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

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

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

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

Current Trends in Knee Arthroplasty: Are Italian Surgeons Doing What Is Expected?

OBJECTIVES: The purpose of this study is to evaluate Italian surgeons' behavior during knee arthroplasty. MATERIALS AND METHODS: All orthopedic surgeons who specialized in knee replacement surgeries and were members of the Italian Society of Knee, Arthroscopy, Sport, Cartilage and Orthopedic Technologies (SIGASCOT) between January 2019 and August 2019 were asked to complete a survey on the management of knee arthroplasty. Data were collected, analyzed, and presented as frequencies and percentages. RESULTS: One-hundred and seventy-seven surgeons completed the survey and were included in the study. Ninety-five (53.7%) surgeons were under 40 years of age. Eighty-five surgeons (48%) worked in public hospitals and 112 (63.3%) were considered "high volume surgeons", with more than 100 knee implants per year. Postero-stabilized total knee arthroplasty was the most commonly used, implanted with a fully cemented technique by 162 (91.5%) surgeons. Unicompartmental knee arthroplasty (UKA) was a rarer procedure compared to TKA, with 77% of surgeons performing less than 30% of UKAs. Most common TKA pre-operative radiological planning included complete antero-posterior (AP) weight-bearing lower limb radiographs, lateral view and patellofemoral view (used by 91%, 98.9% and 70.6% of surgeons, respectively). Pre-operative UKA radiological images included Rosenberg or Schuss views, patellofemoral view and magnetic resonance imaging (66.1%, 71.8% and 46.3% of surgeons, respectively). One hundred and thirty-two surgeons (74.6%) included an AP weight-bearing lower limb X-ray one year after surgery in the post-operative radiological follow-up. Furthermore, 119 surgeons (67.2%) did not perform a post-operative patellofemoral view because it was not considered useful for radiological follow-up. There was no uniformity in the timing and features of post-operative follow-up, with 13 different combinations. CONCLUSIONS: Italian surgeons perform TKA more commonly than UKA. Pre-operative TKA planning is quite uniform rather than UKA planning. Despite literature evidence, there is no agreement on follow-up. It may be useful to create a uniform checklist, including correct timing and exams needed. This analysis is also part of a society surgical educational project for training doctor.

Controversies in ACL revision surgery: Italian expert group consensus and state of the art.

BACKGROUND: Revision ACL reconstruction is a complex topic with many controversies and not-easy-to-make decisions. The authors' aim is to provide some feasible advice that can be applied in daily clinical practice with the goal of facilitating the decision-making process and improving the outcomes of patients subjected to revision ACL reconstruction. METHODS: A national survey with seven questions about the most controversial topics in revision ACL reconstruction was emailed to members of two societies: SIOT and SIAGASCOT. The participants' answers were collected, the most recent literature was analyzed, and a consensus was created by the authors, according to their long-term surgical experience. CONCLUSIONS: The decision-making process in revision ACL reconstruction starts with a standardized imaging protocol (weight-bearing radiographs, CT scan, and MRI). One-stage surgery is indicated in almost all cases (exceptions are severe tunnel enlargement and infection), while the choice of graft depends on the previously used graft and the dimensions of the tunnels, with better clinical outcomes obtained for autografts. Additional procedures such as lateral extra-articular tenodesis in high-grade pivot-shift knees, biplanar HTO in the case of severe coronal malalignment, and meniscal suture improve the clinical outcome and should be considered case by case. LEVEL OF EVIDENCE: V (Expert opinion).

Medial closure supracondylar femoral osteotomy: an effective solution for long-term treatment of arthritic valgus knee?

PURPOSE: The aim of this work was to retrospectively analyze the clinical, subjective, and radiological results of medial closing-wedge distal femur osteotomy (MCW-DFO) for the treatment of osteoarthritis (OA) in valgus knee at medium- to long-term follow-up. MATERIALS AND METHODS: A total of 57 patients (62 knees) treated with MCW-DFO between 1984 and 2018 were included in the study. Patient age at the time of the surgery ranged between 28 and 61 years (average: 48 years). All patients with a minimum follow-up of 4 years were contacted to request for them to undergo clinical, subjective, and radiological evaluation. Preoperative hip-knee-ankle (HKA) angle (i.e., preoperative valgus malalignment) was 8.6° ± 2°. Patients were evaluated using the following scales: the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Knee Society Score (KSS), the International Knee Documentation Committee (IKDC), the Visual Analog Scale (VAS), and the Numeric Rating Scale 11 (NRS-11). RESULTS: Mean follow-up was 11.6 ± 4.9 years, and a total of 17 patients (20 knees) were available for the last examination. At maximum follow-up, 4 patients underwent conversion to a total knee replacement (20%); their survival rate was 100% at 10 years and 66.7% at 15 years, as estimated using the Kaplan-Meier curve. The subjective Knee Society Score improved on average from 37.7 ± 10 to 63.9 ± 15.4. The objective Knee Society Score improved on average from 42.2 ± 11.7 to 75 ± 22.5. The pain detected through the VAS and NRS-11 scales improved from 56.7 ± 12.9 to 42 ± 17.1 and from 5.8 ± 1.1 to 4.4 ± 1.7, respectively. Thirteen patients (70%) required hardware removal at an average time of 19 ± 4 months due to a local nuisance. CONCLUSIONS: MCW-DFO can improve symptoms in patients with osteoarthritis in a valgus knee at medium- to long-term follow-up, reducing the progression of osteoarthritis in properly selected patients.

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.

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.

Protocol and descriptive epidemiology of the SIGASCOT Italian multicentric registry of revision ACL reconstruction: a 1-year pilot study.

The aim of the present study was to present the demographic and baseline results of the first year of course of the SIGASCOT Italian registry of Revision ACL reconstruction.The data of the patients undergoing revision ACL reconstruction, enrolled in by 20 SIGASCOT members from March 2015 to May 2016, were extracted from the Surgical Outcome System (SOS). Overall, 126 patients were enrolled; 18 were excluded due to incomplete data. Mean age at surgery was 30.4 ± 9.3 years (median 29; 23-38), mean BMI was 22.6 ± 2.3 kg/m2 and 77% were males. Revision was performed with a single-bundle technique in 94%, using allograft in 57% of cases and autograft in 43%. Only 28% had both menisci intact, and meniscal repair or replacement was performed in 25% of patients for medial meniscus and 8% for lateral meniscus. During the first year of enrollment, the SIGASCOT Italian ACL revision registry was able to collect the data of more than 100 patients. The revision ACL reconstruction was usually performed with a single-bundle technique, using allograft and autograft almost in the same extent.

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.

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.

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.

Early osteoarthritis of the knee.

There is an increasing awareness on the importance in identifying early phases of the degenerative processes in knee osteoarthritis (OA), the crucial period of the disease when there might still be the possibility to initiate treatments preventing its progression. Early OA may show a diffuse and ill-defined involvement, but also originate in the cartilage surrounding a focal lesion, thus necessitating a separate assessment of these two entities. Early OA can be considered to include a maximal involvement of 50 % of the cartilage thickness based on the macroscopic ICRS classification, reflecting an OARSI grade 4. The purpose of this paper was to provide an updated review of the current status of the diagnosis and definition of early knee OA, including the clinical, radiographical, histological, MRI, and arthroscopic definitions and biomarkers. Based on current evidence, practical classification criteria are presented. As new insights and technologies become available, they will further evolve to better define and treat early knee OA.

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.

Intravenous neridronate in the treatment of acute painful knee osteoarthritis: a randomized controlled study.

OBJECTIVE: The aim of this randomized, double-blind, placebo-controlled study was to assess the efficacy of i.v. neridronate in controlling pain in patients with acute painful knee OA. METHODS: Sixty-four patients with acute knee pain (<3 months duration) suffering from knee OA with an MRI showing bone marrow lesions (BMLs) were randomized to receive either neridronate 100 mg given four times over 10 days or placebo. After 50 days the patients underwent clinical assessment and a further MRI was performed. Primary outcome was pain changes measured by a visual analogue scale (VAS; range 0-100). Secondary endpoints were WOMAC pain score, McGill pain questionnaire and 36-Item Short Form Health Survey. BMLs were evaluated by whole-organ MRI score. RESULTS: At the day of the last infusion the VAS decreased significantly more in the neridronate group [from 59.0 (s.d. 14.7) to 30.4 (s.d. 15.6); -48.4%; P < 0.001]. Fifty days later the VAS remained unchanged in the placebo group, while a further significant decrease was observed in the neridronate group [from 30.4 (s.d. 15.6) to 9.4 (s.d. 10.8); -69.1%; P < 0.001]. Significant improvements compared with the placebo group were found for most of the other indices of pain and quality of life. The BMLs score in the neridronate group showed significant decreases compared with basal values and those of the placebo-treated patients. Four months after the treatment, 72% of the placebo-treated patients resumed analgesic or anti-inflammatory drugs, but only 12.9% resumed treatment in the neridronate group. CONCLUSION: In patients with acute painful knee OA, four infusions of neridronate are associated with a clinically relevant pain benefit. TRIAL REGISTRATION: ClinicalTrials.gov (http://clinicaltrials.gov), NCT01803360.

Medial patellofemoral ligament reconstruction with bioactive synthetic ligament is an option. A 3-year follow-up study.

PURPOSE: The purpose of this study was to evaluate mid-term follow-up results of medial patellofemoral ligament (MPFL) reconstruction using a bioactive synthetic ligament in the treatment of objective patellofemoral (PF) instability. METHODS: Sixteen patients (18 knees) presenting with objective PF instability underwent a MPFL reconstruction, isolated or associated with other surgical procedures for PF stabilization. All patients were clinically evaluated at a minimum follow-up of 3 years. Kujala, subjective IKDC and KOOS scores were used to assess clinical outcome. Pre-operative and post-operative pain was quantified with VAS scale and the overall satisfaction graded according to Insall and Crosby. Although none of the patients in this series were involved in high-level sports activity because of patellofemoral instability, activity level pre-operatively and at follow-up were evaluated according to Tegner scale. RESULTS: No recurrence of dislocation was observed in this series. The overall satisfaction rate was 88.8%. Kujala score improved significantly from 57±8.4 to 84.3±10.2 points (p<.01). Both subjective IKDC (42.4±7.13 to 70.1±3.9) and KOOS (62.7±4.34 to 82.8±8.8) significantly improved from pre-operative evaluation (p<.01). VAS decreased from a mean pre-operative value of 2.5±1.6 to 1.4±1.5 at 3 years follow-up. Only one patient required revision debridement surgery for persistent medial epicondylar pain. CONCLUSIONS: Isolated or associated MPFL reconstruction with bioactive synthetic ligament is a valid option in surgical treatment of objective PF instability, with results at mid-term follow-up comparable to autologous graft, thus minimizing donor-site morbidity and associated complications. LEVEL OF EVIDENCE: IV.

Operational strategies to deal with the COVID-19 emergency: recommendations from the Italian national society SIAGASCOT following the introduction of vaccines against the SARS-CoV-2 infection.

BACKGROUND: This article aims to present the operational recommendations adopted by the Italian national society for orthopaedic surgery, arthroscopy, and sports medicine (SIAGASCOT) in managing patients eligible to undergo elective orthopaedic surgery during the COVID-19 pandemic after the beginning of a national vaccination campaign. MATERIALS AND METHODS: An extensive literature search, analysing medical databases and scientific societies protocols, was performed to support this document. A four-step approach was used: 1-definition of priorities; 2-definition of significant clusters of interventions; 3-extraction of recommendations from international literature; and 4-adaptation of the recommendations to the specific features of the Italian healthcare system. RESULTS: Three operational priorities were defined ("continuity of care and containment of the virus spread", "examination of waiting lists", and "definition of the role of vaccines"), six significant clusters of intervention were identified, and recommendations regarding the risk management for healthcare staff and hospital facility as well as the preoperative, in-hospital, and postoperative management were produced. Patient selection, preoperative screening, and pre-hospitalization procedures, which are regarded as pivotal roles in the safe management of patients eligible to undergo elective orthopaedic surgery, were analysed extensively. CONCLUSIONS: This document presents national-wide recommendations for managing patients eligible to undergo elective orthopaedic surgery with the beginning of the vaccination campaign. This paper could be the basis for similar documents adapted to the local healthcare systems in other countries. LEVEL OF EVIDENCE: Level IV.

Congenital absence of the cruciate ligaments.

Congenital absence of the cruciate ligaments is a rare condition with a prevalence of 0.017 per 1,000 live births. The most important finding of this study was the presence of a posterior menisco-femoral ligament of Wrisberg with cruciate ligaments agenesia and the hypothesis advanced about the development of the ligamentous structures of the knee. Reviewing the literature, we assume that the congenital anomaly that causes the anatomical defect expresses itself around the 7th to 8th post-ovulatory week. Literature teaches us that the need for a knee replacement seems to be inevitable before or after and during the life of a patient without cruciate ligaments.

Cell-free osteochondral scaffolds provide a substantial clinical benefit in the treatment of osteochondral defects at a minimum follow-up of 5 years.

PURPOSE: The treatment of osteochondral lesions is challenging and no consensus has been established about the best option for restoring both cartilage and subchondral bone. Multilayer collagen-hydroxyapatite scaffolds have shown promising clinical results, but the outcome at a follow-up longer than 5 years still has to be proved. The aim was to evaluate the clinical outcome of patients with a knee isolated osteochondral lesion treated with a biomimetic three-layered scaffold at a minimum 5 years of follow-up. METHODS: Twenty-nine patients (23 males and 6 females, mean age 31.5 ± 11.4 years) were evaluated retrospectively before surgery, at 1 and 2 years and at last follow-up (FU). Visual Analog Scale (VAS) for pain, International Knee Documentation Committee (IKDC) Subjective Score, Tegner-Lysholm Knee Scoring Scale and Tegner Activity Level Scale were collected. Mean FU was 7.8 ± 2.0 years (min 5.1 - max 11.3). The etiology of the defect was Osteochondritis Dissecans or osteonecrosis (17 vs 12 cases). RESULTS: At 12 months FU the IKDC score improved from 51.1 ± 21.7 to 80.1 ± 17.9 (p < 0.01), Tegner Lysholm Score from 59.9 ± 17.3 to 92.5 ± 9.0 (p < 0.01), VAS from 6.1 ± 2.1 to 1.7 ± 2.3 (p < 0.01) and Tegner Activity Level Scale from 1.6 ± 0.5 to 4.9 ± 1.7 (p < 0.01). The results remained stable at 24 months, while at last FU a statistically significant decrease in IKDC, Tegner Lysholm and Tegner Activity Scale was recorded, though not clinically relevant. Patients under 35 achieved statistically better outcomes. CONCLUSIONS: The use of a cell-free collagen-hydroxyapatite osteochondral scaffold provides substantial clinical benefits in the treatment of knee osteochondral lesions at a minimum follow-up of 5 years, especially in patients younger than 35 years. LEVEL OF EVIDENCE: Level IV.

Scaffolds for Knee Chondral and Osteochondral Defects: Indications for Different Clinical Scenarios. A Consensus Statement.

OBJECTIVE: To develop patient-focused consensus guidelines on the indications for the use of scaffolds to address chondral and osteochondral femoral condyle lesions. DESIGN: The RAND/UCLA Appropriateness Method (RAM) was used to develop patient-specific recommendations by combining the best available scientific evidence with the collective judgement of a panel of experts guided by a core panel and multidisciplinary discussers. A list of specific clinical scenarios was produced regarding adult patients with symptomatic lesions without instability, malalignment, or meniscal deficiency. Each scenario underwent discussion and a 2-round vote on a 9-point Likert-type scale (range 1-3 "inappropriate," 4-6 "uncertain," 7-9 "appropriate"). Scores were pooled to generate expert recommendations. RESULTS: Scaffold (chondral vs. osteochondral), patient characteristics (age and sport activity level), and lesion characteristics (etiology, size, and the presence of osteoarthritis [OA]) were considered to define 144 scenarios. The use of scaffold-based procedures was considered appropriate in all cases of chondral or osteochondral lesions when joints are not affected by OA, while OA joints presented more controversial results. The analysis of the evaluated factors showed a different weight in influencing treatment appropriateness: the presence of OA influenced 58.3% of the indications, while etiology, size, and age were discriminating factors in 54.2%, 29.2%, and 16.7% of recommendations, respectively. CONCLUSIONS: The consensus identified indications still requiring investigation, but also the convergence of the experts in several scenarios defined appropriate or inappropriate, which could support decision making in the daily clinical practice, guiding the use of scaffold-based procedures for the treatment of chondral and osteochondral knee defects.