All-inside repair of meniscal bucket handle tears: a retrospective study at mean 4-years follow-up evaluation.

Bucket-handle tears represent approximately 10% of all meniscal tears. Despite the common treatment is subtotal meniscectomy, repair is technically feasible although complex, and represents a key strategy to avoid severe meniscal tissue loss that could accelerate joint degeneration over time. The aim of this retrospective study was to determine the outcomes of arthroscopically-assisted bucket-handle tear repair, and to identify factors correlating with clinical results. Fifty-four patients affected by meniscal bucket handle tear were included in the present retrospective analysis and evaluated up to mean 4-years follow-up. All patients were treated by arthroscopic-assisted all-inside repair. The primary outcome was considered the need for a re-operation due to failure of meniscal repair. Patients were also evaluated by the following items: KOOS, Lysholm, Tegner, IKDC-subjective and Quadruple-VAS score. Subgroup analysis was performed to identify whether concurrent ACL reconstruction, side of the lesion, age at surgery and time from injury to repair could influence clinical outcome. Ten out 54 patients (18.5%) were considered failed and needed reoperation, mainly within one year from surgery. Overall, there was a significant increase in all clinical scores considered and patients were able to get back to previous sport activity level. Patients with concurrent ACL reconstruction presented a lower risk of failure (p=0.025). Patients with lateral meniscus repair showed better clinical outcome compared to medial meniscus. Timing from injury and age at surgery did not correlated with clinical outcome. Our series showed fair results in bucket handle repair up to middle term evaluation. Concomitant ACL reconstruction was associated with lower failure rate whereas lateral meniscus involvement was associated with higher functional scores at final follow-up evaluation.

The Iron Man of the Renaissance: the contribution of Girolamo Fabrizi d'Acquapendente.

PURPOSE: To highlight the most relevant contributions of the Italian Renaissance surgeon Girolamo Fabrizi d'Acquapendente in the field of orthopaedics and traumatology. METHODS: An extensive research on the life and achievements of Girolamo Fabrizi was conducted on University Libraries as well as on electronic databases like PubMed. RESULTS: Girolamo Fabrizi d'Acquapendente is known for his embryology and physiology studies, particularly on sensory organs and blood circulation. He founded the world's first permanent anatomical theater established at the University of Padua and inaugurated in 1595. His most notable publications include surgical and definitely orthopedics works such as "De fracturis" (On fractures) and "De luxationibus" (On joint displacement). He outlined some principles of treatment that are still valid nowadays such as anatomical reduction and stabilization of the fracture, that were applied using the equipment available at that time. He described and illustrated maneuvers and instruments, such as pulleys, winches, splint, and bandages. He further depicted the famous "Oplomochlion" ("the armored man"), which is actually a collection of all of the braces used at the time to correct congenital and post-traumatic deformities. CONCLUSION: Bracing and prosthetic replacements have accompanied medical history throughout the centuries, from Ancient Egypt to the present, but it was the ingenuity of Renaissance surgeons that pushed biomedical technology to new heights: Girolamo Fabrizi d'Acquapendente was one of the most illustrious contributors to these great achievements.

Implant strategy affects scaffold stability and integrity in cartilage treatment.

PURPOSE: To identify the most appropriate implantation strategy for a novel chondral scaffold in a model simulating the early post-operative phase, in order to optimize the implant procedure and reduce the risk of early failure. METHODS: Eight human cadaveric limbs were strapped to a continuous passive motion device and exposed to extension-flexion cycles (0°-90°). Chondral lesions (1.8 cm diameter) were prepared on condyles, patella and trochlea for the implant of a bi-layer collagen-hydroxyapatite scaffold. The first set-up compared four fixation techniques: press-fit (PF) vs. fibrin glue (FG) vs. pins vs. sutures; the second compared circular and square implants; the third investigated stability in a weight-bearing simulation. The scaffolds were evaluated using semi-quantitative Drobnic and modified Bekkers scores. RESULTS: FG presented higher total Drobnic and Bekkers scores compared to PF (both p = 0.002), pins (p = 0.013 and 0.001) and sutures (p = 0.001 and < 0.0005). Pins offered better total Drobnic and Bekkers scores than PF in the anterior femoral condyles (p = 0.007 and 0.065), similar to FG. The comparison of round and square implants applied by FG showed worst results for square lesions (Drobnic score p = 0.049, Bekkers score p = 0.037). Finally, load caused worst overall results (Drobnic p = 0.018). CONCLUSIONS: FG improves the fixation of this collagen-HA scaffold regardless of lesion location, improving implant stability while preserving its integrity. Pins represent a suitable option only for lesions of the anterior condyles. Square scaffolds present weak corners, therefore, round implants should be preferred. Finally, partial weight-bearing simulation significantly affected the scaffold. These findings may be useful to improve surgical technique and post-operative management of patients, to optimize the outcome of chondral scaffold implantation.

Kinematics of ACL and anterolateral ligament. Part I: Combined lesion.

PURPOSE: To quantify the influence of ALL lesions on static and dynamic laxity in ACL-deficient knee. METHODS: The study was performed in 10 fresh-frozen knees. The joints were analysed in the following conditions: intact, ACL resection and ACL + ALL resection. Testing parameters were defined as: anterior displacement at 30° and 90° of flexion (AP30, AP90) applying a manual-maximum load; internal rotation at 30° and 90° of flexion (INT30, INT90) applying a 5 N m torque and internal rotation and acceleration during manual pivot-shift (PS) test. Kinematics was acquired by a navigation system; a testing rig and a torquemeter were used to control the limb position and the applied torque. Paired Student's t test was conducted to assess statistical difference, and significance was set at P < 0.05. RESULTS: The ALL resection determined a significant increase in terms of internal rotation (INT30 P = 0.02, INT90 P = 0.03), while AP30 (P n.s) and AP90 (P n.s) were not affected. ALL resection produced a significant increase in terms of acceleration during PS test (P < 0.01), but no significant change in PS internal rotation was observed. CONCLUSION: The ALL plays a significant role in controlling static internal rotation and acceleration during PS test. On the other hand, ALL resection did not produce any significant change in terms of anterior displacement. A trend was seen for the internal rotation during the pivot-shift test to increase after ALL resection was higher when compared to the intact and isolated ACL lesion states; however, the differences were not significant. The results highlight the clinical relevance of this structure that should be assessed before an ACL reconstruction in order to avoid residual laxity.

Evaluation of the sealing function of the acetabular labrum: an in vitro biomechanical study.

PURPOSE: To quantitatively evaluate the biomechanical sealing function of an intact labrum and the effect of labral-chondral separation, cerclage suture labral repair, vertical mattress suture repair and partial labrectomy on distraction load and hip joint centre (HJC) displacement. METHODS: Eight fresh-frozen cadaveric hips were tested using a navigation system for intra-operative kinematic analysis. A six-axis load cell was used to measure the manually applied force when performing the tests: hip pivoting movement and distraction. The HJC displacement that occurred during the distraction test has been evaluated in correspondence of seven different values of applied force. During the pivoting motion, the maximum value of HJC displacement was evaluated. Five different conditions were tested: labrum intact, labral-chondral separation, vertical mattress suture repair, cerclage suture repair, and partial labrectomy. RESULTS: With regard to HJC displacement using at fixed value of force, the paired sample t test underscored the statistically significant differences (p < 0.05) for each of the five tested conditions among themselves. Only the comparison of intact versus labral-chondral separation was not significantly different. During pivoting motion, a statistically significantly greater displacement was identified after labrectomy when compared with the cerclage suture repair (p = 0.03) and vertical mattress repair (p < 0.01) in medial-lateral direction. Along proximal-distal direction, a significant lower displacement after labrectomy was identified when compared to the cerclage suture repair (p = 0.03). Performing the pivoting motion at the extreme ranges of motion demonstrated a higher value of displacement after labrectomy when compared with all the previously tested conditions. CONCLUSIONS: These results suggest that labral repair is important in the function of the hip and that the vertical mattress suture technique may be better than the cerclage suture repair.

Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients.

PURPOSE: To evaluate the effects of kinesiophobia on the outcomes of total knee arthroplasty (TKA), and to investigate whether kinesiophobia represents an independent factor influencing the surgery success or whether the observed effects are driven by other physical or psychological aspects such as anxiety and depression. METHODS: Two hundred patients were evaluated prospectively (mean age 65.7 ± 9.1 years, 134 women and 66 men) at 12 months after TKA. Kinesiophobia was assessed with the Tampa Scale for kinesiophobia (TSK: Activity Avoidance-TSK1 and Harm-TSK2 subscales); anxiety and depression were assessed with STAI and BDI, respectively, and preoperative pain and function, sex, age, BMI, education level, number of painful joints and years of symptoms' duration before surgery were documented as well. Results were evaluated with pain and function on 0-10 numeric rating scales, while the overall clinical outcome was documented with WOMAC and SF-12 (Physical and Mental subscales) scores. RESULTS: TSK1 was correlated with WOMAC results at 12 months (p = 0.005, ρ = 0.197). STAI (p = 0.002, ρ = 0.222), BDI (p < 0.0005, ρ = 0.307), and sex (p = 0.004) also influenced the outcome after TKA, while other parameters, such as age, BMI, education level, and number of painful joints and years of symptoms' duration before surgery, did not correlate with the clinical outcome. The multivariate analysis confirmed the role of BDI (p = 0.006, partial η 2 = 0.038), TSK1 (p = 0.011, partial η 2 = 0.033), and sex (p = 0.048, partial η 2 = 0.020), and a synergic interaction of BDI and TSK1, which together presented an even stronger correlation (p < 0.0005, partial η 2 = 0.111) with WOMAC at 12-month follow-up. CONCLUSIONS: Kinesiophobia is a factor influencing the outcome after TKA independently from other psychological and physical variables. This risk factor may affect TKA results, especially in women, and shows a further synergic interaction with depression in terms of lower surgical outcome. These findings are of clinical relevance because they show the impact of psychological factors such as kinesiophobia, and suggest the possibility of adopting co-interventions to overcome the fear of physical activity, and in the end improve patient recovery and final outcome after TKA. LEVEL OF EVIDENCE: IV.

Polyurethane-based cell-free scaffold for the treatment of painful partial meniscus loss.

PURPOSE: The aim of this study was to document, at mid-term follow-up, the clinical and MRI outcome of a polyurethane-based cell-free scaffold implanted to treat painful partial meniscus loss. METHODS: Eighteen consecutive patients were enrolled and treated with arthroscopic polyurethane meniscal scaffold implantation and, in case of other comorbidities, with concurrent surgical procedures: 16 patients (9 men and 7 women, mean age 45 ± 13 years, mean BMI 25 ± 3, 12 medial and 4 lateral implants) were prospectively evaluated with the subjective and objective IKDC and the Tegner scores at 24, 36, 48, 60, and 72 months of follow-up. Eleven patients were also evaluated by 1.5-T MRI at the final follow-up. RESULTS: The IKDC subjective score showed a significant improvement from baseline to 24 months (45.6 ± 17.5 and 75.3 ± 14.8, respectively; p = 0.02) and subsequent stable results over time for up to 72 months (final score 75.0 ± 16.8). The Tegner score improvement between pre-operative status and final follow-up was also significant (p = 0.039). Nevertheless, the final score remained significantly lower than the pre-injury sports activity level (p = 0.027). High-resolution MRIs documented the presence of abnormal findings in terms of morphology, signal intensity, and interface between the implant and the native meniscus. Implant extrusion and bone oedema at the treated compartment were also observed in most of the cases, even though no correlation was found between imaging findings and clinical outcome. CONCLUSIONS: The present study reports satisfactory clinical outcomes at mid-term follow-up after polyurethane-based meniscal cell-free scaffold implantation. The treatment was effective both in cases of isolated partial meniscal lesions and in complex cases requiring the combination with other surgical procedures. On the other hand, a high rate of altered MRI aspects was documented. However, no correlation was found between the altered imaging parameters and the overall positive clinical findings, thus supporting the use of this procedure to treat painful partial meniscus loss. LEVEL OF EVIDENCE: Case series, Level IV.

Kinematics of ACL and anterolateral ligament. Part II: anterolateral and anterior cruciate ligament reconstruction.

PURPOSE: To quantify the influence of Single-Bundle with Lateral Plasty and Double-Bundle reconstruction on static and dynamic laxity in combined ACL- and ALL-deficient knees. METHODS: The study included 10 fresh-frozen human knees. The joints were analyzed in the following conditions: ACL + ALL resection, Single-Bundle with Lateral Plasty (SBLP) reconstruction, Double-Bundle (DB) reconstruction. Testing parameters were: anterior displacement at 30° and 90° of flexion (AP30, AP90) applying a manual maximum load; internal rotation at 30° and 90° of flexion (INT30, INT90) applying a 5 Nm torque and acceleration and internal rotation Pivot-Shift (PS) test. Kinematics was acquired by a navigation system. Paired Student's t test was conducted to assess statistical difference (P < 0.05). RESULTS: At both 30° and 90° of knee flexion, both SBLP and DB surgical techniques showed a significant reduction (P < 0.01) of anterior-posterior tibial displacement compared to the resection of ACL + ALL. At 30° on knee flexion it is the SBLP that allows the greatest reduction of internal rotational laxity when compared to DB reconstruction. Concerning the PS test, only SBPL procedure had a significant laxity decrease considering the acceleration reached by the joint when compared with the ACL + ALL state (P < 0.01). CONCLUSION: Clinical relevance of this study is that the internal rotation and PS test were more efficiently controlled by the SBLP technique than by the DB one at both 30° and 90° of flexion in case of ACL + ALL lesions.

Patients control preferences and results in knee arthroplasty.

PURPOSE: Patient engagement in a patient-physician decision-making process has been correlated with satisfaction and clinical outcomes. Aim of this study is to evaluate if patient control preference may also influence TKA results. METHODS: One hundred and seventy-six patients (120w-56m, age 66 ± 9 years, BMI 28 ± 4) underwent TKA and were prospectively evaluated, before surgery and at 6 and 12 months. The preoperative assessment included the Control Preference Scale (CPS) and other scales measuring psychological aspects (STAI, BDI, TSK), as well as SF12 (physical and mental subscales) and the assessment of pain and function. Pain, function, and SF12 subscales were then used to evaluate the improvement at 6- and 12-month follow-up. RESULTS: Pain, function, and SF12 scores improved at 6 and 12 months. CPS correlated with the outcome: pain and functional improvement at 6 months (p = 0.014; p = 0.003, respectively), patient function at 6 months (p = 0.022), improvement of SF12 physical subscale at 6 and 12 months (p = 0.027; p = 0.037, respectively), and satisfaction at 6 months (p = 0.033). Moreover, the multivariate analysis confirmed the importance of CPS regardless of other demographic, physical or psychological characteristics. CONCLUSION: In contrast with previous literature findings, this study shows that patients with more propensity for control presented lower improvements of pain and function than those more prone to rely on the physician making the decision. Physicians should be aware that the patient control preference may influence the treatment outcome and undertake measurements to optimize patient participation in the shared process to optimize the chances of TKA success. LEVEL OF EVIDENCE: IV.

Surface morphology, tribological properties and in vitro biocompatibility of nanostructured zirconia thin films.

Deposition of nanostructured and low-wear zirconia (ZrO2) thin films on the metallic component of a total joint implant is envisaged to reduce wear of the soft ultra-high molecular weight polyethylene (UHMWPE) counterpart. In this work, morphological surface features, wear resistance and in vitro-biocompatibility of zirconia thin films deposited by the novel Pulsed Plasma Deposition (PPD) method have been investigated. Film thickness, roughness and wettability were found to be strongly dependent on deposition gas pressure. Interestingly, wear rate of UHMWPE disks coupled to zirconia-coated titanium spheres was only poorly correlated to the contact angle values, while film roughness and thickness seemed not to affect it. Furthermore, wear of UHMWPE, when coupled with zirconia coated-titanium spheres, significantly decreased with respect to uncoated spheres under dry or NaCl-lubricated conditions; besides, when using bovine serum, similar results were obtained for coated and uncoated spheres. Finally, suitable mesenchymal stem and osteoblast cells adhesion, proliferation and viability were observed, suggesting good biocompatibility of the nanostructured zirconia films. Taken together, the results shown in this work indicate that zirconia thin films deposited by the PPD method deserve further investigations as low-wear materials for biomedical applications such as total joint replacement.

ACL rupture and joint laxity progression: a quantitative in vivo analysis.

PURPOSE: Benefits of an early reconstruction and the optimal time lapse between injury and surgery to reduce the effects of altered kinematics in ACL-deficient knees are still controversial. AIM: The aim of this study was to clarify, through a quantitative in vivo evaluation, the effects of the time lapse between ACL injury and surgery in terms of changes in the pre-operative knee laxity. METHODS: An in vivo study was performed on 99 patients who underwent ACL surgery. Just before the graft fixation, six laxity tests were performed for all the subjects at manual-maximum load: anterior-posterior displacement and internal-external rotation at 30° and 90° of knee flexion (AP30, AP90, IE30, IE90) as well as varus-valgus rotation (VV0, VV30) at 0° and 30° of flexion. Kinematics data were acquired by a navigation system. The Spearman rank correlation was used to assess correlation between rank and continuous data. Significance was set at P = 0.05. RESULTS: The analysis highlighted a significant influence of the injury-to-surgery time lapse on VV0 and AP90 compared with pre-operative laxity levels. Meniscus status also significantly affected the pre-operative laxity in the VV0 (Spearman's ρ = 0.203, P = 0.038; GLM with meniscal correction partial Î· = 0.27, P = 0.007) and AP90 (Spearman's ρ = 0.329, P = 0.001; GLM with meniscal correction partial Î· = 0.318, P = 0.017) tests. CONCLUSION: The main finding of this study is that patients with ACL rupture and a higher injury-to-surgery time present higher values of knee laxity involving AP90 displacement and VV30 rotation. Clinical relevance of the study is that ACL-deficient joint laxity, involving anterior-posterior displacement at 90° of knee flexion and varus-valgus rotation at 0° of flexion, is significantly affected by the lapse of injury-to-surgery time. This highlights the importance of considering the effects of delaying surgery when managing patients with such deficiency.

A history of meniscal surgery: from ancient times to the twenty-first century.

The science and surgery of the meniscus have evolved significantly over time. Surgeons and scientists always enjoy looking forward to novel therapies. However, as part of the ongoing effort at optimizing interventions and outcomes, it may also be useful to reflect on important milestones from the past. The aim of the present manuscript was to explore the history of meniscal surgery across the ages, from ancient times to the twenty-first century. Herein, some of the investigations of the pioneers in orthopaedics are described, to underline how their work has influenced the management of the injured meniscus in modern times. Level of evidence V.

Does meniscus removal affect ACL-deficient knee laxity? An in vivo study.

PURPOSE: The purpose of the present study was to determine, in vivo, the effect of different types of meniscectomy on an ACL-deficient knee. METHODS: Using a computer-assisted navigation system, 56 consecutive patients (45 men and 11 women) were subjected to a biomechanical testing with Lachman test (AP30), drawer test (AP90), internal/external rotation test, varus/valgus rotation test and pivot-shift test. The patients were divided into three groups according to the status of the medial meniscus. Group BH, 8 patients with bucket-handle tear of medial meniscus underwent a subtotal meniscectomy; Group PHB, 19 patients with posterior horn body of medial meniscus tear underwent a partial meniscectomy; and Group CG with isolated ACL rupture, as a control group, with 29 patients. RESULTS: A significant difference in anterior tibial translation was seen at 30 grades and in 90 grades between BH and PHB groups compared to the CG. In response to pivot-shift test, no significant differences in terms of AREA and POSTERIOR ACC were found among the three groups (n.s). Concerning the anterior displacement of the pivot shift a statistically significant differences among the three tested groups was found. CONCLUSION: The present study shows that meniscal defects significantly affect the kinematics of an ACL-deficient knee in terms of anterior tibial translation under static and dynamic testing.

Technical variables of ACL surgical reconstruction: effect on post-operative static laxity and clinical implication.

PURPOSE: The hypothesis was that an alteration of different surgical variables of ACL reconstruction would produce significant changes in post-operative static laxity of knee joint. METHODS: Joint laxity was acquired by a surgical navigation system for 17 patients just after graft fixation during single-bundle reconstruction with extra-articular lateral tenodesis. The analysed laxity parameters were: internal/external rotation at 30° (IE30) and 90° (IE90) of flexion, varus/valgus rotation at 0° (VV0) and 30° (VV30) of flexion and anterior/posterior displacement at 30° (AP30) and 90° (AP90) of flexion. As surgical variables, the angles between the tibial tunnel and the three planes were defined as well as the lengths of the tunnel and the relationship between native footprints and tunnels. The same analysis was performed for the femoral side. All surgical variables were combined in a multivariate analysis to assess for predictive factors between them and post-operative laxities values. To quantify the performance of each multivariate model, the correlation ratio (η 2) and the corresponding P value (*P < 0.050) have been evaluated. RESULTS: Multivariate analysis underlined statistically significant models for the estimation of: AP30 (η 2 = 0.987; P = 0.014), IE30 (η 2 = 0.995; P = 0.005), IE90 (η 2 = 0.568; P = 0.010), VV0 (η 2 = 0.932; P = 0.003). The parameters that greatly affected the identified models were the orientation of the tibial tunnel with respect to the three anatomical planes. The estimation of AP30, IE30 and IE90 got lower value as the orientation of the tibial tunnel with respect to transverse plane decreases. Considering the orientation to sagittal ([Formula: see text]) and coronal ([Formula: see text]) plane, we found that their reduction provoked a decrease in the estimation of AP30, IE30 and IE90 (except [Formula: see text] that did not appear in the estimation of AP30). The estimation of VV0 got an increase of [Formula: see text], and [Formula: see text] which led to a laxity reduction. CONCLUSION: The main finding of the present in vivo study was the possibility to determine significant effects on post-operative static laxity level of different surgical variables of ACL reconstruction. In particular, the present study defined the conditions that minimize the different aspects of post-operative laxity at time-zero after surgery.

Current use of navigation system in ACL surgery: a historical review.

PURPOSE: The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years. METHODS: A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery. RESULTS: One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined. CONLUSIONS: Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness. LEVEL OF EVIDENCE: IV.

Patient kinesiophobia affects both recovery time and final outcome after total knee arthroplasty.

PURPOSE: To evaluate the effects of kinesiophobia on both phases immediately after surgery and the final results after total knee arthroplasty (TKA). METHODS: This study evaluated prospectively 101 patients (mean age 66 ± 8.0 years, 70 women and 31 men), 5 days after surgery, at 1, 6, 12 months, and at a mean final follow-up of 3.2 ± 0.7 years (2.0-4.2 years). Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK: Activity Avoidance-TSK1 and Harm-TSK2 subscales), and results were evaluated with range of motion, pain and function on 0-10 numeric rating scales, WOMAC and SF-12 (Physical and Mental subscales) scores. RESULTS: TSK1 was correlated with the acute postoperative pain measured at 5 days (p = 0.031), pain measured at 12 months (p = 0.018), patient perceived function at 12 months (p = 0.025), SF-12P at 6 months (p < 0.001), SF-12P and SF-12M at 12 months (p = 0.001 and p = 0.005, respectively), and WOMAC at both 6 and 12 months of follow-up (p = 0.005 and p = 0.001). The effect of TSK 1 on the final WOMAC score was significant when corrected by age and sex (p = 0.049, η 2 = 0.041): the youngest female patients were affected even by moderate kinesiophobia levels. CONCLUSIONS: Fear of pain and even more avoidance of movement are strongly correlated both with the acute postoperative pain perception and recovery after surgery up to 1 year, thus presenting a relevant clinical impact on the outcome after TKA. Moreover, this study showed that even though at longer follow-up its impact decreases, patients with higher levels of kinesiophobia may present a poorer final outcome, especially women. LEVEL OF EVIDENCE: IV.

DOES TOTAL KNEE REPLACEMENT MODIFY FLEXION AXIS OF THE KNEE ON FRONTAL AND AXIAL PLANE REGARDLESS FROM LIMB ALIGNMENT?

The optimal reference for rotational positioning of femoral component in total knee replacement (TKR) is debated. Navigation has been suggested for intra-op acquisition of patient’s specific kinematics and functional flexion axis (FFA). The main purpose of the present study is to prospectively investigate whether pre-operative FFA in patients with osteoarthritis (OA) and varus alignment changes after TKR and whether a correlation exists between post-op FFA and pre-op alignment. A navigated TKR was performed in 108 patients using a specific software to acquire passive joint kinematics before and after TKR. The knee was cycled through three passive range of motions (PROM), from 0° to 120°. FFA was computed using the mean helical axis algorithm. The angle between FFA and surgical TEA was determined on frontal (αf) and axial (αa) plane. The pre- and post-op hip-knee-ankle angle (HKA) was determined. Post-op FFA was different from pre-op FFA only on frontal plane. No significant difference was found on axial plane. No correlation was found between HKA-pre and αA-pre. A significant correlation was found between HKA-pre and αF–pre. The study concluded that TKR modifies FFA only on frontal plane. No difference was found on axial plane. Pre-op FFA is in a more varus position respect to TEA. The position of FFA on frontal plane is dependent on limb alignment. The present study has demonstrated TKR modifies the position of FFA only on frontal plane. The position of FFA on axial plane is not dependent on the amount of varus deformity and is not influenced by TKR. Level of evidence, IV, case series.

Platelet-rich plasma: why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration.

PURPOSE: The aim of this review was to analyze the available evidence on the clinical application of this biological approach for the injective treatment of cartilage lesions and joint degeneration, together with preclinical studies to support the rationale for the use of platelet concentrates, to shed some light and give indications on what to treat and what to expect from intra-articular injections of platelet-rich plasma (PRP). METHODS: All in vitro, in vivo preclinical and clinical studies on PRP injective treatment in the English language concerning the effect of PRP on cartilage, synovial tissue, menisci, and mesenchymal stem cells were considered. A systematic review on the PubMed database was performed using the following words: (platelet-rich plasma or PRP or platelet concentrate or platelet lysate or platelet supernatant) and (cartilage or chondrocytes or synoviocytes or menisci or mesenchymal stem cells). RESULTS: Fifty-nine articles met the inclusion criteria: 26 were in vitro, 9 were in vivo, 2 were both in vivo and in vitro, and 22 were clinical studies. The analysis showed an increasing number of published studies over time. Preclinical evidence supports the use of PRP injections that might promote a favourable environment for joint tissues healing. Only a few high-quality clinical trials have been published, which showed a clinical improvement limited over time and mainly documented in younger patients not affected by advanced knee degeneration. CONCLUSIONS: Besides the limits and sometimes controversial findings, the preclinical literature shows an overall support toward this PRP application. An intra-articular injection does not just target cartilage; instead, PRP might influence the entire joint environment, leading to a short-term clinical improvement. Many biological variables might influence the clinical outcome and have to be studied to optimize PRP injective treatment of cartilage degeneration and osteoarthritis.

Knee multi-ligament reconstruction: a historical note on the fundamental landmarks.

Several eminent surgeons made breakthroughs in knee surgery throughout the nineteenth and twentieth centuries. Before that, knee injuries were only treated conservatively and it was thanks to the progress made in the field of biomechanics and biology that new surgical treatments were proposed. The history of medicine recalls some illustrious surgeons such as Thomas Annandale and Mayo Robson who were the first to perform and describe their revolutionary experience regarding meniscal and anterior cruciate ligament surgery. Less famous are the forefathers of multi-ligament reconstructive surgery: the purpose of this paper was to shed some light on the pioneers of this particular field of orthopaedic practice, which is gaining increasing interest in current clinical practice. Level of evidence V.

Fibrin glue improves osteochondral scaffold fixation: study on the human cadaveric knee exposed to continuous passive motion.

OBJECTIVE: To evaluate stability and integrity of bi-layer and three-layer collagen-hydroxyapatite (C-HA) osteochondral scaffolds in a human cadaveric knee exposed to continuous passive motion (CPM) with and without loading and the role of added fibrin glue to improve the press-fit fixation of C-HA scaffolds. DESIGN: Osteochondral lesions (2.0 × 1.5 cm) were chiseled out on both condyles and trochlea in eight human cadaveric knees. A total of 24 bi-layer (5 mm, four in each condyle) or three-layer C-HA scaffolds (8 mm, eight in the trochlea, four in each condyle) were first press-fit implanted and underwent testing with CPM, 90 cycles, 0°-90°. The second set of 24 scaffolds was implanted in cleaned lesions with the addition of fibrin glue. Two knees with fibrin glue fixation were additionally exposed to 15 kg loading, with 30 cycles of CPM, 0°-30°. Then, the knees were reopened and the scaffolds were evaluated using semi-quantitative Drobnic and modified Bekkers scores. RESULTS: All but two scaffolds remained in the lesions site throughout CPM. Two implants failed: both were bi-layer osteochondral scaffolds, press-fit implanted at the lateral femoral condyle (LFC). A statistically significant difference was obtained between press-fit and fibrin glue implants with both Drobnic (2.9 ± 0.7 vs 4.3 ± 0.1, P < 0.0005) and Bekkers (3.3 ± 1.0 vs 5.0 ± 0.1, P < 0.0005) scores. Additional knee loading did not affect fibrin glue scaffold fixation or integrity. CONCLUSION: This cadaveric study showed fibrin glue notably improved bi-layer or three-layer C-HA scaffold press-fit fixation regardless of lesion location. It is therefore recommended that fibrin glue be used during surgery to improve early post-operative C-HA scaffold stability and integrity.