Irreducible knee dislocation: improved clinical outcomes of open and arthroscopic surgical treatment. A systematic review of the literature.

PURPOSE: Irreducible knee dislocations (IKDs) are a rare rotatory category of knee dislocations (KDs) characterized by medial soft tissue entrapment that requires early surgical treatment. This systematic review underlines the need for prompt surgical reduction of IKDs, either open or arthroscopically. It describes the various surgical options for ligament management following knee reduction, and it investigates their respective functional outcome scores to assist orthopedic surgeons in adequately managing this rare but harmful KD. METHODS: A comprehensive search in four databases, PubMed, Scopus, Embase, and MEDLINE, was performed, and following the PRISMA guidelines, a systematic review was conducted. Strict inclusion and exclusion criteria were applied. Studies with LoE 5 were excluded, and the risk of bias was analyzed according to the ROBINS-I tool system. This systematic review was registered on PROSPERO. Descriptive statistical analysis was performed for all data extracted. RESULTS: Four studies were included in the qualitative analysis for a total of 49 patients enrolled. The dimple sign was present in most cases. The surgical reduction, either open or arthroscopically performed, appeared to be the only way to disengage the entrapped medial structures. After the reduction, torn ligaments were addressed in a single acute or a double-staged procedure with improved functional outcome scores and ROM. CONCLUSIONS: This systematic review underlines the importance of promptly reducing IKDs through a surgical procedure, either open or arthroscopically. Moreover, torn ligaments should be handled with either a single acute or a double-staged procedure, leading to improved outcomes. LEVEL OF EVIDENCE: IV.

Indications, complications, and clinical outcomes of fixation and acute total hip arthroplasty for the treatment of acetabular fractures: A systematic review.

PURPOSE: Acetabular fracture fixation can be challenging, especially in the elderly. Open reduction and internal fixation (ORIF) alone may not allow for early weight bearing and is associated with a high rate of secondary osteoarthritis; therefore, a combined hip procedure (CHP) or ORIF with acute total hip arthroplasty, may be beneficial in this population. The objective of this study was to perform a systematic review of all reported cases of CHP. METHODS: PubMed, Embase, Scopus, and Cochrane databases were searched for studies analyzing acetabular fractures in the elderly managed with a combined hip procedure (CHP). The research was performed following the PRISMA guidelines. The included studies' methodological quality was evaluated using the MINORS score. The present study was registered on PROSPERO. RESULTS: Eleven clinical studies were included in the final analysis. The mean age was 74.4 (63.2-78) years. Low-energy trauma was the most common mechanism of injury (64%). The most prevalent fracture pattern was the anterior column and posterior hemitransverse (ACPHT) (30.6%). The Kocher-Langenbeck approach was preferred for ORIF of posterior fractures and hip arthroplasty. The ilioinguinal approach and modified Stoppa were generally used for anterior fractures. The overall complication rate was 12.2%, and hip dislocation was the most frequent cause of reoperation (4.4%). The average Harris Hip Score reported postoperatively was 81.6 points, which was considered "good." CONCLUSIONS: CHP is a safe treatment for elderly acetabular fractures with an acceptable complication and reoperation rate that results in good clinical outcomes. LEVEL OF EVIDENCE: Level of evidence IV.

Highly cross-linked polyethylene versus conventional polyethylene in primary total knee arthroplasty: comparable clinical and radiological results at a 10-year follow-up.

PURPOSE: Highly crosslinked polyethylene (HXLPE) was introduced in total knee arthroplasty (TKA) to reduce wear and consequent revisions for loosening due to conventional polyethylene (CPE) wear. This study aims to analyse whether HXLPE is as safe as CPE and could improve the TKA clinical and radiological results in a long-term follow-up. METHODS: This retrospective study included all consecutive starting series of 223 patients with severe primary knee osteoarthritis (OA), with a minimum follow-up of 10 years treated between July 1st, 2007, and July 31st, 2010. After excluding patients who did not respect the inclusion and exclusion criteria, 128 patients were included in the analysis of this study. The patients were then divided into two groups according to the type of polyethylene (PE) implanted: CPE or HXLPE liners. All patients were evaluated for clinical and radiological parameters, causes and revision rates related to the type of PE implanted. RESULTS: HXLPE appears to be as safe as CPE in TKA, reporting no higher revisions for osteolysis, prosthesis loosening, infection, and mechanical failure. Nevertheless, no statistically significant differences were found between the two groups in the clinical and radiological outcomes evaluated. CONCLUSIONS: Clinical, radiological results, and revision rates are similar between HXLPE and CPE in TKA after 10 years of follow-up, although HXLPE benefits remain controversial. LEVEL OF EVIDENCE: III.

A novel geometrical planning method to restore knee joint obliquity in double-level osteotomies.

PURPOSE: Precise preoperative planning is mandatory when a double-level osteotomy (DLO) is required to correct a severe knee deformity. Literature does not report a validated planning method regarding DLO that could be performed directly on digital radiographs using simple measurement tools. This study aims to validate a novel DLO planning method called New Mikulicz-Joint Line (NM-JL) based on essential measurement tools, in which the correction angles are induced by the predicted post-operative joint line obliquity (JLO). METHODS: Twenty-three patients who satisfied the inclusion criteria were enrolled. NM-JL planning method was performed using basic measurement tools to detect corrective angles and gaps. The correction was then simulated using a Virtual Segmentation Software method to obtain the osteotomy fragments. Both planning procedures were performed independently and later repeated by two orthopaedic surgeons to assess the inter and intra-observer reliability. RESULTS: The intraclass correlation coefficient (ICC) regarding corrective angles and gaps showed a significant positive correlation between the values determined using the two procedures by both raters (p < 0.05). Pearson's correlation analysis revealed a significant correlation between the measured results of the two planning methods. (p < 0.05). Finally, the Bland-Altman analysis showed an excellent agreement (p < 0.05) for all measurements performed. CONCLUSIONS: The NM-JL method showed high values of intra and inter-rater reliability. The procedure is built up starting from the predicted value of post-operative joint line obliquity, allowing to maintain this parameter fixed. Other advantages include the quickness, adaptability, and possibility to be performed on any Digital Imaging and Communication in Medicine (DICOM) viewer. LEVEL OF EVIDENCE: Level IV.

Candida periprosthetic infection of the knee: a systematic review of surgical treatments and clinical outcomes.

BACKGROUND: Candida periprosthetic joint infections (PJIs) are a rare cause of prosthesis revision with severe consequences and challenging treatment. This study aims to produce a systematic analysis of types of treatment and outcome of knee Candida PJIs and their correlation with specific pathogen species. METHODS: During April 2021, a literature search was performed according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guideline. Reviewers used the Oxford Level of Evidence (LoE) and Methodological index for non-randomized studies (MINORS) score. Modal value of surgical, pharmacological treatment and outcome along with the correlation between types of treatment and outcome was calculated through Chi-square or Fisher exact test. RESULTS: In total, 115 cases were collected through 51 articles, identifying 116 pathogens. Candida albicans was the most frequent pathogen. Analysis of LoE reveals 40 LoE 5 and 11 LoE 4. Thirteen patients underwent one-stage revision, 46 patients two-stage revision, 6 patients resection arthroplasty and arthrodesis, 4 patients long-term antifungal therapy, and 3 patients debridement with prosthesis retention. Global rate of success was 85.14%. Modal distribution revealed a preference for two-stage revision and Fluconazole in medical therapy. No difference in terms of fungal eradication was found among Candida species (p = 0.503) and for treatments except for two-stage revision and resection arthroplasty (p = 0.0125) or debridement with implant retention (p = 0.0498), and the rest of procedures and resection arthroplasty (0.0192). MINORS score was poor. CONCLUSIONS: Analysis of the literature did not highlight any difference between types of surgical treatment and pathogens in terms of relapse or infection eradication. However, two-stage replacement may be preferred, allowing healing of infection in most cases.

Could anterior closed-wedge high tibial osteotomy be a viable option in patients with high posterior tibial slope who undergo anterior cruciate ligament reconstruction? A systematic review and meta-analysis.

PURPOSE: This study aims to examine the clinical and radiological outcomes of patients who underwent ACL reconstruction (ACLR) combined with anterior closed-wedge high tibial osteotomy (ACW-HTO) for posterior tibial slope (PTS) reduction to investigate the efficacy of this procedure in improving anterior knee stability and preventing graft failure in primary and revision ACLR. METHODS: A literature search was conducted in six databases (PubMed, Embase, Medline, Web of Science, Cochrane, and Scopus). The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The initial screening identified 1246 studies. Each eligible clinical article was screened according to the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence (LoE), excluding clinical studies of LoE V. Quality assessment of the articles was performed using the ROBINS-I methodological evaluation. This systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that were possible to perform a meta-analysis, a p < 0.05 was considered statistically significant. RESULTS: Five clinical studies were included in the final analysis. A total of 110 patients were examined. Pre- and post-operative clinical and objective tests that assess anteroposterior knee stability, PTS, clinical scores, and data on surgical characteristics, complications, return to sports activity, and graft failure after ACLR were investigated. A meta-analysis was conducted using R software, version 4.1.3 (2022, R Core Team), for Lysholm score and PTS outcomes. A statistically significant improvement for both these clinical and radiological outcomes (p < 0.05) after the ACW-HTO surgical procedure was found. CONCLUSION: ACLR combined with ACW-HTO restores knee stability and function with satisfactory clinical and radiological outcomes in patients with an anterior cruciate ligament injury associated with a high PTS and seems to have a protective effect from further ruptures on the reconstructed ACL. LEVEL OF EVIDENCE: Level IV.

Extended trochanteric osteotomy is a safe procedure in two-stage hip revision: a systematic review of the literature.

BACKGROUND: Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate remains about its safety in periprosthetic joint infection (PJI). The primary aim of this study is to analyze the ETO reinfection and union rate in two-stage hip revision. MATERIAL AND METHODS: A systematic literature review was performed regarding all studies reporting ETO outcomes in the two-stage revision for hip PJI up to October 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search was conducted in the following databases: MEDLINE/EMBASE, Scopus, Web of Science, and Cochrane. Quality assessment of the articles was performed using the Methodological Index for Non-Randomized Studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews. Patient demographic, clinical, and surgical data were collected. RESULTS: This systematic review included and analyzed nine clinical studies with a total of 382 ETO PJI hips in two-stage revision. The overall ETO reinfection rate was 8.9% (34 hips), consistent with the reinfection rate after two-stage revision in patients without ETO. The overall ETO union rate was 94.8% (347 hips), comparable to the ETO union rate in non-septic patients. Compared between a group of patients with ETO PJI and a group of patients with non-PJI ETO, there were no significant differences in postoperative complications, both septic and aseptic, and for postoperative HHS. CONCLUSION: ETO proved to be a safe and effective procedure in PJI revisions. It may be a viable option in challenging femoral stem removal during the two-stage hip revision in PJI. LEVEL OF EVIDENCE: IV.

Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature.

BACKGROUND: Periprosthetic joint infection (PJI) of the knee represents a severe complication after 1.5% to 2% of primary total knee replacement. Although two-stage revision was considered the gold-standard treatment for PJI of the knee, in the last decades, more studies reported the outcomes of one-stage revisions. This systematic review aims to assess reinfection rate, infection-free survival after reoperation for recurrent infection, and the microorganisms involved in both primary and recurrent infection. MATERIAL AND METHODS: A systematic review of all studies reporting the outcome of one-stage revision for PJI of the knee up to September 2022, according to PRISMA criteria and AMSTAR2 guidelines, was performed. Patient demographics, clinical, surgical, and postoperative data were recorded. PROSPERO ID: CRD42022362767. RESULTS: Eighteen studies with a total of 881 one-stage revisions for PJI of the knee were analyzed. A reinfection rate of 12.2% after an average follow-up of 57.6 months was reported. The most frequent causative microorganism were gram-positive bacteria (71.1%), gram-negative bacteria (7.1%), and polymicrobial infections (8%). The average postoperative knee society score was 81.5, and the average postoperative knee function score was 74.2. The infection-free survival after treatment for recurrent infection was 92.1%. The causative microorganisms at reinfections differed significantly from the primary infection (gram-positive 44.4%, gram-negative 11.1%). CONCLUSION: Patients who underwent a one-stage revision for PJI of the knee showed a reinfection rate lower or comparable to other surgical treatments as two-stage or DAIR (debridement, antibiotics, and implant retention). Reoperation for reinfection demonstrates a lower success compared to one-stage revision. Moreover, microbiology differs between primary infection and recurrent infection. Level of evidence Level IV.

Periprosthetic patella fractures in total knee replacement and revision surgeries: how to diagnose and treat this rare but potentially devastating complication-a review of the current literature.

PURPOSE: Periprosthetic patella fractures (PPPFs) are infrequent but potentially devastating complications after total knee arthroplasty (TKA) and revision TKA (rTKA). These fractures may occur both in resurfaced and un-resurfaced patella. This review summarizes the current literature on PPPFs to help orthopedic surgeons diagnose and treat this uncommon but extremely challenging TKA complication. METHODS: A comprehensive search was performed in three databases: PubMed, SCOPUS, and EMBASE. All relevant information was retrieved and summarized in this narrative review. RESULTS: In the studies analyzed, there is a general trend in favor of nonsurgical treatment, except for implant loosening or extensor lag with extensor apparatus disruption, because surgery is often associated with poor clinical outcomes and high complication rates. CONCLUSION: PPPF is a rare but catastrophic event in TKA and rTKA, occurring mainly in a reconstructed patella. Patient-, implant-, and surgical technique-related factors contribute to its multifactorial etiopathogenesis. Prevention plays a crucial role in reducing the PPPFs rate. Conservative management is the treatment of choice due to high surgery complication rates unless implant loosening, or extensor apparatus disruption occurs.

Comparable results between crosslinked polyethylene and conventional ultra-high molecular weight polyethylene implanted in total knee arthroplasty: systematic review and meta-analysis of randomised clinical trials.

PURPOSE: Total knee arthroplasty (TKA) has experienced exponential growth over the last decade, including increasingly younger patients with high functional demands. Highly crosslinked polyethylene (HXLPE) has been proven effective in reducing osteolysis and loosening revisions while improving long-term survival and performance in total hip arthroplasty; nevertheless, this superiority is not demonstrated in TKA. The aim of this systematic review and meta-analysis was to examine whether HXLPE improved overall survival and postoperative functional and radiological outcomes compared to conventional polyethylene (CPE) in TKA. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, a literature search of five databases (PubMed, Medline, Scopus, Science Direct and Embase) was made. A PICOS model was performed. The initial screening identified 2541 studies. Each eligible clinical article was analysed according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (LoE). Only randomised clinical trials (RCTs) of LoE 1 and 2 were included. The methodological quality of the articles was assessed using the Risk of Bias 2 (RoB 2) tool. RESULTS: Six clinical studies were included in the final study. This systematic review and meta-analysis were registered on the International Prospective Register of Systematic Reviews (PROSPERO). A total of 2285 knees were included. Eight outcomes (total reoperations, reoperations for prosthesis loosening and infections, radiolucent lines, osteolysis, mechanical failure, postoperative KSS knee score and function score) were analysed. For none of them, a statistically significant difference was found about the superiority of HXLPE over CPE (p > 0.05). CONCLUSIONS: There were no statistically significant differences between HXLPE and CPE for TKA concerning clinical, radiological, and functional outcomes; nevertheless, HXLPE did not show higher failure rates or complications and can be safely used for TKA. LEVEL OF EVIDENCE: II.

Outcomes at 20 Years After Meniscectomy in Patients Aged 50 to 70 Years.

PURPOSE: To report the outcomes of arthroscopic meniscectomy (AM) at 20 years of follow-up through timing/rate of conversion to total knee replacement (TKR) and Knee Injury and Osteoarthritis Outcome Score (KOOS), focusing on detection of specific predictor variables for these outcomes, in patients 50 to 70 years old. METHODS: We performed a retrospective study of 289 patients, ages at surgery 50 to 70 years, with diagnosis of degenerative meniscal tear who underwent arthroscopic meniscectomy. We collected the following baseline data: age, sex, injured meniscus (medial, lateral, or both), knee alignment, osteoarthritis (OA), associated lesion identified during arthroscopy, and associated procedure performed during arthroscopy. At 20 years of follow-up, we collected rate and timing of TKR conversion, and we evaluated clinical outcomes with KOOS. RESULTS: Female sex (P < .01), older age (P < .01), lateral meniscectomy (P = .02), malalignment (P = .03), and advanced chondral lesion (P < .01) were found to be significantly related to subsequent TKR. No significant correlation was found between amount of resection and subsequent TKR (P = .26). Negative predictor factors to obtain equal or superior to age- and sex-adjusted KOOS scores were age 60 to 70 years at time of AM (P = .03) and lateral meniscectomy (P = .02). CONCLUSIONS: We report a 15.7% conversion rate at 20 years from AM to TKR and a mean time between surgeries of 7 years. Subsequent TKR in the 20 years after AM for degenerative meniscus tears were significantly associated with preoperative OA and chondral lesion (Kellgren Lawrence 2; Outerbridge >2), lateral meniscectomy, age at surgery, female sex, and malalignment. Furthermore, age >60 years, lateral meniscectomy, and concurrent anterior cruciate ligament reconstruction were negative predictors for poor clinical outcomes at 20 years. Therefore, if patients present with negative predictor factors, the AM should not be proposed as second-line treatment, and nonoperative management should be continued until TKR is unavoidable. LEVEL OF EVIDENCE: IV, case series.

Kinetic Sensors for Ligament Balance and Kinematic Evaluation in Anatomic Bi-Cruciate Stabilized Total Knee Arthroplasty.

Sensor technology was introduced to intraoperatively analyse the differential pressure between the medial and lateral compartments of the knee during primary TKA using a sensor to assess if further balancing procedures are needed to achieve a "balanced" knee. The prognostic role of epidemiological and radiological parameters was also analysed. A consecutive series of 21 patients with primary knee osteoarthritis were enrolled and programmed for TKA in our unit between 1 September 2020 and 31 March 2021. The VERASENSE Knee System (OrthoSensor Inc., Dania Beach, FL, USA) has been proposed as an instrument that quantifies the differential pressure between the compartments of the knee intraoperatively throughout the full range of motion during primary TKA, designed with a J-curve anatomical femoral design and a PS "medially congruent" polyethylene insert. Thirteen patients (61.90%) showed a "balanced" knee, and eight patients (38.10%) showed an intra-operative "unbalanced" knee and required additional procedures. A total of 13 additional balancing procedures were performed. At the end of surgical knee procedures, a quantitatively balanced knee was obtained in all patients. In addition, a correlation was found between the compartment pressure of phase I and phase II at 10° of flexion and higher absolute pressures were found in the medial compartment than in the lateral compartment in each ROM degree investigated. Moreover, those pressure values showed a trend to decrease with the increase in flexion degrees in both compartments. The "Kinetic Tracking" function displays the knee's dynamic motion through the full ROM to evaluate joint kinetics. The obtained kinetic traces reproduced the knee's medial pivot and femoral rollback, mimicking natural knee biomechanics. Moreover, we reported a statistically significant correlation between the need for soft tissue or bone resection rebalancing and severity of the initial coronal deformity (>10°) and a preoperative JLCA value >2°. The use of quantitative sensor-guided pressure evaluation during TKA leads to a more reproducible "balanced" knee. The surgeon, evaluating radiological parameters before surgery, may anticipate difficulties in knee balance and require those devices to achieve the desired result objectively.

Treatment of knee osteoarthritis by intra-articular injection of concentrated autologous adipose tissue: a twenty four month follow-up study.

PURPOSE: To evaluate the safety and efficacy of autologous concentrated adipose tissue for the treatment of knee OA. METHODS: Eighty-seven patients with knee arthritis from grade 1 to 3, according to Kellgren-Lawrence scale, have been treated with knee arthroscopy and successive intra-articular injection of concentrated adipose tissue. The efficacy of the treatment has been evaluated by the Knee Society Score, Lysholm Score, Forgotten Joint Score, Knee Injury and Osteoarthritis Outcome Score and Noise Reporting Scale. RESULTS: A total of 78/87 patients concluded the study. Overall, the patients were satisfied with the intervention and a significant reduction of the pain was observed in 67 patients, while the others did not report any change in pain severity or worsening. A statistically significant improvement was observed in the considered orthopaedic index, and no major adverse effects were described. The first week after the intervention, most patients reported knee swelling. Five patients failed because they underwent knee replacement surgery between five and nine months from treatment. CONCLUSIONS: In patients with knee OA, a single intra-articular injection of autologous adipose tissue reduced knee pain, stiffness, improved knee function and quality of life without severe complications.

Functional results of allograft vs. autograft tendons in anterior cruciate ligament (ACL) reconstruction at 10-year follow-up.

PURPOSE: The anterior cruciate ligament (ACL) tear is one of the most common sports injuries of the knee, and the arthroscopic reconstruction is the gold standard. Nevertheless, controversies about the surgical techniques and the type of graft still exist. Allografts have been considered by many surgeons as valid alternative to autografts. The aim of this study was to assess the effectiveness of allografts compared to autografts at approximately 10 years of follow-up, investigating the level of physical activity currently performed by patients of each group. METHODS: Ninety-four patients, divided into two groups (allografts and autografts), have been retrospectively studied. The two groups did not significantly differ in preoperative sport activity level, age (mean 40.70 years for autografts and 41.23 for allografts) and characteristics. Allograft group received a fresh-frozen graft from the musculoskeletal tissues bank. Evaluations were made using the International Knee Documentation Committee (IKDC) and Lysholm score; every patient was interviewed for complications. RESULTS: The mean follow-up time was approximately 10 years for both groups, with a minimum of 8 years. There were no statistically significant differences between the two groups. Average IKDC scores were 75.21 (SD 15.36) and 80.69 (SD 13.65) for the allograft and autograft groups, respectively. The mean Lysholm score was 87.57 (SD 9.43) for the allografts and 89.10 (SD 8.33) for the autografts. No major complications linked to the allograft tissue arose. CONCLUSION: Both groups achieved almost the same functional outcomes at an average 10 years of follow-up, indicating fresh-frozen allografts as a reasonable alternative for ACL reconstruction. LEVEL OF EVIDENCE: IV, Retrospective case-control study.

All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).

PURPOSE: The aim of this study was to define the subjective and objective clinical results of all-inside surgical technique at a medium-term follow-up and to compare these results with those obtained from antero-medial (AM) ACL reconstruction technique using hamstrings (HS) or bone-patellar tendon-bone (BpTB) grafts to detect eventual superiority of one technique to another. METHODS: A retrospective analysis of routinely collected data was conducted. Inclusion criteria were ACL reconstruction through all-inside technique or AM technique with HS or BpTB performed between January 2015 and May 2018; age between 15 and 30 year old; minimum 24 months' available follow-up. Exclusion criteria were contralateral ACL reconstruction; need for any other associated procedures during surgery. Clinical outcomes were assessed with KOOS, Lysholm, Tegner scores and KT-1000 device. RESULTS: According to the selection criteria, 157 patients were enrolled and divided subsequently into 3 groups: all-inside (51 patients), AM-HS (53 patients) and AM-BpTB (53 patients). A significant postoperative improvement of each score in all groups was detected. The mean KT-1000 was 3.1 ± 1.0 mm in all-inside group, while 3.3 ± 1.4 mm and 2.5 ± 0.4 mm in AM-HS and AM-BpTB groups, respectively. Comparing the results obtained, no statistically significant difference was found between the three techniques (p = 0.27). Statistically significant differences were highlighted in surgical duration: all-inside method was the longest (117'), followed by AM-BpTB surgery (101') and AM-HS technique (87'). CONCLUSIONS: The all-inside technique showed good postoperative results at medium-term follow-up. It could be a valuable solution for ACL reconstruction, especially in young patients due to its less invasiveness, despite surgical skills and time needed. LEVELS OF EVIDENCE: Level IV.

How much does saving femoral head cost after acetabular fracture? Comparison between ORIF and THA.

We performed a prospective study on patients with acetabular fractures treated either with internal fixation either with arthroplasty comparing clinical outcomes, quality of life, economic resources and cost efficacy in the first five years after surgery. Demographic data, diagnosis, index treatment, costs and subsequent surgeries were recorded. Patients were requested to fulfill Merle d'Aubigné and EQ-5D-5L questionnaires. Clinical differences between treatments are significant only in discharge period. Comparing respectively group with fixation and arthroplasty, cost efficacy was 5483 and 10838 euros/quality-adjusted-life years, mean global costs 23965 and 16878 € and quality of life gained in five years 2.788 and 3.175. Group of arthroplasty showed better quality of life at discharge and at one year. If choice between fixation and arthroplasty should be based only on cost-efficacy, arthroplasty should be suggested but clinical outcomes suggest to consider fixation because results at five years are not different to arthroplasty.

Intravenous use of tranexamic acid reduces postoperative blood loss in total knee arthroplasty.

INTRODUCTION: Blood transfusion is often required in total knee replacement (TKR); several methods of blood preservation are commonly used but the ideal solution is to reduce the blood loss during and after surgery. Aim of the study was to evaluate the hemostatic efficacy and safety of intravenous use of tranexamic acid in patients receiving TKR (cemented). MATERIALS AND METHODS: Forty-five patients after TKR receive treatment with tranexamic acid (TXA, treatment group), and 45 were managed with fibrin tissue adhesive (control group). Hemoglobin values decrease and transfusions in both groups were recorded. Statistical analysis was performed with Student t test and χ (2) test. A statistical model was elaborated to evaluate together all variables and to underline what data can increase transfusions need. RESULTS: A significant reduction was detected in hemoglobin values in the first 3 days after surgery in the treatment group. The difference in all cases was significant. When tranexamic acid was administered, the need for transfusions was lower (difference statistically significant). No major adverse events were recorded in our series. The use of autologous blood preparation before surgery led to a higher transfusion rate. CONCLUSION: Tranexamic acid reduced blood loss in TKR and significantly reduced the blood transfusion need also when compared to fibrin tissue adhesive. The use of tranexamic acid is safe and in future may avoid preparation of autologous blood unit before surgery with a decrease of cost and medical figures involved.

Tibial plateau fractures are associated with ligamentous and meniscal injuries. Preoperative evaluation of magnetic resonance imaging influences surgical treatment.

BACKGROUND: Tibial plateau fractures (TPFs) are usually associated with ligamentous or meniscal injuries that could remain misdiagnosed. An appropriate and early recognition may change the surgical management of these soft tissue injuries (STIs) that could be addressed concomitantly with TPF treatment. Magnetic resonance imaging (MRI) is an efficient diagnostic test to identify all associated STIs in TPFs. This study aims to analyze the MRI impact in identifying and guiding the STIs treatment in TPFs. MATERIAL/METHODS: This retrospective study included a consecutive series of 57 patients with TPFs treated between January 1st, 2022, and December 31st, 2022. All fracture patterns were classified according to the AO/OTA and Schatzker classification. The prevalence of STIs, including medial meniscus (MM), lateral meniscus (LM), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) injuries, was assessed through the MRI evaluation. RESULTS: A statistical significance was found regarding the MRI detection of LM, ACL, PCL and MCL injuries that led to additional surgical procedures at the same time as the TPFs treatment (p < 0.05). In contrast, the amount of additional MM and LCL injuries identified by MRI, which resulted in other surgical procedures, was not statistically significant (p > 0.05). CONCLUSIONS: Preoperative MRI has been demonstrated to be an effective procedure for diagnosing STIs in TPFs, significantly influencing and changing the surgical treatment. LEVEL OF EVIDENCE: IV.

Bi-cruciate retaining total knee arthroplasty is here to stay: A consecutive series transitioning from manual instrumentation to enabling technologies.

BACKGROUND: Bicruciate-retaining (BCR) total knee arthroplasty (TKA) has seen renewed interest due to the potential for more natural knee kinematics with anterior cruciate ligament (ACL) retention. OBJECTIVE: The present study attempts to determine differences in the 2-year survivorship and patient-reported outcomes between two surgical strategies (traditional instrumentation versus robotics) applied to the extensive use of a modern, 2nd generation BCR TKA design. METHODS: We performed a retrospective study with prospectively collected data of 113 patients who underwent primary TKA between 2018 and 2020 using a 2nd generation BCR TKA implant. Patient demographics, PROMS, and intra/post-operative complications were collected. Patients were also evaluated according to the use or not of robotics. A Kaplan-Meier analysis was used to evaluate revision-free survival at follow up. RESULTS: 102 patients were enrolled: 90 received traditional surgery and 12 robotic-assisted surgery. The mean age was 68 years (SD 7.76) with an average BMI of 29.6 kg/m2 (SD 3.56). The mean follow up (FU) was 32.4 ± 6.2 months (range 24-45 months). Survivorship at 2 years was 98% (95% CI: 92.4-99.5). Revisions/reoperations were performed for anterior cruciate ligament (ACL) tear (1/4), pain (1/4), arthrofibrosis (1/4) and acute periprosthetic joint infection (PJI) (1/4). At final FU, 92 patients (90.2%) considered themselves satisfied, showing a mean OKS of 40.6 (SD 5.1) and a mean FKS of 76.7 (SD 11.8). No differences in the outcome were found between traditional and robotic-assisted procedures. CONCLUSION: The modern BCR design evaluated in this study achieved excellent results in terms of implant survivorship, low rate of reoperation and clinical results, independently from the use of enabling technologies.