 5 mm in 11 cases (21.1%) when the measurements were made on the deeper plane. When the inclination on the axial plane was less than 15°, a collision always (P < .001) occurs. When it was more than 20°, no collision occurred (P < .001). No correlation between convergence and the inclination of the ALT tunnel on the coronal plane was detected. CONCLUSIONS: To fix a modified Lemaire ALT through a femoral tunnel avoiding any interference with an anatomic femoral ACL tunnel, we recommend that the femoral tunnel be drilled with an inclination of at least 20° anteriorly. LEVEL OF EVIDENCE: IV, therapeutic case series.

Age over 50 years is not a contraindication for anterior cruciate ligament reconstruction.

PURPOSE: To report clinical and functional results of ACL reconstruction in patients over 50 years old and investigate the influence of surgery on osteoarthritis progression in this cohort of patients. METHODS: A systematic review was performed on PubMed, Scopus, Google scholar, Cochrane library and EMBASE, using a strategy search design to collect clinical studies reporting outcomes of ACL reconstruction in patients aged 50 years or older. The primary outcome measure was clinical and functional results, including failure rate defined as reoperation for revision ACL surgery or conversion to total knee arthroplasty; secondary outcomes included radiological findings, expressed according to the validated grading score. RESULTS: A total of 16 studies were found suitable and included. Overall, 470 arthroscopic ACL reconstructions were performed in 468 patients (278 males, 190 females), with a mean age of 53.6 years (50-75 years). The total failure rate, described as reoperation for revision ACL surgery was 2.7% (10 knees), ranging from 0 to 14.3% in the selected studies. All papers reviewed showed a statistically significant improvement of clinical and functional scores at final follow-up, comparable to younger control group, when reported. Post-operative objective stability testing with KT-1000 arthrometer device or equivalent was performed in seven studies, with a mean side-to-side difference of 2.2 mm (0.2-2.7 mm). Radiographic signs of progression of osteoarthritis were reported in six studies, where severe signs of degeneration (grade 3 or 4 according Kellgren-Lawrence or Ahlbäck classification) shifted from 4 out of 216 knees (1.9%) before surgery to 28 out of 187 knees (15%) following ACL reconstruction, after a mean period of follow-up ranging from 32 to 64 months. CONCLUSION: ACL reconstruction in patients older than 50 years is a safe procedure with good results that are comparable to those of younger patients previously reported. Age itself is not a contraindication to ACL surgery because physiological age, clinical symptoms and functional requests are more important than chronological age in decision process. Since cohort size in the present study is not large enough, and taking into account the high occurrence of concomitant meniscal and chondral lesions, more high-quality studies are necessary to draw definitive conclusions about development of osteoarthritis of the knee after ACL surgery in these patients. LEVEL OF EVIDENCE: IV.

Computed tomography evaluation of total knee arthroplasty implants position after two different surgical methods of implantation.

PURPOSE: The objectives of this study were to determine the reliability of a novel method of measuring the rotational alignment of an anatomical tibial tray, the difference in the rotational alignment of the femoral and tibial component according to pure measured resection or blended technique with tensor, and, finally, the difference in terms of clinical results according to the two different methods. PATIENTS AND METHODS: We performed a total of 60 consecutive TKAs: 30 according to pure measured resection and 30 according to blended technique with tensor (FuZion®). Clinical scores and CT scan were done at six months to measure patient's outcome and prosthetic components rotation. RESULTS: The method of measurement of tibial tray had high agreement between different radiological observers. Mean external rotation alignment of the femur was 2.7° in standard group and 0.5° in the FuZion® group. For all clinical indices, we observed a large and significant improvement at follow-up, better in blended technique group, but without a clear superiority, and no statistically significant difference was evident between the two groups. At follow-up, HSS was to 89.7 in the FuZion® group and 89.0 in the standard group, KSS (clinical) was 92.6 in and 91.3 respectively, and KSS (Functional) was 91.0 in the FuZion® group and 87.6 in the standard group. CONCLUSIONS: Our CT measurement method is reliable and reproducible. All patients operated with this personalized knee system design obtained excellent results; the customization of femoral rotation with a blended technique is, probably, the key to optimize the outcomes and achieve the state of forgotten knee.

Clinical and radiological analysis of a personalized total knee arthroplasty system design.

PURPOSE: The objectives of this study were to determine the radiological outcome of a new personalized total knee arthroplasty (TKA) design and also to analyze the radiological reproducibility of the surgical technique. PATIENTS AND METHODS: A total of 100 consecutive TKAs performed in 99 patients using Persona knee system were recruited. Weight-bearing standing anteroposterior and lateral radiographs were done in all the patients, both pre-operatively as well as post-operatively, and various radiological parameters were analyzed and compared. RESULTS: The full correction of the limb mechanical axis was achieved in 97% of patients, and the radiological parameters of coronal and sagittal alignment of femoral and tibial components showed good results. There were no substantial differences between the mean pre-operative and post-operative patellar height indices, and data were in the normal range. Posterior condylar offset (PCO) and posterior condylar offset ratio (PCOR) had increased as expected after TKA. The coverage of tibia was optimal with data in the normal range. CONCLUSIONS: Radiological assessment of the new personalized knee system design showed excellent results with various parameters restored to the normal values. Therefore, the prosthesis can be considered anatomic, and the surgical technique is reproducible allowing the prosthesis to be implanted easily and with high precision.

Role of MRI in predicting meniscal tear reparability.

OBJECTIVE: To elucidate the role of MRI in predicting meniscal tear reparability according to tear type and location in relation to vascular zones. MATERIALS AND METHODS: In this retrospective study, two readers evaluated 79 pre-surgical MRIs of meniscal tears arthroscopically treated with meniscectomy or meniscal repair. Tears were classified according to type into vertical, horizontal, radial, complex, flaps and bucket handle and were considered reparable if the distance measured from the tear to the menisco-capsular junction was less than or equal to 5 mm. Predictions were compared with the surgical procedure performed in arthroscopy. We assessed the diagnostic performance of MRI, agreement between MRI and arthroscopy, and interrater agreement. Then, we conducted an ROC analysis on the distances measured by the first reader and built a multivariate logistic regression model. RESULTS: MRI had a sensitivity, specificity, PPV, NPV and accuracy, respectively, of 85%, 79%, 86%, 76% and 83% in predicting meniscal tear reparability. Correct predictions for the specific tear pattern were 76% for vertical, 84% for horizontal, 88% for radial, 86% for complex, 84% for flaps and 86% for bucket handle. Agreement between the two readers' predictions and arthroscopy was good (k = 0.65 and 0.61, respectively). Inter-rater agreement was almost excellent (k = 0.79). The ROC analysis revealed sensitivity and specificity of 73% and 83% with a cutoff value of <4 mm (p < 0.001). Anterior cruciate ligament injury and medial meniscal tear increased the likelihood of meniscal tear reparability. CONCLUSIONS: MRI can be a reliable and accurate tool to predict the reparability of meniscal tears, with higher prediction rates for bucket-handle tears.

How to repair medial meniscal ramp lesions: A systematic review of surgical techniques.

Purpose: to provide a comprehensive overview of all the surgical techniques published in the literature for repairing meniscal ramp lesions focusing on the technical aspects and the pros and cons of every procedure. Such lesions can be managed using various approaches, each of this with its specific advantages and disadvantages. Methods: Pubmed Central, Scopus, and EMBASE databases were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines for studies on surgical techniques for repairing meniscal ramp lesions through May 2023. Overall, 32 articles matched the selection criteria and were included in the study. Results: Debridement alone may be sufficient for small stable meniscal ramp lesions but, for tears in the menisco-capsular junction that affect the stability of the medial meniscus, it seems reasonable to repair it, even though the clinical results available in literature are contrasting. All-inside sutures through anterior portals seems to be an effective solution for meniscal ramp lesions with MTL tears. All-inside sutures through posteromedial portals are particularly useful for large meniscal ramp lesions, in which an inside-out suture can also be performed. Conclusion: Meniscal ramp lesions can be managed using various approaches, each of this with its specific advantages and disadvantages. Further research is required to determine the optimal technique that can be considered as the gold standard and can provide the better results. Level of Evidence: Level III, systematic review.

In-silico study of the biomechanical effects of proximal-fibular osteotomy on knee joint contact pressure in varus-valgus misalignment.

The aim of this work is to investigate in-silico the biomechanical effects of a proximal fibular osteotomy (PFO) on a knee joint with different varus/valgus deformities on the progression of knee osteoarthritis (KOA). A finite element analysis (FEA) of a human lower extremity consisting of the femoral, tibial and fibular bones and the cartilage connecting them was designed. The FEA was performed in a static standing primitive position to determine the contact pressure (CP) distribution and the location of the center of pressure (CoP). The analysis examined the relationship between these factors and the degree of deformation of the hip-knee angle in the baseline condition. The results suggested that PFO could be a simple and effective surgical treatment for patients with associated genu varum. This work also reported that a possible CP homogenization and a CoP correction can be achieved for medial varus deformities after PFO. However, it reduced its effectiveness for tibial origin valgus misalignment and worsened in cases of femoral valgus misalignment.