Learning curve of Persona Partial Knee (PPK) arthroplasty: a clinical trial.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) procedures are considered to be more technically demanding than conventional total knee arthroplasty (TKA), requiring a longer learning curve and more expert surgical skills. Despite some clear advantages of UKA over TKA (such as lesser blood loss, greater bone stock, greater knee performances, etc.), UKA evidenced a greater rate of revision. OBJECT: This study investigated the learning curve of Persona Partial Knee (PPK) arthroplasty for primary medial UKA performed by a single, non-designer surgeon. PPK is a fixed-bearing, compartment-specific implant. The primary outcome of interest for this study was to evaluate the learning curve of the surgical duration. The secondary outcome of interest was to evaluate the learning curve of radiological implant positioning. METHODS: Patients who underwent primary medial UKA using PPK (Zimmer-Biomet, Warsaw IN, USA) were prospectively enrolled for the study. All surgeries were performed by a single, non-designer surgeon experienced in knee and hip arthroplasty. The primary outcome of interest was to evaluate the surgical duration. The secondary outcome of interest was to evaluate the implant positioning. The learning curve was estimated using an appropriate nonlinear polynomial regression model with a lower Akaike Information Criterion (AIC). RESULTS: One hundred twenty five patients were enrolled in the study. 59% of them (74 of 125 patients) were women. The patients' mean age at the time of surgery was 70.1 ± 9.5 years and their mean body mass index (BMI) was 27.8 ± 4.2 kg/m2. Curve stabilisation of the surgical time was at the 94th patient, of the tibial angle at the 47th patient, of the tibial slope at the 54th patient, of the anterior protrusion at the 29th patient, and of the posterior protrusion at the 51st patient. CONCLUSIONS: The learning curve for component positioning was achieved in approximately 50 cases. The curve of the surgical time achieved a plateau at 94 Persona Partial Knee. Additionally, the factors directly correlated with earlier stabilization of the learning curve in terms of component positioning were: male gender, younger age, right side, and larger components.

Editorial Commentary: Don't Neglect the Medial Side of the Knee in Patients With Anterior Cruciate Ligament Injury.

The medial collateral ligament (MCL) of the knee, as well as the posteromedial complex (including the posterior oblique ligament [POL] and ramp lesions of the meniscus) is often considered the "neglected" ligament or corner because of the belief that these anatomic structures have enormous regenerative potential and therefore hardly ever need surgical treatment. In patients with anterior ligament cruciate (ACL) tears, the overall combined prevalence of MCL (superficial [sMCL] and deep [dMCL]) and isolated dMCL injuries is high (16.5% + 24.8% = 41.3%). In terms of the POL, with a restraint to both internal tibial rotation and valgus rotation during extension, I have some doubts regarding its role in anteromedial instability (AMRI). In fact, AMRI of the knee is caused mainly by injury to both the ACL and the MCLs, resulting in coupled anterior tibial translation and external rotation, causing the medial tibial plateau to subluxate anteriorly. The sMCL provides the most substantial restraint, and the dMCL and POL play more minor roles. Finally, in ACL-deficient knees, ramp lesions are prevalent (9.3%-24.0%), and failing to identify and treat these lesions results in knee instability. In my experience, all unstable ramp lesions should be repaired. In ACL-deficient knees in patients with a tibial slope >5°, an occult ramp lesion should be strongly suspected. In summary, the medial compartment of the knee is complex and encompasses many structures (MCL, POL, ramp, tibial slope), and I believe that we will increasingly move toward individualized treatment.

Quality of YouTube Videos Regarding Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft Is Unsatisfactory.

PURPOSE: To assess the validity and informational value of teaching material regarding anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon (QT) autograft provided on the YouTube video platform. METHODS: An extensive systematic search of the YouTube video platform was performed, and all videos that met the criteria were included in the analysis. The analysis of the video content was performed using the DISCERN instrument, Journal of American Medical Association (JAMA) benchmark criteria, and Global Quality Score (GQS). The duration of the videos, the date of publication, and the number of likes and views were recorded. Furthermore, videos were categorized based on the source (physicians, companies, patients), the subject (surgical technique, patient experience and overview [overview videos were videos in which multiple aspects were analyzed]), and the type of content (educational or subjective patient experience). RESULTS: A total of 88 videos were included in the analysis. Seventy-one (80.7%) videos were published by physicians, 15 (17.0%) by patients, and 2 (2.3%) by companies. The majority of the videos described various surgical techniques (59%-67.0%), 80.7% of the videos (72%-81.8%) had an educational nature, and the remaining 18.2% described patient experiences. The mean length of the videos was 8.21 ± 7.88 minutes. The mean number of views was 3,988.51 ± 9,792.98 (range 9-56,047), whereas the mean numbers of comments and likes were 30.07 ± 70.07 (range 0-493) and 4.48 ± 14.22 (range 0-82), respectively. The mean DISCERN score, JAMA score, and GQS were 27.43 ±11.56 (95% confidence interval [CI] 25.01-29.85; range: 17-68), 1.22 ± 0.85 (95% CI 1.04-1.40; range 0-3), and 1.82 ± 0.93 (95% CI 1.63-2.01; range 1-4), respectively. For all scores, videos published by physicians had greater quality (DISCERN score, JAMA score, and GQS) (P < .05). Among all of the analyzed videos, overview videos were of the highest quality (P < .05). CONCLUSIONS: YouTube is a fast and open-access source of mass information. The overall quality of the videos on ACLR performed using QT autograft was unsatisfactory, demonstrating low educational quality and reliability. Currently, YouTube cannot be recommended as a reliable source of information on ACLR with the QT.

Both Hamstring and Quadriceps tendon autografts offer similar functional outcomes after arthroscopic ACL reconstruction in patients over 50 years of age.

PURPOSE: The purpose of this study was to compare the outcomes of hamstring tendon (HT) and quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction in patients older than 50 years in terms of patient-reported functional outcomes, graft failure rates, complications, return to sports activity and the preference for sports. METHODS: Between 2010 and 2022, prospectively collected data were obtained from an institutional database. Patients older than 50 years with primary arthroscopic ACL reconstruction using either HT or QT autograft and a minimum of 2 years of follow-up were included. Patients with concomitant meniscus, cartilage and MCL injury were also included. Patients undergoing a revision ACL reconstruction or undergoing a primary ACL reconstruction using a graft other than HT or QT autograft, and patients with a contralateral knee injury or ipsilateral osteoarthritis (Ahlback stage 2 or higher) were excluded. Patients were evaluated for pre-injury and 2-year follow-up Lysholm knee score, Tegner activity level, Visual Analog Scale (VAS) for pain, graft failure, quadriceps tendon rupture, and return to sport. Mann-Whitney test was used for unpaired samples, whereas the Friedman test was used for analyzing variables over time. The chi-square statistic test was used to determine differences in categorical data between groups RESULTS: The number of patients in the QT and HT groups was 85 and 143 respectively. The mean age was 54.4 [50-65] and 56.4 [50-65] for the QT and HT groups respectively, 49% and 51% were males in the QT and HT groups respectively. The two groups did not differ significantly in terms of age, gender, time from injury to surgery and concomitant injuries. No significant differences were found in the pre-injury patient-reported outcome scores (PROMs) as Lysholm, Tegner activity level and VAS for pain between the two groups (p>0.05). At the 2-year follow-up, Lysholm knee score, Tegner activity level and VAS for pain improved to pre-injury level and no significant difference was noted between pre-injury and 2-year follow-up functional scores between the two groups (p>0.05). Furthermore, at the 2-year follow-up, Lysholm score, and VAS didn't show significant differences between QT and HT groups. (p=.390; p= .131). Similarly, no differences have been reported in Tegner activity level scores between HT and QT groups at 2 years of follow-up. No significant differences in terms of minimal clinically important difference (MCID) have been detected between the two groups for Lysholm and Tegner activity scores (p = 0.410 and p = 0.420 for Lysholm score and Tegner activity level score respectively). The two groups did not differ in terms of patient's percentage of sports participation at baseline, and 2 years of follow-up (p>0.05). A significant decrease (p=0.01) in skiing/snowboarding was reported in the HT group at a 2-year follow-up compared to baseline [116 (81%) vs 98 (69%)]. No case of graft failures and quadriceps tendon rupture was reported in either of the groups. CONCLUSION: Arthroscopic ACL reconstruction by using HT or QT autograft in athletically active older than 50 years patients provide satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity.

High incidence of RAMP lesions and a nonnegligible incidence of anterolateral ligament and posterior oblique ligament rupture in acute ACL injury.

PURPOSE: The purpose of this study was to assess the frequency of medial collateral ligament (MCL), posterior oblique ligament (POL) and anterolateral ligament (ALL) tears and different types of RAMP lesions of patients with verified acute anterior cruciate ligament (ACL) tears by magnetic resonance imaging (MRI). METHODS: MRI was performed on patients with a clinical diagnosis of acute ACL injury. Patients were eligible for inclusion if they had an initially clinically noted ACL tear confirmed on MRI within 30 days of trauma. RESULTS: A total of 146 patients were included in the study, 42 (28.8%) females and 104 (71.2%) males. The mean age at MRI was 27.2 ± 9.4 years, and the mean time from injury to MRI was 15.7 ± 7.8 days. Thirty-four (23.3%) patients had a complete MCL lesion, 32 (21.9%) had a complete POL lesion and 28 (19.2%) had a complete ALL lesion. One hundred and fourteen patients (78.1%) presented with RAMP lesions, while 20 (13.7%) patients reported other meniscal lesions. The mean medial and lateral tibial slopes were 4.0° ± 2.7° and 4.0° ± 3.1°, respectively. Only 10 (6.8%) patients reported no lesions associated with ACL rupture. The most common injuries were isolated RAMP type 3 (18-12.3%) and isolated RAMP type 1 (17-11.6%). Thirteen (8.9%) patients had a combination of MCL, POL and ALL rupture. CONCLUSIONS: Isolated lesions of the ACL are extremely rare. In most cases, a single RAMP lesion should be investigated. In the presence of MCL injury, POL injury should always be suspected as well, while nearly 20% of patients present a rupture of the ALL. About one in 10 patients had three lesions (MCL, ALL and POL), and most of them had a combined RAMP lesion. LEVEL OF EVIDENCE: Level IV.

Outcomes and complications of Total Hip Arthroplasty in patients with a pre-existing pathologic spine-hip relation. A systematic review of the literature.

BACKGROUND: There has been a growing interest in pathologic spine-hip relations (PSHR) in current literature, with the aim of reducing the risk of prosthetic impingement, dislocation, and edge loading in total hip arthroplasty (THA). The primary objective of this review is to determine the effect of different PSHR on primary THA outcomes and complication profile. The secondary objective is to stratify the risk of different subgroups of PSHR patients. METHODS: A systematic review of the literature was performed in accordance with PRISMA guidelines. Randomised controlled trials, comparative cohort studies and case-control studies comparing outcomes and complication rates of primary THA in patients with and without a PSHR (spinal fusion; degenerative spinal conditions determining stiff spine and/or spinal misalignment) were included. The quality of the included studies and the risk of bias were assessed. The revision rate, complications, and clinical and radiological data were analysed. Complications included: aseptic loosening (AL), periprosthetic joint infections (PJI), hip dislocations and periprosthetic fractures (PF). RESULTS: Fifteen articles were included with 3.306.342 THAs. The mean follow-up (FU) was 31.4 ± 21.7 months. The population was divided into three subgroups: spinal fusion patients (48.315 THAs); non-fused patients with spinal stiffness (106.110 THAs); non-fused patients with normal spines (3.151.917 THAs). A statistically significant risk stratification was observed about dislocation rate (5.98 ± 6.9% SF, 3.0 ± 1.9% non-SF Stiff and 2.26 ± 1.4% non-SF; p = 0.028). Similarly, about THA revision rate, a statistically significant risk stratification was also observed (7.3 ± 6.8% SF, 6.4 ± 3.1% non-SF Stiff and 2.7 ± 1.7% non-SF; p = 0.020). No statistically significant difference was observed when analysing AL, PJI and PF. CONCLUSION: A statistically significant risk stratification of dislocation and revision rate was observed in the different PHSR, as theorised by the Bordeaux classification. Fused patients present a higher risk, degenerated and/or stiff spine an intermediate risk and mobile spines a lower risk profile. A standardised approach to THA candidate patients must consider the possible PSHR to improve clinical outcomes and reduce adverse events of THA.

Change in patellar height in medial and lateral unicompartmental knee arthroplasty: a clinical trial.

INTRODUCTION: Evidence on patellar height changes following unicompartmental knee arthroplasty (UKA) is lacking. Therefore, this study compared the patella height in patients who underwent medial versus lateral UKA. Moreover, a subgroup analysis was conducted to investigate whether sex, age, and BMI of the patients exert an influence on the postoperative patellar height. METHODS: Radiographs and hospital records of patients undergoing UKA were prospectively collected. Surgeries were performed by one author with long experience in UKA in a highly standardised fashion. The implants were fixed-bearing medial PPK (Zimmer Biomet, Warsaw, Indiana, USA) and fixed-bearing lateral ZUK (Lima Corporate, Udine, Italy). The patellar height was measured using the Insall-Salvati and Caton-Deschamps indices. RESULTS: A total of 203 patients were included: 119 patients were included in the medial and 84 in the lateral UKA. The mean age of the patients was 68.9 ± 6.7 years, and the mean BMI was 28.1 ± 4.1 kg/m2. 54% (110 of 203 patients) were women. On admission, between-group comparability was found in age, BMI, sex, and length of the follow-up. No between-group and within-group difference was detected pre- and post-operatively in the Insall-Salvati and Caton-Deschamps indices in patients who have undergone medial versus lateral UKA. Concerning the subgroup analyses, no between-group and within-group difference was detected pre- and post-operatively in all comparisons according to sex, age, and BMI. CONCLUSION: No difference was found in patella height in patients who have undergone medial compared to lateral UKA. Furthermore, there was no evidence of an association between patient characteristics (sex, age, BMI) and patella height between medial and lateral UKA.

Italian research on anterior cruciate ligament: a bibliometric analysis.

INTRODUCTION: This study analysed the trend of publications on anterior cruciate ligament (ACL) in Italy. It was hypothesised that publications on this topic have quickly increased in recent years due to increased knowledge of both clinical and radiological pathology. METHODS: PubMed and Scopus were accessed on 29/11/2023. This retrieved 838 articles from PubMed and 1050 from Scopus. We analysed the top 10 authors, and journals in publication numbers, citation numbers, and citations per year. We have also looked at the top 10 institutions publishing on anterior cruciate ligament from Scopus as PubMed does not give this information in the output. Data mining was performed using the Orange software, Mac version 3.32.0 ( https://orangedatamining.com/ ) from the titles of all articles. A word cloud analysis of titles, authors, journals and universities was performed. RESULTS: The peak of citations was in 2017 with 1529, whilst the peak of publications was in 2019 with 59 articles published. Analysing the number of publications and citations for the journal, the most impacted journal is Knee Surgery, Sports Traumatology, Arthroscopy with 5472 citations and 183 articles, followed by The American Journal of Sports Medicine, with 2722 citations and 56 articles and Arthroscopy with 1990 citations and 62 articles. Considering also international collaborations, the most cited author is Della Villa F. in 2020 with 43.67 citations per year. The Italian author with the major number of publications is Zaffagnini S. with 39 articles, whilst the author with the higher number of citations is Aglietti P. with 1612 citations. CONCLUSIONS: ACL reconstruction has gained growing interest amongst the scientific community. Publications and citations presented a rising trend, the majority of the highly cited papers were contributed by few centres, and clinical trials were the most cited study designs. The long-term outcomes of ACL lesions have attracted interest. The authors hypothesised that shortly there will be an increase in articles analysing the results of ACL revisions, the use of lateral extra-articular tenodesis, and meniscus transplants. LEVEL OF EVIDENCE IV: Cross-Sectional Study.

TikTok content as a source of health education regarding epicondylitis: a content analysis.

PURPOSE: This study aimed to assess the validity and informational value of TikTok content about epicondylitis. The hypothesis tested herein was that TikTok video content would not provide adequate and valid information. METHODS: The term "epicondylitis" was used as a keyword to comprehensively search for TikTok videos, and the first 100 videos that were retrieved were subsequently included for analysis. The duration, number of likes, number of shares and number of views were recorded for each video. Furthermore, the videos were categorized on the basis of their source (medical doctor, physiotherapist, or private user), type of information (physical therapy, anatomy, clinical examination, etiopathogenesis, patient experience, treatment, or other), video content (rehabilitation, education, or patient experience/testimony), and the presence of music or voice. Assessments of video content quality and reliability were conducted using the DISCERN tool, the Journal of the American Medical Association (JAMA) benchmark criteria, and the Global Quality Score (GQS). RESULTS: A total of 100 videos were included in the analysis: 78 (78.0%) were published by physiotherapists, 18 were published by medical doctors (18.0%), and 4 were published by private users (4.0%). Most of the information pertained to physical therapy (75; 75.0%) and most of the content was about rehabilitation (75; 75.0%). The mean length of the videos was 42.51 ± 24.75 seconds; the mean number of views was 193,207.78 ± 1,300,853.86; and the mean number of comments, likes, and shares were 22.43 ± 62.54, 1578.52 ± 8333.11, and 149.87 ± 577.73, respectively. The mean DISCERN score, JAMA score, and GQS were 18.12 ± 5.73, 0.80 ± 0.53, and 1.30 ± 0.52, respectively. Videos posted by medical doctors/private users had higher scores (p < 0.05) than videos posted by physiotherapists. Videos that focused on education or patient experience had higher scores (p < 0.05) than videos based on rehabilitation. CONCLUSIONS: TikTok can be an unreliable source of information regarding epicondylitis treatment. It is common to find nonphysicians who share medical advice on the platform, with medical treatments demonstrating the weakest level of supporting evidence. Elbow surgeons should advise their patients that treatment recommendations from TikTok may not align with established guidelines. LEVEL OF EVIDENCE: Level IV-Cross-sectional study.

Similar Clinical Outcomes for Arthroscopic Labral Reconstruction in Irreparable Cases Using the Indirect Head of the Rectus Femoris Tendon With an All-Inside Technique for Small Defects and the Iliotibial Band For Large Defects.

PURPOSE: The primary objective of this study was to evaluate the clinical outcomes and satisfaction rate of patients who underwent arthroscopic labral reconstruction for an irreparable labral tear with a minimum follow-up period of 2 years. Additionally, this study aimed to compare 2 different reconstructive techniques for small and large labral defects: the indirect head of the rectus femoris tendon (IHRFT) autograft with an all-inside technique used to repair small defects (≤3 hours) and the iliotibial band (ITB) autograft for large defects (>3 hours). METHODS: A total of 24 hips treated with the IHRFT were compared with 24 hips treated with the ITB. All patients underwent clinical evaluation before surgery and during the most recent follow-up (42 ± 18 months). The evaluation included patient satisfaction, the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score (HOS), the Hip Outcome Score-sport subscale (HOS-ss), the 12-item International Hip Outcome Tool (iHOT-12), and the visual analog scale (VAS) pain score. RESULTS: All clinical scores were significantly improved (P < .001) at the latest follow-up in both groups. The final satisfaction was 7.1 ± 2.8 and 8.8 ± 1.6 for the IHRFT and ITB groups, respectively (P = .006). There was a significant difference in age (41.2 ± 6.0 years for the IHRFT group and 33 ± 8.5 for the ITB group; P = .004) and in surgery time (147.3 ± 39.4 minutes for the ITB group and 105.3 ± 25.7 for the IHRFT group; P < .001). One patient (4.2%) in the IHRFT group underwent total hip arthroplasty after 21.3 months (P = .999). CONCLUSIONS: At the 2-year follow-up, treating small defects using IHRFT and larger defects using ITB resulted in good Patient Reported Outcome Measures with a low rate of complications and failures. The ITB group reported a higher level of satisfaction at the final follow-up. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Good clinical and radiological results following remnant-preserving posterior cruciate ligament reconstruction: a systematic review.

PURPOSE: The objective of this systematic literature review was to report the results and complications of recent remnant preservation techniques in posterior cruciate ligament (PCL) reconstruction. METHODS: A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "posterior cruciate ligament" or "PCL" and "remnant preserving." The outcome measures extracted from the studies were the Lysholm score, the International Knee Documentation Committee's (IKDC) subjective and objective scores, Tegner scores, Orthopädische Arbeitsgruppe Knie (OAK) rate of return to sports, and rate of complications. Data were also extracted from studies that used stress radiographs to perform a quantitative assessment of the preoperative and postoperative anteroposterior stability. RESULTS: The systematic review included 13 studies. The patient cohort of consisted of 643 participants (544 [84.6%] men and 99 [15.4%] women) with a mean age of 32.9 ± 4.0 years. The mean postoperative follow-up was 34.5 ± 10.9 months (range: 24-96 months), while the mean time from injury to surgery was 14.4 ± 9.9 months (range: 0-240 months). All studies reported clinically significant improvement at final follow-up, as evident from the measured subjective and objective IKDC scores, Lysholm score, Tegner score, and OAK rate. Only three studies reported return to sports activity, with a mean percentage of 90.8% (99/109). All studies showed a significant improvement in posterior translation, from 11.5 ± 1.2 mm to 3.3 ± 1.1 mm, using radiography (side-to-side difference). This systematic review revealed 13 (2.0%) failures and 33 (5.1%) minor complications: 10 (1.6%) cases of stiffness, 21 (4.9%) screws removal, 1 (0.2%) injury of the peroneal nerve, and 1 (0.2%) fibular fracture. CONCLUSIONS: With the currently available data, all studies included in the review on posterior cruciate ligament reconstruction with remnant preservation demonstrated satisfactory outcomes at mid-term follow-up (> 24 months), despite varying surgical techniques and graft types, and intervals from injury to surgery. For clinical relevance, standard PCL reconstruction is a highly effective operation in terms of improvement in functional status, knee stability, quality of life, and cost effectiveness. The remnant preservation technique requires more comprehensive diagnostic assessments of the PCL remnant patterns and more complicated surgical procedures. Given the absence so far of high quality studies with long-term follow-up, the remnant-preserving techniques should be recommended only by experienced knee arthroscopic surgeons. LEVEL OF EVIDENCE: Level IV. STUDY REGISTRATION: reviewregistry1376- www.researchregistry.com .

Quadriceps tendon autograft with or without bone block have comparable clinical outcomes, complications and revision rate for ACL reconstruction: a systematic review.

PURPOSE: The purpose of this systematic review is to report complications, graft failure, fixation methods, rehabilitation protocol, clinical and patient-reported outcomes, and return to sports with the use of quadriceps tendon graft with the bone block (QT-B) and without bone block (QT-S). METHODS: According to the PRISMA guidelines a comprehensive search was performed across PubMed/MEDLINE, Scopus, EMBASE, and Cochrane Library databases from inception until April 2022. Only prospective studies using quadriceps tendon autograft with a minimum of 20 patients were considered for inclusion. The outcome measures extracted from the studies were the KT-1000, Lysholm score, Subjective and Objective IKDC, Tegner, Marx Score, complications, failures and/or revision surgery, and rate of return to sports. Cochrane risk of bias and MINORS tool were used for the risk of bias assessment of all included studies. RESULTS: A total of 13 studies were included, consisting of 5 randomized controlled trials, 6 cohort studies, 1 case-control and 1 case series. A total of 484 patients received QT-S in 6 studies of which 224 (46.2%) were males and 212 (43.8%) females with a mean age of 21.5 ± 7.5 (range 14-58). While 243 patients received QT-B in 7 studies of which 167 (68.7%) were males and 76 (31.3%) females with a mean age of 28.9 ± 4.5 (range: 18-49). The studies analyzed had a mean MINORS score of 14.6 (range, 12-19). Both QT-B and QT-S for ACL reconstruction reported satisfactory results in terms of patient-reported outcome measures. Although, a slightly higher anterior laxity was found with the QT-S than with the QT-B. CONCLUSION: Quadriceps tendon with a bone block (QT-B) or without bone block (QT-S) for ACL reconstruction is supported by current literature. Both grafts are safe and viable options for ACL reconstruction with comparable clinical outcomes, complications and revision rates. LEVEL OF EVIDENCE: Level IV. REGISTRATION: PROSPERO-CRD42022347134; https://www.crd.york.ac.uk/prospero/.

Similar survivorship at the 5-year follow-up comparing robotic-assisted and conventional lateral unicompartmental knee arthroplasty.

PURPOSE: This retrospective study aims to analyse the survivorship and functional outcomes of two samples with similar preoperative clinical and demographic data of lateral unicompartmental knee arthroplasty (UKA) performed with robotic and conventional surgery at a minimum 5-year follow-up. METHODS: In this retrospective study, the clinical records of two cohorts for 95 lateral UKA implants were analysed. The first cohort consisted of 43 patients with cemented lateral UKA performed with the conventional procedure (Conventional group). The second cohort consisted of 52 patients who received robot-assisted cemented lateral UKA (Robotic group). Clinical evaluation of the two samples entailed evaluating the Knee Injury and Osteoarthritis Outcome Score divided into subscales (symptoms and stiffness, pain, function in daily living, function in sport and recreation and quality of life) for each patient. Revision was defined as the failure of the implant (periprosthetic joint infection, periprosthetic fracture or aseptic loosening), and survival was based on implant revision. RESULTS: The mean follow-up time was 90.3 ± 9.1 months for the Conventional Group and 95.4 ± 11.0 months for the Robotic Group (n.s.). Each patient was clinically evaluated on the day before surgery (T0), at a minimum 1-year follow-up (T1) and at a minimum 5-year follow-up (T2). In both groups, all clinical scores improved between T0 and T1 and between T0 and T2 (p < 0.05); for both groups, no differences were noted in any clinical scores between T1 and T2 (n.s.). No significant differences in any clinical score were found between the two groups at each follow-up (n.s.). Survival analysis reported no differences between the two groups at the final 1-year follow-up, with three failures (2 aseptic loosening and 1 periprosthetic fracture) in the Conventional group and two failures (1 patellofemoral osteoarthritis and 1 inexplicable pain) in the Robotic group (n.s.). CONCLUSIONS: This study shows excellent clinical outcomes and revision rates in robotic arm-assisted and manual techniques for lateral UKA, with no clinical differences at medium- to long-term follow-up. LEVEL OF EVIDENCE: Level III-comparative study.

Multiple revision anterior cruciate ligament reconstruction: not the best but still good.

PURPOSE: Given the paucity of literature on the re-revision of ACL, the current study was undertaken. The purpose of this systematic review was to synthesise and qualitatively assess the currently available evidence in the literature regarding the re-revision of ACL reconstruction (rrACLR). METHODS: A systematic review was conducted based on the PRISMA guidelines. The following search terms were used in the title, abstract and keywords fields: "ACL" or "anterior cruciate ligament" AND "revision" or "multiple" or "repeat". The outcome data extracted from the studies were the Lysholm score, Subjective IKDC, Marx Score, Tegner, Marx Score, KOOS score, radiological changes and the rate of return to sports. Complications, failures and/or revision surgery were also analysed. RESULTS: The cohort consisted of 295 patients [191 (64.7%) men and 104 (35.3%) women] with a mean age of 29.9 ± 2.8 years (range 14-58 years) from 10 studies. The mean postoperative follow-up (reported in all studies except one) was 66.9 ± 44.7 months (range 13-230.4 months). Associated injuries were 103 (34.9%) medial meniscus tears, 57 (19.3%) lateral meniscus tears, 14 (4.7%) combined medial plus lateral meniscus tears, 11 (3.7%) meniscal tears (not specified), 252 (85.4%) cartilage lesions, 6 (2.0%) medial collateral ligament injury and 2 (0.7%) lateral collateral ligament injuries. In 47 (15.9%) patients an extra-articular plasty was performed for the anterolateral ligament. In all studies that reported pre- and post-operative IKDC (subjective and objective) and Lysholm score, there was a significant improvement compared to the pre-operative value (p < 0.05). At the final follow-up, laxity measured with KT-1000 was found to be 2.2 ± 0.6 mm. 31 (10.5%) out of 295 patients returned to their pre-injury activity level. A total of 19 (6.4%) re-ruptures were found, while only 4 (1.4%) complications (all minors) were reported, out of which 2 (0.7%) were superficial infections, 1 (0.3%) cyclops lesion and 1 (0.3%) flexion loss. CONCLUSION: Multiple revisions of anterior cruciate ligament reconstruction allow acceptable clinical results and a good degree of knee stability with a low rate of subsequent new re-ruptures but the possibility of regaining pre-injury sports activity is poor; whenever possible, it is preferred to revise the ligament in one stage. This surgery remains a challenge for orthopaedic surgeons and many doubts persist regarding the ideal grafts, additional extra-articular procedures and techniques to use. LEVEL OF EVIDENCE: IV. STUDY REGISTRATION: PROSPERO-CRD42022352164 ( https://www.crd.york.ac.uk/prospero/ ).

Satisfactory results after endoscopic gluteus medius repair combined with selective gluteus maximus reflected tendon release for the treatment of a full-thickness tear of gluteus medius.

PURPOSE: The current study aimed to report the mid-term follow-up results of endoscopic gluteus medius repair combined with a systematic release of the gluteus maximus reflected tendon. METHODS: Twenty-two patients with a symptomatic full-thickness tear of the gluteus medius tendon, as diagnosed by clinical examination and imaging (MRI), and who had a failure of conservative treatment for at least 6 months, were retrospectively enrolled for this study. An endoscopic repair of gluteus medius was performed for all patients in combination with gluteus maximus reflected tendon release according to the Polesello technique. The Visual Analogue Scale (VAS) for pain, Modified Harris Hip Score (mHHS), Lower Extremity Functional Scale (LEFS), Hip Outcome Score-Activity Daily Life (HOS-ADL), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS) were administered to each patient before surgery for 6 months, 1 year, and every following year after surgery. RESULTS: All analysed hip scores (mHHS, LEFS, HOS-ADL, and HOS-SSS) showed statistically significant improvements between the pre-operative and post-operative values at 6 months, 1 year, and the latest follow-up appointments after surgery (p < 0.001). The mean pre-operative pain was 8.6 ± 1.0 on the VAS. After surgical treatment, the pain was significantly reduced (p < 0.001) on the VAS at 6 months (5.4 ± 1.5), 1 year (4.4 ± 1.8) and the latest follow-up control visit (3.6 ± 2.2). No patient-reported major complications (re-rupture, deep infection or neurovascular injury). Eleven (50%) patients indicated the results as excellent, 7 (32%) as good, 2 (9%) as fair, and 2 (9%) as poor. CONCLUSION: The use of abductor tendon repair in combination with a systematic release of the reflected tendon of the gluteus maximus according to the Polesello technique seems to be a safe and effective endoscopic way of treating a full-thickness tear of the gluteus medius. LEVEL OF EVIDENCE: Level IV.

Good results after treatment of RAMP lesions in association with ACL reconstruction: a systematic review.

PURPOSE: This study aimed to systematically evaluate the clinical, functional, and radiological outcomes, complications, and rate of return to sports among patients with RAMP lesion of the medial meniscus encountered during anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic review was conducted based on the PRISMA guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "ACL" or "anterior cruciate ligament," and "RAMP lesion." The outcome measures extracted from the studies were the Short Form-12 (SF-12) in its mental and physical component (MCS and PCS), Lysholm score, Subjective IKDC, Marx Score, WOMAC Score, Tegner, Radiological changes, complications, failures and/or revision surgery, and rate of return to sports. RESULTS: The cohort of patients consisted of 1,243 participants with a mean age of 28.6 ± 2.6. The mean postoperative follow-up was 40.9 ± 6.3 months. A total of 1145 (92.1%) RAMP lesions were repaired with concomitant ACL reconstruction, while only 98 (7.9%) lesions were left untreated (or treated with abrasion only). The Lysholm score was used in 6 studies (in one only at final follow-up), with a significant improvement in all the studies (Lysholmpre 60.03 ± 6.12; Lysholmpost 89.9 ± 5.0). Eight studies out of nine reported Subjective IKDC score, and a significant improvement was noted in all cases (IKDCpre 56.2 ± 5.8. IKDCpost 84.9 ± 3.7). Of 18 (1.4%) complications reported, 15 (1.2%) were related to RAMP/ACL surgery, and of the remaining three (0.2%) two (0.2%) were hematomas and one (0.1%) a contralateral ACL lesion. Of the 106 (8.5%) revision surgeries required, 5 (0.4%) were in non-treated lesions [two (0.2%) ACL re-ruptures and three (0.2%) medial meniscus re-injury]. In treated patients, the revision occurred for the following reasons: 75 (6.0%) meniscectomy, 14 (1.1%) meniscal suture revisions, 11 (0.9%) ACL failures and one (0.1%) arthrolysis. CONCLUSIONS: It is not yet clear if, in all cases of ACL reconstruction in which a medial meniscal RAMP lesion is encountered, the lesion needs to undergo surgical repair. Accordingly, it is recommended that in the repair of all unstable medial meniscal RAMP lesions during an ACL reconstruction in cases associated with a stable RAMP lesion, the surgeon may decide on repair based on the patient profile. LEVEL OF EVIDENCE: Level IV.

In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review.

PURPOSE: This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus. METHODS: A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS). RESULTS: In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity. CONCLUSIONS: In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis. LEVEL OF EVIDENCE: Level IV. STUDY REGISTRATION: PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).

Similar rate of return to sports activity between posterior-stabilised and cruciate-retaining primary total knee arthroplasty in young and active patient.

PURPOSE: Cruciate-retaining and posterior-stabilised implant designs are available for primary total knee arthroplasty. However, whether the implant design is associated with a difference in the level of activity still remains unclear. This clinical trial compared posterior-stabilised and cruciate-retaining implants in sport-related patient-reported outcome measures, range of motion, rate of return to sport, and weekly time dedicated to sport in active adults. It was also hypothesised that in young and active patients both implants lead to a similar rate of return to sport in terms of hours per week, type of sport, and joint mobility. METHODS: All patients were evaluated preoperatively and for a minimum of 36 months follow-up. The University of California Los Angeles activity scores, High-Activity Arthroplasty Score, and Visual Analogue Scale were administered preoperatively and at the last follow-up. The range of motion was investigated at admission and the last follow-up. Data concerning the hours per week dedicated to sports and the type of sport practiced were also collected at admission and at the last follow-up. The Kaplan-Meier Curve was performed to compare implant survivorship. RESULTS: Data from 227 procedures (cruciate-retaining: 109, posterior-stabilised: 118) were prospectively collected. At the last follow-up, no difference was reported in The University of California Los Angeles activity scores (p = 0.6), High-Activity Arthroplasty Score (p = 0.1), Visual Analogue Scale (p = 0.9), flexion (p = 0.7) and extension (p = 0.4). No difference was found in the rate of return (p = 0.1) and weekly hours dedicated to sport (p = 0.3). The Kaplan-Meier curve evidenced no statistically significant difference in implant survivorship (p = 0.6). CONCLUSIONS: At approximately five years of follow-up, no difference was reported between cruciate-retaining and posterior-stabilised implants in active adults in sport-related patient-reported outcomes measures, range of motion, pain, weekly time dedicated to sport, rate of return to sport, and implant survivorship. LEVEL OF EVIDENCE: Level II, prospective study.

Management of the first episode of traumatic patellar dislocation: an international survey.

PURPOSE: This international survey aimed to evaluate the potential controversies regarding the management of first patellar dislocation amongst experienced knee surgeries in the treatment of the first episode of patellar dislocation without osteochondral fragments. METHODS: An online survey was conducted from February 2021 to December 2021 to assess the global trend in the diagnosis and management of first-time patellar dislocation without osteochondral fragments. The online survey was accessible on the homepage of the website of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The questionnaire consisted of multiple-choice questions and was divided into three sections. The first section consisted of eight questions regarding demographic information, professional activity, and responder experience. The second section consisted of 13 questions regarding the approach to a first patellar dislocation (clinical examination, imaging, and rehabilitation). The third section contained 2 questions concerning the relevance of patient characteristics to the therapeutic algorithm (age, sports, and pathoanatomical predisposing risk factors). RESULTS: A total of 438 orthopaedic surgeons worldwide completed the questionnaire. At the first approach to diagnose a first-time patellar dislocation, 251 (57%) of the surgeons requested plain radiographs, and 158 (36%) requested magnetic resonance imaging (MRI). In conservatively treated patients, 368 (84%) of the respondents recommended the use of a knee brace. Amongst them, 14 (3%) advocated its use for one week, 75 (17%) for two weeks, 123 (28%) for three weeks, 105 (24%) for four weeks, and 97 (22%) for six weeks. In conservatively treated patients, 215 (49%) of the surgeons recommended load to tolerance, 148 (34%) recommended 30% to 60% of the bodyweight, and 75 (17%) advised against weight-bearing. More than half of the surgeons considered a patient aged less than 35 years practising contact sports to be a candidate for the medial patello-femoral ligament (MPFL) procedure. In addition, a tibial tuberosity to trochlear groove distance (TT-TG) distance of 15 to > 20 mm (for > 75% of the surgeons) and a trochlea types C and D (for > 70% of the surgeons) were considered possible indications for direct surgical management. CONCLUSION: At the first approach to diagnose a first-time patellar dislocation, plain radiographs and MRI should be performed. In conservatively treated patients, most of the surgeons recommend weight-bearing to tolerance and a knee brace during the first four weeks, with range of motion of full extension to 30° during the first 15 days and up to 60° for an additional 15 days. Surgical management should be performed in patients in the second and third decades of life practising contact sports and in those patients who present types C and D trochlea dysplasia and patella alta. LEVEL OF EVIDENCE: IV.

Clinical outcomes, complications, and survivorship for unicompartmental knee arthroplasty versus total knee arthroplasty in patients aged 80 years and older with isolated medial knee osteoarthritis: a matched cohort analysis.

PURPOSE: The primary goal of this study is to compare clinical outcomes, complication rate, and survivorship in octogenarians who underwent total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA) by performing a matched cohort analysis. METHODS: We analyzed 75 medial UKAs performed by a single experienced surgeon. The included cases were matched with 75 TKAs performed during the same study period. Potential TKA matches used identical exclusion criteria. UKAs were age-, gender-, and body mass index (BMI)-matched at the rate of 1 UKA to 1 TKA from our departmental database. Clinical evaluation included the visual analog scale for pain, range of motion (ROM-flexion and extension), Knee Society Score (KSS), and Oxford Knee Score (OKS). Each patient was clinically evaluated on the day before the surgery (T0) and at two follow-ups at least 12 months (T1) and 24 months (T2) after the surgery. For the survivorship, revision was defined as failure of the implant (periprosthetic joint infection, periprosthetic fracture, or aseptic loosening), and survival was based on implant revision or patient death. Undesirable clinical developments that were not present at baseline or that increased in severity after treatment were classified as adverse events. RESULTS: The mean age at the time of the surgery was 82.1 ± 1.9 years for UKA and 81.5 ± 1.8 years for TKA (p = 0.06). The two groups differed in regard to surgical time (UKA 44.9 ± 7.2 min; TKA 54.4 ± 11.3 min; p < 0.001); furthermore, the UKA group showed better function (ROM; flexion and extension) than the TKA group at each follow-up time point (p < 0.05). Both groups reported a significant improvement in all clinical scores (KSS and OKS) when compared with their preoperative status (p < 0.05), while no differences were found between the groups at each follow-up (p > 0.05). The UKA group reported 7 (9.3%) failures, while TKA reported 6 failures. There were no survival differences between the groups (T1: p = 0.2; T2: p = 0.5). Overall complication rate was 6% in the UKA group versus 9.75% in TKA (p = 0.2). CONCLUSION: The UKA and TKA patients had similar clinical outcomes, post-operative range of motion, and survivorship in octogenarians with medial knee osteoarthritis, with comparable complication rate. Both the surgical procedures may be considered in this patient population, but further long-term follow-up is needed. LEVEL OF EVIDENCE: Level III.