Accuracy and Cost-Effectivenss of a Novel Method for Alpha Defensins Measurement in the Diagnosis of Periprosthetic Joint Infections.

BACKGROUND: Two methods for detecting synovial fluids alpha defensins are available: the enzyme-linked immunosorbent assay and the lateral flow test. For both, the proper role and accuracy remain uncertain. The purpose of this study was to assess the accuracy of the matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) for alpha defensin detection in synovial fluids of patients with total knee arthroplasty/total hip arthroplasty failures. The hypothesis was that the alpha defensin measurement through MALDI-TOF MS assay could be a high sensitive and specific test for periprosthetic joint infections (PJI) diagnosis as compared with Musculoskeletal Infection Society (MSIS) criteria. METHODS: The study included 138 patients. The 2018 MSIS criteria were used to diagnose PJIs. Synovial fluids were assessed for routinely synovial fluid tests and alpha defensin measurement through MALDI-TOF MS. Sensitivity, specificity, overall diagnostic accuracy, positive and negative predictive values, receiver operator curves, and area under the curve were calculated. RESULTS: As per the 2018 MSIS criteria, 59 PJIs (43%) and 79 aseptic failures (57%) were diagnosed. The MALDI-TOF MS assay showed an overall accuracy of 94.9%. The sensitivity was 93%, the specificity was 96%, the positive predictive value was 95%, and the negative predictive value was 95%. Receiver operator curves analysis demonstrates an area under the curve of 0.95 (P < .001). CONCLUSION: The MALDI-TOF MS assay showed high sensitivity and specificity for alpha defensin detection in case of total knee arthroplasty/total hip arthroplasty failures. The advantages of the technology, such as the few milliliters of sample needed, the rapidity of obtaining results, and the cost-effectiveness of the procedure could make the MALDI-TOF MS alpha defensin assay a useful and widespread test in clinical practice.

Measurement technique for posterior tibial slope on radiographs can affect its relationship to the risk of anterior cruciate ligament rupture.

PURPOSE: The purpose of this study was to determine the most reliable radiographic measurement method to evaluate PTS as a risk factor for ACL reconstruction failure. METHODS: Patients who underwent ACL reconstruction or ACL revision reconstruction between January 2009 and December 2014 by a single surgeon were included. Fifty-two consecutive patients who underwent ACL revision reconstruction were compared to a random selection of 52 patients who underwent primary ACL reconstruction and a control group of 52 patients without ACL injury. ACL reconstruction was performed using either ipsilateral (primary) or contralateral (revision) quadrupled hamstring autograft. Lateral knee radiographs were evaluated using three methods: (1) longitudinal axis, (2) anterior tibial cortex axis, and (3) posterior tibial cortex. RESULTS: A significant difference was found between subjects who underwent ACL reconstruction and control knees (6.79° vs. 5.31°, p = 0.046) using the posterior tibial cortex method. No other statistical significance was found between groups. A multiple linear regression analysis found that the PTS as measured by any method was not affected by the patient's age, sex, height, weight, and BMI. All methods of measurement for PTS demonstrated excellent (ICC > 0.90) intra-rater and inter-rater reliability, but only the posterior tibial cortex method maintained excellent intra-rater and inter-rater reliability (ICC > 0.90) when evaluating patients with ACL revision reconstruction. CONCLUSIONS: The posterior tibial cortex measurement is the most reliable method for analyzing the PTS on lateral knee radiographs in patients undergoing ACL revision reconstruction.

Bilateral Post Traumatic Myositis Ossificans of Adductor Longus in a Young Soccer Player: A Case Report and Literature Review.

ABSTRACT: Myositis ossificans traumatica (MOT) is a self-limiting and self-resolving pathology. In most cases, conservative treatment is chosen as the first step. Surgical treatment is reserved for cases of failure of conservative treatment with persistence of pain and mass. The case presented concerns an 18-year-old soccer player suffering from bilateral adductor longus (AL) MOT results following two different sports injuries. The patient reports the appearance of swelling and palpable mass at the proximal and medial region of the thigh, about 2 cm from the pubic symphysis, along the course of the adductor magnus. The radiological investigation showed the presence of a calcification along the course of the right and left AL muscles. Surgical treatment was considered for the right thigh injury, being symptomatic 1 year after the onset and refractory to other treatments. At 3 months of follow-up, the patient was asymptomatic and completed the rehabilitation program for the recovery of muscle strength and range of motion (ROM). In cases where MOT manifests with resistant pain, ROM restriction and daily activity reduction, surgical excision is the preferred option.

Detection of α-defensin in synovial fluids by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry as an innovative and cost-effective assay for improved definition of periprosthetic joint infections.

RATIONALE: Detection of α-defensins in synovial fluid is gaining more and more interest in the field of correct diagnosis of periprosthetic joint infections (PJIs). At present, they can be assessed by a quantitative enzyme-linked immunosorbent assay which is expensive and time-consuming and by a qualitative lateral flow immunoassay which is rapid but quite expensive and whose clinical sensitivity is debated. Thus, developing an alternative rapid, accurate, and low-cost assay for α-defensins is important to make α-defensins actionable as novel key clinical markers. METHODS: Synovial fluid (SF) samples were obtained from 18 patients undergoing revision of primary joint arthroplasty. Of these, eight met the 2013 Musculoskeletal Infection Society (MSIS) criteria for PJIs, the remaining were classified as aseptic failure. Microbiological analysis and Synovasure assays were carried out on all samples. Sample preparation and the matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) settings were adjusted to detect human neutrophil peptide (HNP)-1, -2 and -3 and to obtain optimal results in term of sensitivity and stability. RESULTS: MALDI-TOF MS was able to detect HNPs in SF from septic patients. No signals for HNPs were detected in SF from aseptic failure. The limits of detection (LOD) were 2.5 and 1.25 µg/mL for HNP-2 and HNP-1, respectively. The turnaround time of the analysis is 20 min, and SF samples are stable at -20°C for up to 3 days. Assay sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 100% for all parameters. On the same SF samples, the Synovasure assay showed lower sensitivity specificity, and PPV and NPV of 87.5%, 90%, 87.5% and 90%, respectively. Microbiological analysis of SF confirmed the presence of bacteria only in SF MSIS-positive patients. CONCLUSIONS: The reported MALDI-TOF MS assay was able to detect and differentiate HNPs in SF samples and showed a slightly better diagnostic accuracy than the Synovasure assay.

Rupture of the Patellar Tendon After Platelet-Rich Plasma Treatment: A Case Report.

INTRODUCTION: Rupture of the patellar tendon is becoming more and more frequent, even in sports activities overloading the extensor mechanism of the knee. Platelet-rich plasma (PRP) treatment has been recently introduced in treatment for several knee- and sport-related injuries including muscle strain cartilage defect and tendinopathies. The aim of this case report is to present a case of rupture of the patellar tendon occurred after injections of PRP. CASE REPORT: A case of a 40-year-old male soccer player sustaining a patellar tendon rupture after a series of 4 PRP injections. At surgery, a complete rupture in the middle of the patellar tendon was found, with severe degenerative changes of the tendon tissue. This case questions the actual efficacy and safety of PRP in severe degenerative tendinopathies.

Comorbidities rather than age affect medium-term outcome in octogenarian patients after total knee arthroplasty.

PURPOSE: As the population ages, it is important to determine whether total knee arthroplasties (TKA)s are safe and beneficial in the octogenarian population. The aims of the present study were: (1) to assess the effect of comorbidities and age on the incidence of postoperative complications following TKA and (2) to evaluate the mid-term outcome of octogenarian patients. METHODS: A retrospective matched-paired analysis by gender, BMI and duration of follow-up was conducted on 206 patients older than 80 years and younger than 75 years between 2009 and 2016, undergoing primary TKA. The mean follow-up was 5 years. Outcome measures including Oxford Knee Score (OKS), Knee Society Score (KSS), Knee Society Function Score (KSFS), postoperative complications, length of stay (LOS) and survivorship were analysed. The association between complications and comorbidities was assessed using multivariable logistic regression after adjusting for age, Deyo-Charlson Comorbidity Index (D-CCI) and the American Society of Anesthesiologist's (ASA) physical status classification. RESULTS: In the multivariable models, D-CCI class is an independent predictor for postoperative cardiac complications, delirium and transfusion rate (OR ranging from 1.2 to 69.5 in respect to D-CCI reference class 0). Being ≥ 80 years old was associated with an increased risk of transfusion (OR 3.4; 95% CI 1.7-6.8) and 1.7-day increase in LOS (p < 0.001). Both groups showed significant improvement in postoperative knee scores following TKA. CONCLUSION: Octogenarians experienced good clinical results when compared to their younger counterparts. Comorbidities, rather than age itself, are responsible for the increase in postoperative morbidity. Preoperative risk assessment has to be optimized in order to reduce complications.

Could the tendon degeneration and the fatty infiltration of the gluteus medius affect clinical outcome in total hip arthroplasty?

PURPOSE: The aim of this prospective study was to perform a clinical and radiologic evaluation of patients undergoing total hip arthroplasty (THA). The hypothesis is that there is a correlation between the pre-operative degeneration state of the gluteal muscle-tendinous unit and the clinical outcome in terms of functional recovery. METHODS: Fifty-five patients have met inclusion criteria. All patients included in the sample were subjected to clinical evaluation. The ultrasound examination of the patients of the study was conducted and the following parameters were assessed: Thickness in mm of the gluteus medius tendon; Quality of the gluteus medius tendon; and Trophy and muscular composition. RESULTS: The degree of degeneration of the pre-operative tendon shows a negative statistical correlation with all the pre- and post-operative clinical scales, but presents statistical significance (p < 0.05) only with the post-operative Harris, the post-operative Oxford, the Harris and HOOS-modified post-operative, lameness, and Trendelenburg; it correlates positively with the quality of the macroscopic tendon detected intra-operatively, the degree of the pre-operative contralateral tendon, and the operated and contralateral pre-operative muscle (p < 0.05). The degree of fatty degeneration of the pre-operatively operated muscle correlates negatively (p < 0.05) with all pre- and post-operative clinical scales except for the pre-operative WOMAC and HOOS modified, with the lameness and the Trendelenburg sign; it correlates positively (p < 0.05) with age, the quality of the macroscopic tendon detected intra-operatively, degree of tendon degeneration, fatty infiltration of the contralateral pre- and post-operative muscle and of the post-operative operated muscle. CONCLUSION: Tendon degeneration and fatty infiltration of the gluteus medius muscle appeared to be determinants of the post-operative persistence of lameness and Trendelenburg sign positivity in patients undergoing hip arthroplasty.

Suspension arthroplasty versus interposition arthroplasty in the treatment of trapeziometacarpal osteoarthritis: a clinical and magnetic resonance imaging study.

INTRODUCTION: Biological arthroplasties are the most used surgical techniques, for the treatment of trapeziometacarpal osteoarthritis; all of them provide the reconstruction of trapeziometacarpal joint by a tendon graft. The aim of the study is to compare two surgical techniques: interposition arthroplasty and suspension arthroplasty at 12-month follow-up in order to evaluate the clinical and radiographic results. METHODS: Sixty-seven patients surgically treated for basal thumb osteoarthritis were divided into two groups: 36 patients, (8 M; 27 F) (39 hands), treated with interposition arthroplasty are included in group A and 31 patients, (6 M; 25 F) (34 hands), treated with suspension are included in group B. Both groups were radiographically evaluated with X-ray and MRI at 12 months and clinically evaluated with DASH score, VAS, Grind test, hand grip tests, Kapandji test and ROM before surgery and at final follow-up. RESULTS: At final follow-up about Kapandji test, in group A, 31 hands (79.4%) presented Kapandji score of 10 and eight hands (20.6%), a Kapandji score of 8. In group B, six hands (17.6%) reported a Kapandji score of 8 and 28 patients (82.4%), a Kapandji score of 10 (p < 0.05). Regarding the radial abduction, patients of group A recovered on average 79.5° of abduction and in group B recovered on average 78°. About DASH score and VAS score, group B shows better results. Mean decalage was 2.3 mm in group A and 0 mm in group B. Jamar dynamometer shows statistically better results for group B in all tests (hand grip test, pulp pinch and key pinch test). CONCLUSIONS: Suspension arthroplasty seems to guarantee better outcomes in terms of pain reduction, clinical score and recovery of grip strength. Moreover, it seem to be associated with better results at MRI like absence of I ray decalage and minor scaphoid subchondral oedema at final follow-up.

The unhappy triad of the knee re-revisited.

AIM OF THE STUDY: To describe the surgical findings of the anterolateral complex in patients with the "unhappy triad" lesion of the knee. METHOD: One hundred and twenty-five consecutive patients presenting with acute anterior cruciate ligament (ACL) tears were selected for this study. Only cases, evaluated with a valgus stress test under fluoroscopy, with a medial opening more than 5 mm of the medial collateral ligament (MCL) were included in the study (11 patients). For the included cases, open MCL surgical repair was performed only in cases with a valgus stress test more than 10 mm as revealed by fluoroscopy (3 patients). All included cases (11 patients) underwent ACL reconstruction and exploration of the anterolateral complex that was then assessed, photographed, classified, and eventually repaired. RESULTS: At clinical evaluation under anaesthesia, all patients presented a positive Lachman test and a pivot shift test graded as ++ in four cases and +++ in five cases, not valuable in two cases. At surgical exploration, the anterolateral complex was involved in all cases (11 patients): one case demonstrated a type I injury, eight cases a type II injury, two cases a type III injury, and no patient with a type IV injury (Segond's fracture). All anterolateral complex lesions were repaired by direct suture and re-tensioning. DISCUSSION: On the basis of a recent analysis performed by other authors, we could speculate that injuries of ACL and anterolateral compartment occur in the very early phase of the injury when the knee is forced into internal rotation. The MRI evidence of bone bruising in the lateral compartment in most cases of the present series support the hypothesis of an internal rotation torque. CONCLUSIONS: The unhappy triad of injuries to the knee is actually a tetrad involving not just the ACL, MCL, and medial/lateral meniscus but also involved the anterolateral complex.

Revision Anterior Cruciate Ligament Reconstruction With Hamstrings and Extra-articular Tenodesis: A Mid- to Long-Term Clinical and Radiological Study.

PURPOSE: To present the mid- to long-term clinical and radiographic outcomes of a series of patients who underwent revision anterior cruciate ligament (ACL) reconstruction with doubled gracilis and semitendinosus (DGST) autograft and a lateral extra-articular tenodesis (LET). METHODS: Patients who underwent revision ACL reconstruction with DGST and LET by a single surgeon between January 1997 and December 2013 were included. Revision was indicated by ACL failure noted on magnetic resonance imaging, persistent clinical instability, or laxity on clinical exam. Patients were evaluated preoperatively and at latest follow-up by an independent board-certified orthopaedic surgeon. Outcomes included Lachman and pivot shift tests, validated clinical and patient reported outcomes scores, and radiographic analysis. The presence of previous meniscectomy or chondral injury was recorded intraoperatively. RESULTS: A total of 118/132 potential patients (89.4%) was available for follow-up at a mean 10.6 years (3-19 years) postoperatively. Lachman and pivot shift examinations as well as the side-to-side difference on an KT-1000 arthrometer demonstrated significant improvement at latest follow-up (P < .05) versus preoperative evaluation. Severe degenerative disease was present in 25% of patients on radiograph and correlated with worsened clinical outcomes. Previous meniscectomy was the only risk factor analyzed that correlated with worsened radiographic grade. No patients had a graft tear based on clinical and/or magnetic resonance imaging evaluation, but 9 (7.6%) failed based on a side-to-side difference of >5 mm on the KT-1000, a grade ≥2+ on pivot shift, or report of continued instability. CONCLUSIONS: Revision ACL reconstruction with DGST and LET at mid- to long-term follow-up provides continued improvement in clinical and radiological outcomes from preoperative assessment. Meniscectomy was the only factor related to worsened radiological grades and clinical outcomes. LEVEL OF EVIDENCE: Level IV, case series.

The Effect of Sequential Tearing of the Anterior Cruciate and Anterolateral Ligament on Anterior Translation and the Pivot-Shift Phenomenon: A Cadaveric Study Using Navigation.

PURPOSE: To evaluate the effect of progressive lesions of the anterior cruciate ligament (ACL) and anterolateral ligament (ALL) on anterior tibial translation (ATT) as evaluated through the Lachman test and internal tibial rotation (ITR) during a dynamic pivot-shift test in a cadaveric model. METHODS: A total of 7 specimens were tested using a navigation system (2.2 OrthoPilot ACL navigation system). The anterior stability of the knee was measured through the Lachman test and dynamic rotational stability was measured through the pivot-shift test in 3 different conditions: intact knee; ACL-deficient knee; and finally, ACL- and ALL-deficient knee. The resulting measurements from the navigation system recorded the real-time changes in both translation and internal rotation during the Lachman and pivot-shift maneuvers. RESULTS: Mean ATT was 7.57 ± 0.53 mm in the intact knee, 14 ± 2.44 mm in the ACL-deficient knee, and 14 ± 2.44 mm in the ACL- and ALL-deficient knee. Mean ITR during the pivot-shift test was 10.14° ± 2.26° in the intact knee, 12.14° ± 2.19° in the ACL-deficient knee, and 18.86° ± 2.73° in the ACL- and ALL-deficient knee. There was a statistically significant difference in static ATT between the intact and ACL-deficient knees (P = .039) but no difference through the addition of an ALL lesion (P = .068). For dynamic rotational control testing, there was no significant difference in ATT between groups but a significant difference in ITR was found (F = 25.17, P = .00034). CONCLUSIONS: During the pivot-shift test, a combined lesion of the ACL and ALL has a significant effect on ITR whereas an isolated lesion of the ACL has no effect on either ATT or ITR. During the Lachman test, an isolated lesion of the ACL has a significant effect on ATT but an additional lesion of the ALL does not affect ATT. CLINICAL RELEVANCE: Dynamic rotational control as tested by the pivot-shift test is greatly influenced by a combined lesion of the ACL and ALL. In clinical cases of a pivot shift, addressing the anterolateral structures may be considered.

Endoscopic Excision of Symptomatic Os Trigonum in Professional Dancers.

The present study reports the clinical results of excision of a symptomatic os trigonum using an endoscopic procedure in professional ballet dancers. The hypothesis was that posterior endoscopic excision of the os trigonum would be safe and effective in treating posterior ankle impingement syndrome related to the os trigonum. Twelve professional dancers underwent excision of a symptomatic os trigonum for PAIS using a posterior endoscopic technique after failure of conservative treatment. The patients were evaluated pre- and postoperatively according to the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner activity scale score, and the visual analog scale score. The surgical time, timing of a return to sports, patient satisfaction, and any complications related to the procedure were recorded. The average postoperative follow-up duration was 38.9 ± 20.6 (range 12 to 72) months. The mean Tegner activity scale score increased from 4.3 ± 0.8 (range 3 to 5) preoperatively to 9 ± 0.2 postoperatively (p < .05). The mean American Orthopaedic Foot and Ankle Society scale score increased from 67.8 ± 6.0 (range 58 to 76) preoperatively to 96 ± 5.1 (range 87 to 100) postoperatively, with 7 of 12 patients (58.3%) reporting the maximum score of 100 points (p < .05). The return to sports was 8.7 ± 0.7 (range 8 to 10) weeks. No major complications were recorded. The results of the present study demonstrate that the endoscopic excision of symptomatic os trigonum using a 2-portal technique after failure of conservative treatment is characterized by excellent results with low morbidity.

Segond's fracture: a biomechanical cadaveric study using navigation.

BACKGROUND: Segond's fracture is a well-recognised radiological sign of an anterior cruciate ligament (ACL) tear. While previous studies evaluated the role of the anterolateral ligament (ALL) and complex injuries on rotational stability of the knee, there are no studies on the biomechanical effect of Segond's fracture in an ACL deficient knee. The aim of this study was to evaluate the effect of a Segond's fracture on knee rotation stability as evaluated by a navigation system in an ACL deficient knee. MATERIALS AND METHODS: Three different conditions were tested on seven knee specimens: intact knee, ACL deficient knee and ACL deficient knee with Segond's fracture. Static and dynamic measurements of anterior tibial translation (ATT) and axial tibial rotation (ATR) were recorded by the navigation system (2.2 OrthoPilot ACL navigation system B. Braun Aesculap, Tuttlingen, Germany). RESULTS: Static measurements at 30° showed that the mean ATT at 30° of knee flexion was 5.1 ± 2.7 mm in the ACL intact condition, 14.3 ± 3.1 mm after ACL cut (P = 0.005), and 15.2 ± 3.6 mm after Segond's fracture (P = 0.08). The mean ATR at 30° of knee flexion was 20.7° ± 4.8° in the ACL intact condition, 26.9° ± 4.1° in the ACL deficient knee (P > 0.05) and 30.9° ± 3.8° after Segond's fracture (P = 0.005). Dynamic measurements during the pivot-shift showed that the mean ATT was 7.2 ± 2.7 mm in the intact knee, 9.1 ± 3.3 mm in the ACL deficient knee(P = 0.04) and 9.7 ± 4.3 mm in the ACL deficient knee with Segond's fracture (P = 0.07). The mean ATR was 9.6° ± 1.8° in the intact knee, 12.3° ± 2.3° in the ACL deficient knee (P > 0.05) and 19.1° ± 3.1° in the ACL deficient knee with Segond's lesion (P = 0.016). CONCLUSION: An isolated lesion of the ACL only affects ATT during static and dynamic measurements, while the addition of Segond's fracture has a significant effect on ATR in both static and dynamic execution of the pivot-shift test, as evaluated with the aid of navigation.

Interlocking horizontal mattress suture versus Kakiuchi technique in repair of Achilles tendon rupture: a biomechanical study.

BACKGROUND: In recent years, the type of surgical treatment for Achilles tendon rupture has been the subject of controversial debate. This biomechanical study evaluates for the first time in literature the ultimate failure load (UFL) of interlocking horizontal mattress (IHM) suture as compared with Kakiuchi suture in Achilles tendon rupture. The hypothesis is that IHM suture can be performed also for Achilles tendon rupture and ensures higher resistance compared with the traditional Kakiuchi suture. MATERIALS AND METHODS: Twenty fresh bovine Achilles tendons were obtained. Ten preparations were randomly assigned to each of two different groups: group A (10 specimens) sutured by IHM technique, and group B (10 specimens) sutured by Kakiuchi technique. Each construct was mounted and fixed on a tensile testing machine. Static preconditioning of 50 N was applied for 5 min as initial tensioning to stabilize the mechanical properties of the graft, then a load to failure test was performed at crosshead speed of 500 mm/min. RESULTS: Ten specimens were tested for each group. The mean UFL was 228.6 ± 98.6 N in the IHM suture group and 96.57 ± 80.1 N in the Kakiuchi suture group. Statistical analysis showed a significant difference (p < 0.05) with better UFL in the IHM group. In both groups, the failure mode registered in each specimen was suture breakage (rupture of suture thread). CONCLUSIONS: IHM suture achieved better UFL compared with Kakiuchi suture in an animal model of Achilles tendon repair. These results seem to support IHM as a valid option in Achilles tendon rupture.

Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players.

PURPOSE: The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players. METHODS: Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker-Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing. RESULTS: At a mean follow-up of 72.6 ± 8.1 months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100 %). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture. DISCUSSION: The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain. CONCLUSIONS: The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity.

Clinical and radiographic outcomes of an accelerometer-based system for the tibial resection in total knee arthroplasty.

PURPOSE: The accelerometer-based system is a portable surgical navigation system for TKA that does not require the use of a large computer console for registration and alignment feedback as required in computer-assisted surgery (CAS). The purpose of this prospective study was to determine the accuracy of the accelerometer-based system in the tibial component positioning and also to evaluate clinical outcomes. METHODS: Between December 2011 and July 2012, a total of 53 consecutive patients with primary gonarthrosis were prospectively enrolled for unilateral TKA using a handheld surgical navigation system to perform the tibial resection. Pre-operatively and postoperatively, patients were asked to fill out a visual analogue scale for pain (VAS) and a knee injury and osteoarthritis outcome score (KOOS). Standing antero-posterior (AP) hip-knee-ankle (HKA) and lateral knee-to-ankle radiographs were performed to determine the varus/valgus alignment and the posterior slope of the tibial components relative to the mechanical axis. RESULTS: The mean duration of follow-up was 23 months. Average preoperative VAS was 8.3 ± 0.67, which significantly improved to a mean 1.2 ± 0.57 at final follow up (P < 0.001). All scores significantly increased compared with pre-operative scores, except for the KOOS sport component (P = 0.075) and quality of life (P = 0.19). Intra-operatively, the average reading provided by the system with regard to varus/valgus alignment before performing the tibial resection was 0.55° ± 0.43. The average postoperative radiographic alignment of the tibial component in the coronal plane was 0.65° ± 0.59 of deviation by the ideal alignment (P > 0.05). CONCLUSION: This study demonstrates that the OrthAlign navigation system combines the accuracy of the computer-assisted surgery systems with the ease of use and familiarity of the traditional instruments while avoiding the drawbacks of the CAS technique and disadvantages of conventional IM femoral alignment systems. The system could demonstrate an improvement in the incidence of outliers in final coronal alignment, as compared with a patient-specific cutting guide.

Patient-specific instruments in total knee arthroplasty.

PURPOSE: In recent years, patient-specific instruments (PSI) has been introduced with the aim of reducing the overall costs of the implants, minimising the size and number of instruments required, and also reducing surgery time. The purpose of this study was to perform a review of the current literature, as well as to report about our personal experience, to assess reliability of patient specific instrument system in total knee arthroplasty (TKA). METHODS: A literature review was conducted of PSI system reviewing articles related to coronal alignment, clinical knee and function scores, cost, patient satisfaction and complications. RESULTS: Studies have reported incidences of coronal alignment ≥3° from neutral in TKAs performed with patient-specific cutting guides ranging from 6% to 31%. CONCLUSIONS: PSI seem not to be able to result in the same degree of accuracy as the CAS system, while comparing well with standard manual technique with respect to component positioning and overall lower axis, in particular in the sagittal plane. In cases in which custom-made cutting jigs were used, we recommend performing an accurate control of the alignment before and after any cuts and in any further step of the procedure, in order to avoid possible outliers.

Smartphone versus knee ligament arthrometer when size does not matter.

PURPOSE: The use of available mechanical methods to measure anterior tibial translation (ATT) in anterior cruciate ligament (ACL)-deficient knees are limited by size and costs. This study evaluated the performance of a portable device based on a downloadable electronic smartphone application to measure ATT in ACL-deficient knees. METHODS: A specific smartphone application (SmartJoint) was developed for this purpose. Two independent observers nonsequentially measured the amount of ATT during execution of a maximum manual Lachman test in 35 patients with an ACL-deficient knee using KT 1000 and SmartJoint on both involved and uninvolved knees. As each examiner performed the test three times on each knee, a total of 840 measurements were collected. Statistical analysis compared intertest, interobserver and intra-observer reliability using the interclass correlation coefficient (ICC). An ICC > 0.75 indicates excellent reproducibility among measurements. RESULTS: Mean amount of ATT on uninvolved knees was 6.1 mm [standard deviation (SD = 2)] with the KT 1000 and 6.4 mm (SD = 2) with SmartJoint. Mean side-to-side difference was 8.1 mm. (SD = 4) with KT 1000 and 8.3 mm (SD = 3) with SmartJoint. Intertest reliability between the two methods yielded an ICC 0.797 [95 % confidence interval (CI) 0.717-0.857] for the uninvolved knee and of 0.987 (CI 0.981-0.991) for the involved knee. Interobserver ICC for SmartJoint and KT 1000 was 0.957 (CI 0.927-0.976) for the uninvolved knee and 0.992 (CI 0.986-0.996) for the involved knee and 0.973 (CI 0.954-0.985) for the uninvolved knee and 0.989 (CI 0.981-0.994) for involved knee, respectively. CONCLUSION: The performance of SmartJoint is comparable and highly correlated with measurements obtained from KT 1000. SmartJoint may provide a truly portable, noninvasive, accurate, reliable, inexpensive and widely accessible method to characterize ATT in ACL-deficient knee.

Evaluation of the accuracy of a patient-specific instrumentation by navigation.

PURPOSE: The aim of this study is to evaluate the accuracy of a patient-specific instrumentation (PSI) as assessed by the intraoperative use of knee navigation software during the surgical procedure. METHODS: Fifteen patients with primary gonarthrosis were selected for unilateral total knee arthroplasty. The first three patients were excluded from this study, as they were considered to be a warm up to set-up the procedure. All patients were operated on with a cemented posterior-stabilised prosthesis cruciate ligament-sacrificing by the same surgeon using the patient matched cutting jigs. The size of the implant, level of resection, and alignment in the coronal and sagittal planes were evaluated. An unsatisfactory result was considered an error ≥2° in both planes for each component as a possible error of 4° could result in aggravation. RESULTS: On the coronal plane the mean deviation of the tibial guide from the ideal alignment was 1.2 ± 1.5 (range 0-5°) and in the sagittal plane was 3.8 ± 2.4 (range 0-7.5°). On the coronal plane the mean deviation of the femoral guide from the ideal alignment was 1.2 ± 0.6 and in the sagittal was 3.7 ± 2. CONCLUSION: On the basis of this preliminary experience the PSI system based only on data acquisition with A-P radiograms and RMN cannot be defined as accurate. In cases of the use of the custom made cutting jigs it is recommended to perform an accurate control of the alignment before making the cuts, for any step of the procedure. LEVEL OF EVIDENCE: II.