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.

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.

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.

Arthroscopic-assisted reduction and fixation of proximal tibial fractures: personal surgical technique.

Purpose The purpose of this study was to describe the authors' arthroscopic-assisted reduction and fixation (ARIF) technique in the treatment of type Schatzker I-III tibial plateau fractures, with the use of instruments commonly used in anterior cruciate ligament reconstruction, evaluating clinical and radiological outcomes on four patients at short-term follow-up.   Methods A retrospective analysis was performed in our Institution considering 4 patients who underwent ARIF procedure between 2018 and 2020 at minimum 3 months of follow-up. All patients were evaluated clinically (Rasmussen Score, VAS and Crosby-Insall Grading) and radiographically (after surgery and at 6 weeks).   Results Mean follow-up was 9 months (range 6-12 months). Rasmussen score and VAS were respectively 26 (Excellent) and 1 at the last follow-up. According to the Crosby-Insall Grading System, all patients reported excellent results. At final control the mean ROM in the injured knee was 125°(range 100°-140°). Mean hospitalization was 2 days (range 1-4 days). No adverse events were reported.   Conclusions ARIF  is a reliable technique for tibial plateau fracture (Schatzker I-III). The technique described is very cheap and reproducible in any hospital . This procedure allows to well understand the pattern of fracture and to obtain an anatomical reduction with a great tissue sparing and a faster recovery of knee function.   Level of Evidence: Level IV   Keywords: tibial plateau fractures, treatment, arthroscopy, surgery, artrhoscopic-assisted.

The Evaluation of Trochlear Osseous Morphology: An Epidemiologic Study.

BACKGROUND: The femoral trochlea is considered the most significant osseous factor affecting stability in the patellofemoral joint. The true prevalence of trochlear dysplasia in the general population is largely unknown. PURPOSE/HYPOTHESIS: To investigate the prevalence of trochlear dysplasia in the general population. Our hypothesis was that, while trochlear dysplasia is not uncommon, there is a low prevalence of severe dysplasia in the general population. STUDY DESIGN: Descriptive epidemiology study. METHODS: Five observers were asked to evaluate 692 skeletally mature femoral specimens from 359 skeletons for trochlear dysplasia at 2 time points. We further subclassified the dysplastic trochlea in 62 femora with the highest rated degree of dysplasia. RESULTS: Sex (P = .11) and race (P = .2) had no effect on the severity of dysplasia. Interobserver reliability was excellent (0.906 and 0.904), and intraobserver reliability was good to excellent (0.686 to 0.808). The percentages of trochlea graded as normal, mildly dysplastic, moderately dysplastic, and severely dysplastic were 61.5%, 21.4%, 12.7%, and 4.4%, respectively, in the first evaluation, and 58.5%, 23.7%, 12.7%, and 5.1% in the second evaluation. Of the 62 trochlea with the highest scores for dysplasia, 36 had trochlear dysplasia without a supratrochlear spur, 8 had trochlear dysplasia with medial femoral condyle hypoplasia, and 18 had trochlear dysplasia with a supratrochlear spur. CONCLUSION: Observers with differing degrees of clinical experience had similar opinions on the degree of trochlear dysplasia. Also, our cohort showed that moderate to severe dysplasia is not uncommon, as it is present in approximately 17% of knees in our cohort. Our findings also suggest that clinicians are speaking the same language when identifying and describing trochlear dysplasia on gross inspection.

Validation of a new topographic classification of bone marrow lesions in the knee: the six-letter system.

PURPOSE: The aim of this study was to propose and validate a new six-item topographical classification of knee bone marrow lesions in coronal MRI images, to provide an easy-to-use aid to describe their location in a more reproducible and accurate way. METHODS: This study was conducted in four phases. The first was to do a literature search for methods of describing bone marrow lesions in MRI of the knee. The second was creation of a six-area topographic classification of bone marrow lesions in coronal MRI of the knee. The third phase was selection of cases with bone marrow lesions on knee MRI performed in a single hospital between January of 2017 and December of 2018. The fourth phase was categorization of the bone marrow lesions' location according to the new proposed classification by three independent examiners, two orthopedic surgeons and one radiologist. Patient's demographic data and associated lesions were collected. The inter-observer and intra-observer reliability of the proposed classification was then calculated. RESULTS: MRI examination of 4000 patients were studied and in 520 patients a total of 666 bone marrow lesions were identified and their location classified using the new system. The inter-observer and intra-observer reliability analysis found a Fleiss' Kappa value of 0.96 (0.95-0.97) and 0.97 (0.96-0.97), respectively, confirming the high reproducibility of the proposed classification. CONCLUSIONS: The proposed six-location classification of bone marrow lesions is highly reproducible and can help researchers develop studies and share information in a more accurate and reliable way. The correct classification of bone marrow lesions can lead to a more accurate description of this pathology and help clinicians to propose appropriate therapies for this group of patients. LEVEL OF EVIDENCE: V.

Total knee arthroplasty after distal femoral osteotomy: a systematic review and current concepts.

INTRODUCTION: Distal Femoral Osteotomy (DFO) is a common procedure for correcting lower limb valgus deformity and lateral compartment overload. Low 20-year survivorship rate was reported with a consequent need for total knee arthroplasty (TKA). This study aims to review literature and to analyse the influence of a previous distal femoral osteotomy on outcomes of patients undergoing TKA. METHODS: A systematic literature review was performed in PubMed/Medline and Embase in May 2020. Papers were selected based on the following criteria: patient with a previous distal femoral osteotomy; total knee replacement; Pre- and Postoperative outcomes; surgical outcomes: clinical scores, range of motion, radiographic evaluation and revisions for any cause; case series, retrospective studies, observational studies, open-label studies, randomized clinical trials; systematic reviews and meta-analyses were included to extract primitive studies. RESULTS: 306 articles were found, of which five papers were considered eligible for this review. In every study included, postoperative clinical outcomes (Knee Society Score or Hospital for Special Surgery score) statistically improved from the preoperative. Complications were not uncommon; implant survivorship at the available follow-up seems to be similar to primary TKA, although being too short to draw any conclusions. CONCLUSIONS: Limited and highly heterogeneous evidence is currently available on the influence of DFO on outcomes after TKA. Knee replacement improves clinical middle-term outcomes in patients with previous distal femoral osteotomy. In this complex surgery, the use of technical tips and tricks could help surgeons to obtain an accurate knee balancing and better long-term results.

Proximal medial patellar restraints and their surgical reconstruction.

Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.

Should the patella be everted during primary total knee arthroplasty? A systematic review of overlapping meta-analyses.

Patellar eversion during total knee arthroplasty (TKA) is a debated issue. The aim of this study is to perform a review of overlapping meta-analyses analyzing clinical outcomes of patellar eversion compared to noneversion. A search was performed in PubMed\MEDLINE, Scopus, and Cochrane Library. Inclusion criteria were meta-analysis of randomized controlled trials (RCTs) or quasi-RCTs;l comparison between TKAs with or without patellar eversion; and at least one outcome, such as reoperation rate, pain, and functional scores. Meta-analyses were evaluated with the A Measurement Tool to Assess Systematic Review (AMSTAR) score, addressing the most relevant one with the Jadad algorithm. Three meta-analyses were identified and included in this review. No significant differences were found regarding complications, quadriceps strength, functional, and radiological outcomes. The meta-analysis by Zan et al. was selected as the best available one. Patellar eversion group showed a shorter tourniquet time but a longer skin incision. In conclusion, eversion and noneversion techniques did not demonstrate any significant or clinically relevant difference. Level of Evidence: Level II, systematic review of meta-analyses.

Italian consensus statement for the use of allografts in ACL reconstructive surgery.

PURPOSE: Graft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the "Allografts for Anterior Cruciate Ligament Reconstruction" consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making. METHODS: In March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members. RESULTS: A different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients. CONCLUSIONS: Results of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R. LEVEL OF EVIDENCE: IV, consensus of experts.

Patient-Specific Instrumentation Affects Perioperative Blood Loss in Total Knee Arthroplasty.

Patient-specific instrumentation (PSI) may contribute to reduced blood loss related to total knee arthroplasty (TKA). The purpose of this study was to compare the estimated hemoglobin (Hb) and red blood cell volume (RBC) losses in two groups of patients undergoing TKA with PSI and conventional instrumentation. Pre- and postoperative blood samples were collected from 22 patients randomly assigned to receive a PSI-assisted or conventional TKA. Post- to preoperative Hb difference was calculated and RBC loss was estimated according to Sehat et al. A significant difference in Hb reduction in favor of the PSI group was registered on the last day of stay (p = 0.0084) and significant treatment effect (p = 0.027) on Hb reduction after intervention was found with a regression model for longitudinal measurements. This study demonstrated that PSI leads to a significant trend in earlier Hb regain. These promising results suggest a beneficial effect of PSI in blood loss reduction.

Treatment of unstable knee osteochondritis dissecans in the young adult: results and limitations of surgical strategies-The advantages of allografts to address an osteochondral challenge.

Joint surface incongruence resulting from osteochondritis dissecans (OCD) alters the articular physiologic congruence, increasing the contact stress on adjacent joint surfaces and accelerating wear and the cascade of joint degeneration. Accordingly, the restoration of articular surface integrity is of major importance, especially in young adults where, in lesions left untreated or following simple fragment excision, early osteoarthritis can be anticipated. Therefore, the treatment algorithm in unstable knee OCD of the young adult foresees surgical options to restore the articular surface. Several procedures have been proposed, including refixation of the detached fragment bone marrow stimulation, osteochondral autograft implantation, fresh osteochondral allograft transplantation, and cell-based or cell-free regenerative techniques. The aim of this review was to summarize the evidence for these surgical strategies, reporting their results and limitations. The overall evidence documents positive results for each of the assorted surgical procedures applied to treat unstable OCD, thus indicating support for their selected use to treat osteochondral defects paying particular attention to their specific indications for the lesion characteristics. The fixation of a good quality fragment should be pursued as a first option, while unfixable small lesions may benefit from autografts. For large lesions, available cell-based or cell-free osteochondral scaffold are a feasible solution but with limitation in terms of regenerated tissue quality. In this light, fresh allografts may offer articular surface restoration with viable physiologic osteochondral tissue providing a predictably successful outcome, and therefore they may currently represent the most suitable option to treat unstable irreparable OCD lesion in young adults. LEVEL OF EVIDENCE: V.

Significant differences between manufacturer and surgeon in the accuracy of final component size prediction with CT-based patient-specific instrumentation for total knee arthroplasty.

PURPOSE: Patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) may improve component sizing. Little has been reported about accuracy of the default plan created by the manufacturer, especially for CT-based PSI. The goal of this study was to evaluate the reliability of this plan and the impact of the surgeon's changes on the final accuracy of the guide sizes. METHODS: Forty-five patients eligible for primary TKA were prospectively enrolled. The planned implant sizes were prospectively recorded from the initial manufacturer's proposal and from the final plan adjusted in light of the surgeon's evaluation; these two sizes where then compared to the actually implanted sizes. Fisher's exact test was used to test differences for categorical variables. Agreement between pre-operative plans and final implant was evaluated with the Bland-Altman method. RESULTS: The manufacturer's proposal differed from the final implant in 9 (20.0%) femoral and 23 (51.1%) tibial components, while the surgeon's plan in 6 (13.3%, femoral) and 12 (26.7%, tibial). Modifications in the pre-operative plan were carried out for five (11.1%) femoral and 23 (51.1%) tibial components (p = 0.03). Appropriate modification occurred in 22 (88.0%) and 19 (76.0%) cases of femoral and tibial changes. The agreement between the manufacturer's and the surgeon's pre-operative plans was poor, especially with regard to tibial components. CONCLUSION: The surgeon's accuracy in predicting the final component size was significantly different from that of the manufacturer and changes in the initial manufacturer's plan were necessary to get an accurate pre-operative plan of the implant sizes. CLINICAL RELEVANCE: Careful evaluation of the initial manufacturer's plan by an experienced knee surgeon is mandatory when planning TKA with CT-based PSI. LEVEL OF EVIDENCE: II.

Patellar resurfacing versus patellar retention in primary total knee arthroplasty: a systematic review of overlapping meta-analyses.

PURPOSE: The need of patellar resurfacing in total knee arthroplasty (TKA) is a subject of debate. This systematic review of overlapping meta-analyses aimed to assess and analyze current evidence regarding patellar resurfacing and non-resurfacing in TKA. METHODS: A systematic literature search was performed in March 2017 in PubMed, CINAHL and Cochrane Library. Inclusion criteria were meta-analysis of randomized controlled trials that compared TKA with and without patellar resurfacing considering as outcomes re-operations rate, complications, anterior knee pain, functional scores. The quality of meta-analyses was evaluated with AMSTAR score and the most relevant meta-analysis was determined by applying the Jadad algorithm. RESULTS: Ten meta-analyses, published between 2005 and 2015, were included in the systematic review. Two studies found a significantly increased Knee Society Score in the resurfacing group. According to four meta-analyses, anterior knee pain incidence was lower in resurfacing group. Six of the included studies described a greater risk of re-intervention in the non-resurfacing groups. The overall quality of included studies was moderate. The most relevant meta-analysis reported no differences in functional scores and incidence of anterior knee pain between the groups. CONCLUSIONS: Comparable outcomes were found when comparing patellar resurfacing and non-resurfacing in TKA. The higher risk of re-operations after non-resurfacing should be interpreted with caution due to the methodological limitations of the meta-analyses regarding search criteria, heterogeneity and the inherent bias of easier indication to reoperation when the patella is not resurfaced. There is no clear superiority of patellar resurfacing compared to patellar retention. LEVEL OF EVIDENCE: Level II, systematic review of meta-analyses.

Suture Anchors Fixation in MPFL Reconstruction using a Bioactive Synthetic Ligament.

Medial patellofemoral ligament (MPFL) reconstruction has a key role in patellofemoral instability surgery. Many surgical techniques have been described so far using different types of grafts (autologous, heterologous, or synthetic) and fixation techniques. The hereby described technique for MPFL reconstruction relies on the use of a biosynthetic graft (LARS Arc Sur Tille, France). Fixation is obtained by means of suture anchors on the patellar side and a resorbable interference screw on the femoral side locating the insertion point according to Schottle et al. An early passive range of motion (ROM) recovery is fundamental to reduce the risk of postoperative stiffness; a partial weight bearing with crutches is allowed until 6 weeks after the surgery. In our experience, the use of a biosynthetic graft and suture anchors provides stable fixation, minimizing donor site morbidity and reducing the risk of patellar fracture associated with transosseous tunnels. This technique represents a reliable and reproducible alternative for MPFL reconstruction, thereby minimizing the risk of possible complications.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study.

BACKGROUND: Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES: Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN: A web-based prospective observational registry. SETTING: Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS: Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S): Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES: Experience of PPSP according to the type of peri-operative analgesia. RESULTS: Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION: Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02147730.

Is There Any Benefit in Anterior Cruciate Ligament Reconstruction in Patients Older Than 60 Years?

BACKGROUND: Results of anterior cruciate ligament (ACL) reconstruction are traditionally excellent in younger and nonarthritic patients. During the past few decades, people older than 60 years have become more active than ever, with more demanding physical lifestyles. An increase also has been noted in active patients with diagnosed ACL injuries. More patients are requesting treatment for ACL deficiency in hopes of returning to preinjury levels of activity. PURPOSE: The aims of this study were to evaluate the results of ACL reconstruction in patients older than 60 years in terms of functional recovery, return to sports, and postoperative incidence of osteoarthritis and to compare their results with published results of different age groups. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients older than 60 years with isolated ACL tear and no established osteoarthritic lesions (Ahlbäck grade 1 or no arthritis) who were treated from 2008 to 2013 were retrospectively included in this study. Primary ACL reconstruction was performed with the same technique in all patients by means of single-bundle autologous hamstring tendon graft. Meniscal injuries were treated with partial debridement when required. No further treatment on cartilage lesions was performed. Postoperative rehabilitation was the same in every case. The International Knee Documentation Committee (IKDC) objective grade, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were assessed before and after surgery, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) score was recorded during the final follow-up. Postoperative incidence of osteoarthritis was evaluated on weightbearing radiographs during final follow-up, and anteroposterior laxity was measured pre- and postoperatively with the use of stress radiographs. RESULTS: Twelve patients with mean age (±SD) of 61.0 ± 1.4 years at the time of surgery were included. They were followed-up for a mean period of 49.6 ± 24.0 months. Eight patients had associated meniscal tears, and 6 patients had International Cartilage Repair Society stage 1 or 2 chondral lesions. Preoperatively, the objective IKDC grades were B in 4 patients, C in 5, and D in 3. After surgery, the IKDC grades were A in 4 patients, B in 7, and grade C in 1. The mean subjective IKDC and Lysholm scores were a respective 43.4 ± 8.4 and 55.7 ± 12.4 preoperatively and 83.8 ± 9.4 and 93.2 ± 9.0 at the final follow-up ( P < .05). Ten patients (83%) reported recovery of sports activities, with 6 patients (50%) reaching the same level as before injury. The mean ACL-RSI score was 76.2%. Preoperatively, 50% (n = 6) of patients had Ahlbäck stage 1 medial compartment arthritis, versus 58% (n = 7) at the final follow-up ( P = nonsignificant). The side-to-side difference in anterior tibial translation on stress radiographs was 7.2 ± 6.4 mm preoperatively and 1.9 ± 4.3 mm postoperatively ( P < .05). No major complications were reported. CONCLUSION: ACL reconstruction in active patients older than 60 years without arthritis restored knee stability in all treated cases. In these patients, as in younger age groups, ACL reconstruction showed good results on functional recovery while not increasing the risk of midterm functional knee deterioration or evolution of knee arthritis. The majority of patients returned to activities at their preinjury level. These data show that older and active patients with nonarthritic ACL-deficient knees need not be excluded from surgical treatment.

Early osteoarthritis of the patellofemoral joint.

Patellofemoral joint cartilage lesions are associated with a variety of clinical situations including blunt trauma, lateral patella dislocations, or as a secondary development in the setting of abnormal joint loading. There is a need for more clarity on how to best address these lesions. Most specifically, when is it necessary to surgically treat these lesions of the patella and trochlea and which technique to use? This review will focus on the spectrum of patellofemoral disease/injury and their treatment strategies, with special emphasis on cartilage damage and early osteoarthritis. Chapter sections will review the most common scenarios of cartilage damage in the patellofemoral joint, with an attempt to summarize current treatment, their outcomes, remaining challenges and unanswered questions.