A low carrying angle is measured in elite tennis players just before ball impact during the forehand, suggesting a dynamic varus instant accommodation moving towards full extension.

PURPOSE: The goal of this study was to use image analysis recordings to measure the carrying angle of elite male tennis players during the forehand stroke, with the hypothesis that elite tennis players overstress their elbow in valgus over the physiological degree in the frontal plane just before ball contact on forehand groundstrokes. METHODS: The carrying angle of male tennis players ranked in the top 25 positions in the ATP ranking was measured on selected video frames with the elbow as close as possible to full extension just before the ball-racket contact in forehands. These frames were extracted from 306 videos professionally recorded for training purposes by a high-profile video analyst. All measures were conducted by three independent observers. RESULTS: Sixteen frames were finally included. The mean carrying angle was 11.5° ± 4.7°. The intraclass correlation coefficient value was 0.703, showing good reliability of the measurement technique. The measured carrying angle was lower than what has been observed in historical cohorts using comparable measurement methodology, suggesting a possible instant varus accommodation mechanism before hitting the ball. CONCLUSIONS: The observed decrease in the carrying angle is a consequence of an increase in elbow flexion position dictated by the transition from a closed to open, semi-open stances. As the elbow flexes during the preparation phase, it is less constrained by the olecranon and its fossa, increasing the strain on the medial collateral ligament and capsule structures. Moving towards full extension before the ball-racket contact, the elbow is dynamically stabilised by a contraction of the flexor muscles. These observations could provide a new explanation for medial elbow injuries among elite tennis players and drive specific rehabilitation protocols. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level IV.

Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications.

PURPOSE: This literature review aims to present evidence-based clinical recommendations for the eight most debated topics related to perioperative management in total knee arthroplasty: counselling, prehabilitation, transfusion risk, tranexamic acid, drainage, analgesia, urinary catheter and compression stockings. METHODS: A multidisciplinary team conducted a systematic review on these topics. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the literature review and result presentation. The research encompassed articles from 1 January 2009 to 28 February 2023, retrieved through the MEDLINE database via PubMed, Embase database and Cochrane Library. RESULTS: Forty-five articles were selected. Preoperative counselling has limited evidence for its impact on postoperative outcomes; yet, it can help alleviate surgery-related anxiety and manage postoperative symptoms. Prehabilitation can also prepare patients for surgery, reducing hospital stays and improving postsurgery functionality. Numerous studies suggest that preoperative Hb levels are independently linked to transfusion risk, with a recommended level of 13 g/dL. Combining intravenous and local tranexamic acid administration is strongly advised to reduce perioperative blood loss, while drainage after primary total knee arthroplasty offers no functional advantages. Employing a multimodal analgesia approach yields better results with reduced opioid usage. Indwelling urinary catheters provide no benefit and avoiding them can lower the risk of urinary tract infections. As for compression stockings, there is insufficient evidence in the literature to support their efficacy in preventing venous thromboembolism. CONCLUSION: The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. It is success relies on a collaborative, resource-adaptive approach led by a multidisciplinary team. Both patients and hospitals benefit from this approach, as it enhances care quality and lowers costs. Several studies have highlighted the significance of a patient-centred approach in achieving high-quality care. Creating a novel treatment protocol could be a prospective goal in the near future. LEVEL OF EVIDENCE: Level III.

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

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

Look for the POLESTAR (POsteroLateral Engagement of Soft Tissue And Radial head) while navigating around elbow dislocation.

BACKGROUND: Elbow dislocation is frequently associated with bony and osteochondral posterolateral capitellar lesions that are often under-reported. We aim to examine the radiologic signs of posterolateral lesions on computed tomography (CT). METHODS: A retrospective analysis of CT scans was performed. Patients were classified into 4 groups: (1) simple elbow dislocation, (2) elbow dislocation with a fracture of the coronoid tip, (3) elbow dislocation with coronoid tip fracture and a radial head fracture inferior or equal to the anterior third, and (4) terrible triad defined as elbow dislocation with concomitant coronoid and radial head fracture with a more important involvement. Patients with a more complex fracture pattern were excluded. The presence of POsteroLateral Engagement of Soft Tissue And Radial head (POLESTAR) patterns was analyzed and subclassified as impaction type or fragmentation type. RESULTS: Fifty-one CT scans met the inclusion criteria. POLESTAR lesions were identified in 48 cases (94%): 46% impaction-type and 54% fragmentation-type POLESTAR. Analyzing patients from grade 1 to 4, impaction-type POLESTAR was found, respectively, from 40% to 57%, whereas fragmentation type was present from 60% to 43%. CONCLUSIONS: This study shows a high incidence of POLESTAR lesions (94%) that can be present as impaction type or fragmentation type. Based on our preliminary results, impaction type is more common in grades 3 and 4, whereas fragmentation type is more frequent in grades 1 and 2.

Proximal radio-ulna joint but not posterolateral instability is present in SMILE patients compared to controls.

INTRODUCTION: The elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament (LUCL) and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like SMILE (Symptomatic Minor Instability of the Lateral Elbow) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathological condition. MATERIALS AND METHODS: Twenty-eight patients were included in this study: half of them were operated for suspected SMILE while the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, four parameters were analyzed: Annular Drive Through (ADT), Ulnar-humeral Stressed Distance (UHSD) at 45° and 30° of flexion, and Loose Collar Sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to do measurements. RESULTS AND DISCUSSION: A statistically significative difference was found for LCS (p value 0,0003) and ADT (p value 0,000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly. Progressive stretching of the RLCL and annular ligament may lead to their elongation, allowing a pathological antero-posterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radio-ulnar instability. CONCLUSIONS: RLCL and annular ligament are elongated in SMILE patients compared to controls, causing instability of the proximal radio-ulnar joint (PRUJ) and confirming that ligament incompetency is involved in SMILE condition.

Allografts use in orthopedic surgery: trend change over the past 11 years from a regional tissue bank.

Allografts are the second most transplanted tissue in medicine after blood and are now increasingly used for both primary and revision surgery. Allografts have the advantages of lower donor site morbidity, availability of multiple grafts, and shorter operative time. The Banks represents the bridge between Donor and Recipient and guarantees the quality and safety of the distributed allografts Given the increasing interest in these tissues, a retrospective analysis of data collected from the Regional Musculoskeletal Tissue Bank registry over an 11-year period (2009-2019) was conducted. The statistical analyses used were the Shapiro-Wilk normality test and a Poisson regression model. From January 2009 to December 2019, a total of 14,199 musculoskeletal tissues stored in the Regional Musculoskeletal Tissue Bank were provided for surgical allograft procedures. In 2009, the number of allografts performed was 925; this figure has steadily increased to 1599 in 2019. Epiphyses were taken as the reference tissue with an almost constant trend over the period, while a significant increase was denoted for extensor mechanism allograft, ligaments, tendons and long bone corticals (p < 0.001), processed bone tissues had no change in trend (p = 0.841). There was also a gradual decrease in the rate of microbiological positivity, as determined by bacteriological and serological tests performed on the collected tissues. This phenomenon is due to improved sampling techniques and the training of a dedicated team. Thus, we have seen how the use of allografts in orthopedic surgery has increased over the past 11 years, uniformly in terms of tissue type, except for the noticeable increase in ligamentous tissue.

Exploring the prevalence and clinical impact of fibromyalgia syndrome in patients with shoulder diseases: a cross-sectional study.

OBJECTIVES: Fibromyalgia (FM) is a musculoskeletal syndrome characterised by widespread chronic pain often associated with systemic manifestations such as mood disturbances, persistent fatigue, unrefreshed sleep, and cognitive impairment, substantially impacting patients' health-related quality of life. Based on this background, this study aimed to evaluate the prevalence of FM syndrome in patients referring to an outpatient clinic in a central orthopaedic institute for a painful shoulder. The demographic and clinical characteristics of patients fulfilling the criteria for FM syndrome were also correlated with the severity of symptoms. METHODS: Consecutive adult patients referring to the shoulder orthopaedic outpatient clinic of the ASST Gaetano Pini-CTO, Milan, Italy, to undergo a clinical evaluation were assessed for eligibility in an observational, cross-sectional, monocentric study. RESULTS: Two hundred-one patients were enrolled: 103 males (51.2%) and 98 females (48.8%). The mean age ± standard deviation (SD) of the patients was 55.3 ± 14.3 years in the whole population. Of all the patients, 12 (5.97%) fulfilled the 2016 FM syndrome criteria based on the FM severity scale (FSS). Of these, 11 were females (91.7%, p=0.002). The mean age (SD) was 61.3 (10.8) in the positive criteria sample. Patients with positive criteria had a mean FIQR of 57.3 ± 16.8 (range 21.6-81.5). CONCLUSIONS: We found that FM syndrome is more frequent than expected in a cohort of patients referring to a shoulder orthopaedic outpatient clinic, with a prevalence rate (6%) more than double that of the general population (2%).

Platelet-rich plasma does not improve clinical results in patients with rotator cuff disorders but reduces the retear rate. A systematic review and meta-analysis.

PURPOSE: To assess whether the use of Platelet-rich plasma (PRP) produces a clinical benefit in patients with rotator cuff disorders, treated either conservatively or surgically. METHODS: A systematic review was performed according to PRISMA guidelines on three databases (PubMed, Cochrane Library, Web of Science) to identify randomised controlled trials (RCTs) on the use of PRP in patients with rotator cuff disorders, treated either conservatively or surgically. A meta-analysis was performed on articles reporting results for Constant, UCLA, VAS, SST scores and retear rate. The RoB 2.0 and the modified Coleman Methodology Score were used to assess methodological quality. RESULTS: A total of 36 RCTs (20 surgical, 16 conservative) were included, for a total of 2,443 patients. Conservative treatment showed high heterogeneity and no clear consensus in favour of PRP. The meta-analysis of the studies with surgical treatment showed no benefit in using PRP in any of the clinical outcomes, either at the short or medium/long-term follow-up. However, the retear rate was lower with PRP augmentation (p < 0.001). The overall quality of the studies was moderate to high, with the surgical studies presenting a lower risk of bias than the conservative studies. CONCLUSION: The use of PRP as augmentation in rotator cuff surgical repair significantly reduces the retear rate. However, no benefits were documented in terms of clinical outcomes. PRP application through injection in patients treated conservatively also failed to present any clear advantage. While there are many studies in the literature with several RCTs of moderate to high quality, the high heterogeneity of products and studies remains a significant limitation to fully understanding PRP potential in this field. LEVEL OF EVIDENCE: Level I.

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 meniscal extrusion index is a reliable indirect sign of different meniscal lesion patterns: a classification based on percentage of meniscal extrusion.

PURPOSE: This study's goal is to propose a straightforward classification system based on the MEI (Meniscal Extrusion Index), a measure of meniscal extrusion, that relates to various meniscal lesion patterns and has clinical and biomechanical significance. The study's secondary goal is to determine whether the standard 3 mm meniscal extrusion parameter still has value by correlating the MEI with it. METHODS: 1350 knee MRIs that were performed over the course of 2 years made up the study cohort. Following the application of inclusion and exclusion criteria, 200 of those patients were qualified to participate in the study. All the measurements examined for this study underwent an interobserver reliability test. RESULTS: In the 1350 MRIs that were examined for this study, meniscal extrusion of any grade was present 18.9% of the time. The use of the MEI revealed three groups of patients: those with a MEI < 20%, who are likely para-physiological; those with a MEY between 20% and 40%, who are in a grey area; and those with a MEY > 40%, who have lesions that are impairing the proper meniscal function. According to the authors' findings, the percentage of meniscal extrusion did not correlate with the finite number (3 mm), making the 3 mm parameter an unreliable evaluation method. CONCLUSIONS: This study is clinically relevant, because it proposes a simple and reproducible classification of meniscal extrusion that may aid in evaluating the severity of an extrusion and help in the diagnosis of lesions that might be difficult to identify on MRI. LEVEL OF EVIDENCE: Level IV.

Bone marrow lesions in the knee are associated with meniscal lesions and cartilage pathologies according to the six-letter system.

PURPOSE: This study aims to find a correlation between bone marrow lesions (BMLs) in knee MRI and pathologies of joint structures. In addition, according to the six-letter system classification, the authors analyzed a potential association between the area affected by BMLs and the specific type of joint lesion. METHODS: The authors screened all the knee MRIs performed in the investigation center between 2017 and 2018 to identify the presence of BMLs. The lesions were then categorized following the "six-letter system". The authors searched the presence of associated meniscal, chondral or ligamentous lesions. Finally, the authors researched a correlation between the lesion type described by the six-letter system classification and the associated lesions. RESULTS: MRI exams of 4000 patients were studied, identifying 666 BMLs. The associated lesions were collected for all patients, resulting in an overall prevalence of related lesions in almost 90% of patients. The authors found a statistical significance for type TLD (Tibia-Lateral-Articular) and ACL rupture. The study suggests a strong positive correlation between type E (Edge) and meniscal fracture or extrusion. CONCLUSION: BMLs in the knee are associated in 90% of cases with a radiological sign of related injury to the joint structures. The six-letter system of BMLs type TLD can be considered a sign of ACL rupture and type E as a high suspicious sign for meniscal extrusion. Those very typical BML patterns can help the clinician in the diagnosis of ACL tears and meniscal extrusion. Furthermore, the presence of a BML must be, for the clinician, a high suspicious sign of joint-related injuries. LEVEL OF EVIDENCE: Level 1.

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations.

BACKGROUND: Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients. METHODS: Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed. RESULTS: A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury. CONCLUSIONS: Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

Italian Orthopaedic and Traumatology Society (SIOT) position statement on the non-surgical management of knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) is a chronic disease associated with a severe impact on quality of life. However, unfortunately, there are no evidence-based guidelines for the non-surgical management of this disease. While recognising the gap between scientific evidence and clinical practice, this position statement aims to present recommendations for the non-surgical management of knee OA, considering the available evidence and the clinical knowledge of experienced surgeons. The overall goal is to offer an evidenced-based expert opinion, aiding clinicians in the management of knee OA while considering the condition, values, needs and preferences of individual patients. METHODS: The study design for this position statement involved a preliminary search of PubMed, Google Scholar, Medline and Cochrane databases for literature spanning the period between January 2021 and April 2023, followed by screening of relevant articles (systematic reviews and meta-analyses). A Società Italiana Ortopedia e Traumatologia (SIOT) multidisciplinary task force (composed of four orthopaedic surgeons and a rheumatologist) subsequently formulated the recommendations. RESULTS: Evidence-based recommendations for the non-surgical management of knee OA were developed, covering assessment, general approach, patient information and education, lifestyle changes and physical therapy, walking aids, balneotherapy, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, pharmacological interventions and injections. CONCLUSIONS: For non-surgical management of knee OA, the recommended first step is to bring about lifestyle changes, particularly management of body weight combined with physical exercise and/or hydrotherapy. For acute symptoms, non-steroidal anti-inflammatory drugs (NSAIDs), topic or oral, can be used. Opioids can only be used as third-line pharmacological treatment. Glucosamine and chondroitin are also suggested as chronic pharmacological treatment. Regarding intra-articular infiltrative therapy, the use of hyaluronic acid is recommended in cases of chronic knee OA [platelet-rich plasma (PRP) as second line), in the absence of active acute disease, while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.

The Efficacy of Conservative Treatment of Bone Marrow Edema Syndrome: A Scoping Review of the Last Ten Years of Literature.

PURPOSE: The purpose of this review was to conduct a literature search assessing the efficacy of various conservative treatments of BMES. METHODS: According to the PRISMA guidelines, a literature search was conducted in April 2021 in MEDLINE database via PubMed and Embase to identify original articles describing the results of conservative treatments for BMES of hip and knee published in the last ten years. For each study, information regarding study characteristics, description of the treatment, patient's demographic and clinical data, length of follow-up, clinical outcome measure, disability, adverse events, classification, and extent and of edema on MRI, were extracted. RESULTS: A total of 12 studies were identified. Two studies described treatment with iloprost, three with hyperbaric oxygen (HBO), two with bisphosphonates, five with extracorporeal shockwave therapy (ESWT). The total number of patients was 351: 34 treated with iloprost, 64 with hyperbaric oxygen, 37 with bisphosphonates, 216 with ESWT. In ESWT studies, treatment with a higher flux density and a higher number of therapy sessions lead to better clinical and radiological scores. In iloprost studies, a more remarkable improvement in the VAS scale was observed in the study on hip patients. CONCLUSIONS: The treatment of idiopathic bone marrow edema is currently not standardized, making it difficult to find data that can be compared in a highly reliable way. The studies available in the literature show promising results as for the possibility to cure bone marrow edema efficiently. Standardized radiological scores for evaluating bone marrow edema area are needed in future studies.

Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: Clinical and Radiological Results of a Prospective Randomized Controlled Trial Study at 10-Year Follow-Up.

PURPOSE: The aim of the study is to compare, at 10-year follow-up, the clinical and radiological outcomes of arthroscopic rotator cuff repair with or without the addition of platelet-rich plasma (PRP) over the tendon-bone interface at the end of the surgical procedure. METHODS: Of 53 patients recruited in the study, and randomly divided into 2 groups (PRP = 26; control = 27), 38 were re-evaluated at least 10 years after the index procedure. The clinical evaluation was carried out through: University of California at Los Angeles (UCLA) Shoulder Score, Visual Analogue Scale (VAS), Simple Shoulder Test, Constant-Murley Score (CMS), Single Assessment Numerical Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) and isometric strength in abduction, forward flexion and external rotation. Musculoskeletal ultrasonography had been used to evaluate the integrity of the repaired cuff. RESULTS: A number of 38 (71%) patients (PRP = 17; control = 21) with a median age of 71 [64.75-76.50] years have been evaluated. Satisfaction at follow-up is high (90%), without statistically significant difference between the two groups. We report good and excellent clinical results in both groups (PRP vs control): CMS (81.62 [72.47-85.75] vs 77.97 [69.52-82.55] points), UCLA (34 [29.00-35.00] vs 33 [29.00-35.00] points), VAS (0.34 [0.00-1.85] vs 0.70 [0.00-2.45] cm). It was not possible to find a statistically significant difference for the variables analyzed, except for ASES and SANE. On average, 37% of the operated patients had a re-rupture at the ultrasound examination, regardless of the treatment group (P = 1.00). Compared with the previous radiological control at the 2-year follow-up, new retears occurred in 6% of the patients who received PRP treatment, whereas in the control group the percentage raises to 14% (P = .61). CONCLUSION: The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the 2 groups. The minor differences that had been observed at 2-year follow-up disappeared at long term. Patients' satisfaction is still high 10 years after surgical treatment. LEVEL OF EVIDENCE: Level II, randomized controlled trial, treatment study.

Good patient satisfaction with low complications rate after trochleoplasty in patellofemoral instability.

PURPOSE: Trochlear dysplasia has been recognized as the most common factor in patients with patellofemoral dislocation. Trochleoplasty is a surgical procedure whose primary goal is to modify the femoral trochlea's abnormal shape in patients suffering from patellar instability, requiring good surgical skills, correct indication, and accurate patient information. METHODS: The review aims to describe preoperative planning, patient selection, most common surgical techniques, and clinical results of trochleoplasty in patellar instability in a reproducible manner. RESULTS: Trochleoplasty can be considered a general term to describe a group of different procedures that reduce trochlear dysplasia's impact on patellar instability, aiming to restore patella-trochlear congruency, remove the supratrochlear bump, allowed a new groove positioning and are generally associated with other procedures. Recent studies showed satisfactory long-term results with the restoration of patellar stability, improving radiological findings of patellofemoral instability. CONCLUSION: Trochleoplasty is a technically demanding technique, requiring careful patient selection, detailed knowledge, and surgical skills to avoid severe complications. Good patient satisfaction with a low risk of significant complications such as patellofemoral arthritis has been revealed. In conclusion, trochleoplasty should be systematically included in the treatment of patellar dislocation, if indicated. LEVEL OF EVIDENCE: V.

Low grade of osteoarthritis development after Latarjet procedure with a minimum 5 years of follow-up: a systematic review and pooled analysis.

PURPOSE: The purpose of this systematic review and pooled analysis was to evaluate incidence and risk factors for glenohumeral osteoarthritis (OA) in patients who underwent Latarjet procedure with a minimum of 5-year follow-up. METHODS: The PRISMA guidelines were followed to perform this systematic review. PubMed and EMBASE were searched up to February 29, 2020 for English, human in vivo studies that evaluated glenohumeral OA in patients undergoing Latarjet procedure at least 5 years after surgery. A pooled analysis on the included databases sent by authors was performed to evaluate the risk factors influencing the development or progression of dislocation arthropathy after the Latarjet procedure. RESULTS: Four studies, including a total of 280 patients (213 males and 67 females), were analysed. In our study population, the median age at surgery was 25.0 years (range 20.8-32.6 years). and 92.1% were athletes. In 90% of the cases, the number of dislocations before surgery were fewer than 5. The recurrence of instability after Latarjet procedure was observed only in seven patients (2.5%). The position of the bone graft resulted flush to the anterior glenoid rim in 238 cases (85.3%), medial in 8 (2.9%) and overhanging in 33 (11.8%). Radiological signs of development or progression of shoulder OA were observed in 25.8% of the patients, of which 88.6% presented a grade 1 of OA according to Samilson and Prieto classification. The overhanging position of the bone graft resulted statistically significant for onset or worsening of OA. The age at surgery, the number of dislocations before surgery and the Hill-Sachs lesion were not significantly associated with joint degeneration. Instead, hyperlaxity showed a prevention role in the development of OA after open Latarjet procedure. CONCLUSION: The Latarjet procedure is a valid and safe surgical treatment in recurrent anterior shoulder instability with a low risk of developing moderate or severe OA also at long-term follow-up. The overhanging position of the bone graft represents the principal risk factor of joint degeneration, whereas the hyperlaxity seems to be protective. Finally, age, gender, time between first dislocation and surgery, and number of dislocations do not seem to affect the onset of OA after Latarjet procedure. Therefore, an accurate execution of the Latarjet procedure can be considered a valid treatment even in young and athletes thanks to the low recurrence rates and the low development of major long-term complications. LEVEL OF EVIDENCE: IV.

Treatment of partial rotator cuff lesions is associated with a higher frequency of post-operative shoulder stiffness. A prospective investigation on the role of surgery-related risk factors for this complication.

PURPOSE: Post-operative shoulder stiffness (SS) is a common complication after arthroscopic rotator cuff (RC) repair. The aim of this prospective study is to evaluate the role of surgical risk factors in the development of this complication, with special focus on the characteristics of the RC tears. METHODS: Two-hundred and twenty patients who underwent arthroscopic RC repair for degenerative posterosuperior RC tears were included. Surgery-related risk factors for development of post-operative SS belonging to the following five categories were documented and analyzed: previous surgery, RC tear characteristics, hardware and repair type, concomitant procedures, time and duration of surgery. The incidence of post-operative SS was evaluated according to the criteria described by Brislin and colleagues. RESULTS: The incidence of post-operative SS was 8.64%. The treatment of partial lesions by tear completion and repair technique was significantly associated with development of post-operative SS (p = 0.0083, pc = 0.04). A multivariate analysis revealed that treatment of partial lesions in patients younger than 60 years was associated to a higher risk of developing post-operative SS (p = 0.007). Previously known pre-operative risk factors such as female sex and younger age were confirmed. No other significant associations were documented. CONCLUSION: The treatment of partial lesions of the RC may lead to a higher risk of post-operative SS than the treatment of complete lesions, in particular in patients younger than 60 years. Possible explanations of this finding are the increased release of pro-inflammatory cytokines caused by the additional surgical trauma needed to complete the lesion and the different pain perception of the subgroup of patients who require surgical treatment already for partial tears. EVIDENCE: A higher risk of post-operative SS should be expected after tear completion and repair of partial lesions, especially in young patients. Appropriate pre-operative counseling and post-operative rehabilitation should be considered when approaching this subgroup of RC tears. LEVEL OF EVIDENCE: Prognostic study, level II.

Anatomic relations of the median nerve to the ulnar insertion of the brachialis muscle: safety issues and implications for medial approaches to the elbow joint.

INTRODUCTION: Preventing nerve injury is critical in elbow surgery. Distal extension of medial approaches, required for coronoid fracture fixation and graft-replacement, may endanger the median nerve. This study aims to describe an easily identifiable and reproducible anatomical landmark to localize the median nerve distal to the joint line and to delineate how its relative position changes with elbow flexion and forearm rotation. MATERIALS AND METHODS: The median nerve and the ulnar insertion of the brachialis muscle were identified in eleven fresh-frozen cadaveric specimens after dissection over an extended medial approach. The elbow was brought first in full extension and then in 90° flexion, and the shortest distance between the two structures was measured while rotating the forearm in full pronation, neutral position and full supination. RESULTS: The distance between the median nerve and the brachialis insertion was highest with the elbow flexed and the forearm in neutral position. All distances measured in flexion were larger than those in extension, and all distances measured from the most proximal point of the brachialis insertion were larger than those from the most distal point. Distances in pronation and in supination were smaller than to those in neutral forearm position. CONCLUSIONS: The ulnar insertion of the brachialis is a reliable landmark to localize and protect the median nerve at the level of the coronoid base. Elbow flexion and neutral forearm position increase significantly the safety margins between the two structures; this information suggests some modifications to the previously described medial elbow approaches. LEVEL OF EVIDENCE: Basic Science Study.

Arthroscopic remplissage is safe and effective: clinical and magnetic resonance results at a minimum 3 years of follow-up.

BACKGROUND: Large Hill-Sachs lesions are considered a risk factor for recurrence of instability after arthroscopic Bankart repair alone. The aim of this study was to demonstrate that remplissage is a safe procedure that effectively reduces the risk of recurrent dislocations without causing fatty degeneration of the infraspinatus at medium-term follow-up. METHODS: Patients who underwent arthroscopic Bankart repair and remplissage with a minimum 3 years of follow-up were included. Constant-Murley (CMS), American Shoulder and Elbow Surgeons (ASES), and Walch-Duplay scores were evaluated. Magnetic resonance imaging (MRI) was performed to detect the appearance of fatty infiltration inside the infraspinatus muscle, the percentage of the Hill-Sachs lesion filled by the tendon and its integration, and the onset of rotator cuff tears. RESULTS: Thirteen patients (14 shoulders) with a mean follow-up of 55.93 (± 18.16) months were enrolled. The Walch-Duplay score was 95.00 [87.25-100.00], with a return to sport rate of 100%. Both the CMS and the ASES indicated excellent results. The affected shoulders showed a statistically significant reduction in active external rotation both with the arm at the side (ER1) and with the arm at 90° of abduction (ER2) (p = 0.0005 and p = 0.0010, respectively). A reduction in infraspinatus isometric strength was found for both ER1 and ER2, but this reduction was only statistically relevant in ER2 (p = 0.0342). There was a traumatic recurrence of instability in two cases (14.28%). MRI evaluation demonstrated an absence of adipose infiltration in 50% of cases and only a minimal amount in the remaining 50%. In 12 cases (85.72%), the capsulotenodesis completely filled the lesion and good tendon-bone integration was observed. CONCLUSION: Arthroscopic remplissage provided successful clinical outcomes without fatty infiltration of the infraspinatus and with good healing of the tissues. The low risk of recurrence was associated with an objective limitation on active external rotation, but this did not influence the patients' daily or sports activities. LEVEL OF EVIDENCE: Cohort study, level of evidence 3.