Physeal-sparing ACL reconstruction provides better knee laxity restoration but similar clinical outcomes to partial transphyseal and complete transphyseal approaches in the pediatric population: a systematic review and meta-analysis.

PURPOSE: The aim of this meta-analysis was to evaluate complete transphyseal (CTP), partial transphyseal (PTP), and physeal-sparing (PS) techniques for anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic literature search of the PubMed, Web of Science, Cochrane Library, and Scopus literature databases was performed on 10.05.2021. All human studies evaluating the outcomes of CTP, PTP, and PS techniques were included. The influence of the selected approach was evaluated in terms of rates of retears, return to previous level of sport competition, IKDC subjective and objective scores, Lysholm score, rate of normal Lachman and pivot-shift tests, limb length discrepancy, and hip-knee angle (HKA) deviation. Risk of bias and quality of evidence were assessed following the Downs and Black checklist. RESULTS: Forty-nine out of 425 retrieved studies (3260 patients) met the inclusion criteria. The results of the meta-analysis comparing CTP, PTP, and PS approaches for ACL reconstruction in the under 20-year-old population showed a significant difference in terms of differential laxity (CTP 1.98 mm, PTP 1.69 mm, PS 0.22 mm, p < 0.001). No significant differences were seen in terms of growth malalignment, rate of normal Lachman and pivot-shift tests, and rate of normal/quasi-normal IKDC objective score. CONCLUSIONS: The present meta-analysis found overall similar results with the three ACL reconstruction approaches. The PS technique showed better results in terms of knee laxity than the PTP and CTP approaches, but this did not lead to a significant difference in terms of subjective and objective scores. No clear superiority of one technique over the others was found with respect to re-ruptures, growth disturbances, and axial deviations. While the argument for avoiding growth malalignment does not seem to be a crucial point, the PS technique should be the preferred approach in a young population to ensure knee laxity restoration. LEVEL OF EVIDENCE: Level III.

Torsional deformities and overuse injuries: what does the literature tell us.

Overuse injuries imply the occurrence of a repetitive or an increased load on a specific anatomical segment which is unable to recover from this redundant microtrauma, thus leading to an inflammatory process of tendons, physis, bursa, or bone. Even if the aetiology is controversial, the most accepted is the traumatic one. Limb malalignment has been cited as one of the major risk factors implicated in the development of overuse injuries. Many authors investigated correlations between anatomical deviations and overuse injuries, but results appear mainly inconclusive. Establishing a causal relationship between mechanical stimuli and symptoms will remain a challenge, but 3D motion analysis, musculoskeletal, and finite element modelling may help in clarifying which are the major risk factors for overuse injuries.

Trochlear Development in Children From 1 Month to 10 Years of Age: A Descriptive Study Utilizing Analysis by Magnetic Resonance Imaging.

BACKGROUND: Understanding the morphology of cartilage/bony maturation in preadolescents may help explain adult trochlear variation. PURPOSE: To study trochlear morphology during maturation in children and infants using magnetic resonance imaging (MRI). STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty-four pediatric cadaveric knees (10 male and 14 female knees; age, 1 month to 10 years) were included. High-resolution imaging of the distal femoral secondary ossification center was performed using 7-T or 9.4-T MRI scanners. Three-dimensional MRI scans were produced, and images were reformatted; 3 slices in the axial, sagittal, and coronal planes images were analyzed, with coronal and sagittal imaging used for image orientation. Biometric analysis included lateral and medial trochlear height (TH); cartilaginous sulcus angle (CSA); osseous sulcus angle (OSA); trochlear depth; and trochlear facet (TF) length symmetry. Sex comparisons were considered when ≥1 specimen from both sexes of the same age was available; these included 11 knees spanning 4 age groups (ages 1, 3, 4, and 7 years). RESULTS: The analysis of trochlear morphology showed a lateral TH greater than the medial TH at all ages. The thickest cartilage was found on the lateral TF in the younger specimens. Regarding the development of osseous and cartilaginous trochlear contour, a cartilaginous sulcus was present in the 3-month-old specimen and continued to deepen up to the age of 4 years. The shape of the osseous center evolved from round (1 month) to oval (9 months) to rectangular (2 years); no distinct bony trochlear sulcus was present, although a well-formed cartilaginous sulcus was present. The first evidence of formation of a bony sulcus was at 4 years. By the age of 7 to 8 years, the bony contour of the adult distal femur resembled its cartilaginous contour. Female samples had a shallower CSA and OSA than did the male ones in all samples that had a defined OSA. CONCLUSION: Female trochlear grooves tended to be shallower (flatter). The lateral trochlea was higher (TH) and wider (TF length) during growth than was the medial trochlea in both sexes; furthermore, the development of the osseous sulcus shape lagged behind the development of the cartilaginous sulcus shape in the authors' study population. CLINICAL RELEVANCE: Bony anatomy of the trochlear groove did not match the cartilaginous anatomy in preadolescent children, suggesting that caution should be used when interpreting bony anatomy in this age group.

Recurrent Patellar Dislocations Without Untreated Predisposing Factors: Medial Patellofemoral Ligament Reconstruction Versus Other Medial Soft-Tissue Surgical Techniques-A Meta-analysis.

PURPOSE: To provide a direct comparison between medial patellofemoral ligament (MPFL) reconstruction and the other medial patellofemoral soft-tissue surgeries in the restoration of the medial patellar restraint after lateral patellar dislocations in the absence of untreated predisposing factors such as high grade trochlear dysplasia, knee malalignment, patella alta or high tibial tubercle-trochlear groove distance. METHODS: PubMed, Cochrane-library, Web of Science, and gray literature databases were searched to find all the relevant records. Study selection, data extraction, and risk of bias assessment were performed following the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Different techniques to treat lateral patellar dislocation in the absence of untreated predisposing factors were compared in terms of redislocation and complication rates, Kujala, Lysholm, International Knee Documentation Committee, and Tegner scores at the short-term (3 years) and long-term (>3 years) follow-up through meta-analyses. RESULTS: Six studies involving 319 knees were included in the meta-analysis. The analyses of redislocation (0.7% vs 2.9%) and minor complication rates (12% vs 9%) showed no significant differences between MPFL reconstruction and other medial soft-tissue surgeries. Significant differences favoring MPFL reconstruction were documented in Kujala and Lysholm scores at short-term (8.6, P< .001; 10.9, P < .001) and long-term follow-ups (6.3, P = .02; 13.5, P < .001). No significant differences were found in the analyses of International Knee Documentation Committee (P = .10) and Tegner scores (P = .19). Level of evidence was low or very low. CONCLUSIONS: MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent LPD. LEVEL OF EVIDENCE: Level III (meta-analysis of randomized and nonrandomized comparative trials).

A Meta-analysis of Surgical Versus Nonsurgical Treatment of Primary Patella Dislocation.

PURPOSE: To compare outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation (LPD) through a meta-analysis of randomized controlled trials (RCTs) in terms of redislocation rate and clinical outcome, investigating both short-term (<6 years) functional recovery and overall benefit over time (>6 years). METHODS: A systematic search of the literature was performed in November 2018. Risk of bias and quality of evidence were evaluated according to the Cochrane guidelines. RCTs investigating differences between surgery and nonsurgical treatment in primary LPD were included. The outcomes evaluated were redislocation rate, reinterventions, and Kujala score at short-, mid-, and long-term follow-up, with subanalyses for the pediatric population. RESULTS: We included 510 patients from 10 RCTs in the meta-analysis. Redislocation rate was 0.40 (0.25 to 0.66; P < .001) and 0.58 (0.29 to 1.15; P = .12) at the short- and mid-term follow-ups, respectively, and the risk ratio for the need for further operations at 6 to 9 months' follow-up was 0.14 (0.02 to 1.03; P = .05), all favoring surgery. Concerning the Kujala score, an advantage of the surgical approach of 10.2 points (1.6 to 18.7; P = .02) at short-term follow-up was seen, whereas long-term follow-up results were similar between the groups. The subanalysis of the pediatric population at heterogeneous follow-up confirmed a lower risk of recurrence in surgery, with a risk ratio of 0.60 (0.26 to 1.37; P = .22), although not significant. CONCLUSION: The literature documents a low number of high-level trials. The meta-analysis of RCTs underlined that the redislocation rate is higher with the nonsurgical approach compared with the surgical one. Moreover, when looking at the clinical outcome, more favorable findings were found with the surgical approach up to 6 years, whereas results seems to be similar at a longer follow-up after either surgical or nonsurgical treatment of primary LPD. LEVEL OF EVIDENCE: II, meta-analysis of level I and level II randomized clinical trials.

Recurrent patellar dislocations: trochleoplasty improves the results of medial patellofemoral ligament surgery only in severe trochlear dysplasia.

PURPOSE: Medial patellofemoral ligament (MPFL) surgery combined with trochleoplasty (TP), is often performed to restore the normal patellofemoral biomechanics avoiding recurrent lateral patellar dislocation (LPD) in patients with trochlear dysplasia (TD). However, it is still unclear whether combining TP and MPFL surgery would be more beneficial than performing MPFL surgery on its own. This meta-analysis quantitatively synthesizes and compares published data on the outcomes of recurrent LPD treatment using MPFL surgery without or with TP in patients affected by TD. METHODS: A systematic literature search about the treatment of recurrent LPD in the presence of TD was conducted. The primary outcome was redislocation rate, analyzed for different types of TD. Kujala, and IKDC scores, as well as complication rate, were also analyzed through a separate meta-analysis. RESULTS: No statistically significant difference was found in the overall redislocation rate of MPFL surgery without and with TP. There was, however, a statistically significant difference (p < 0.001) in redislocation rate after MPFL surgery without TP between patients with type A or B TD (2.7%) and in patients with type C or D TD (18.6%). In the analysis for every single type of TD, the following results were obtained: redislocation rate of 1.8% in type A, 3.2% in type B, 11.9% in type C, and 7.4% in type D. A statistically significant difference in the complication rate, favouring MPFL surgery without TP, was documented. Both surgical approaches provided a significant improvement with no difference in Kujala and IKDC scores. These results were confirmed when data were analyzed including only patients with type B, C, or D TD, or without additional bone remodelling procedures. CONCLUSION: Isolated MPFL is as effective as combined TP and MPFL surgery in preventing redislocation and improving clinical and functional outcomes in patients with recurrent LPD and knees affected by moderate TD. However, in case of severe TD, the redislocation rate is lower when TP is performed in combination with MPFL surgery, although with comparable clinical outcomes and a higher risk of post-operative range of motion (ROM) limitation. LEVEL OF EVIDENCE: Systematic review and meta-analysis, Level IV.

A useful combination for the treatment of patellofemoral chondral lesions: realignment procedure plus mesenchymal stem cell-retrospective analysis and clinical results at 48 months of follow-up.

INTRODUCTION: Osteochondral lesions of the patellofemoral joint (OLPFJ) are defects of the cartilage surface and subchondral bone, which often require surgical treatment. Reparative treatments have shown some limitations in the long-term follow-up. The one-step bone marrow-derived cells transplantation (BMDCT) achieved good to excellent results in the treatment of osteochondral lesions of the femoral condyles. The aim of this study was to report the 48-month clinical and radiological results among 28 patients with OLPFJ treated with the one-step BMDCT technique associated with the anteromedialization tibial tuberosity (AMTT). MATERIALS AND METHODS: Twenty-eight patients from 2010 to 2013 with OLPFJ underwent the BMDCT with the one-step technique associated with the AMTT. Clinical evaluation was performed at 6, 12, 18, 24, 36 and 48 months after surgery using the Kujala PF scale, the IKDC score and the Tegner activity scale. Eighteen lesions were located on patella and ten lesions on trochlea. RESULTS: The preoperative Kujala score improved from 68.2 ± 4.7 to 87.2 ± 1.2 at the mean final follow-up, while the IKDC subjective score improved from 55.1 ± 6.2 to 92.13 ± 5.5. Tegner scale showed an increase from 1.7 ± 1.3 preoperatively to 5.3 ± 2.7 at the final follow-up. MRI analysis at 24-month follow-up showed an overall good filling of the lesions. DISCUSSION AND CONCLUSIONS: The one-step BMDCT associated with the AMTT permitted good clinical results durable over time with a high rate of patients' satisfaction. These results confirm the validity of the one-step technique also in patellofemoral joint.

Autologous Chondrocyte Implantation for Talar Osteochondral Lesions: Comparison Between 5-Year Follow-Up Magnetic Resonance Imaging Findings and 7-Year Follow-Up Clinical Results.

Autologous chondrocyte implantation (ACI) is an established surgical procedure that has provided satisfactory results. The aim of the present study was to correlate the clinical outcomes of a series of 20 patients treated by ACI at a 7-year follow-up examination with the magnetic resonance imaging (MRI) T2-mapping 5-year follow-up findings. We evaluated 20 patients using the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and the established follow-up protocol until 87.2 ± 14.5 months. MRI T2-mapping sequences were acquired at the 5-year follow-up examination. At the MRI examination (60 ± 12 months), the mean AOFAS score improved from 58.7 ± 15.7 to 83.9 ± 18.4. At the final follow-up examination at 87.2 ± 14.5 months, the AOFAS score was 90.9 ± 12.7 (p = .0005). Those patients who experienced an improvement between 5 and 7 years after surgery had a significant greater percentage of T2-map value of 35 to 45 ms (hyaline cartilage) compared with those patients who did not improve (p = .038). MRI T2 mapping was shown to be a valuable tool capable of predicting reproducible clinical outcomes after ACI even 7 years after surgery. The quality of the regenerated tissue and the degree of defect filling became statistically significant to the clinical results at the final follow-up examination.

Tissue Bioengineering in the Treatment of Osteochondritis Dissecans of the Talus in Children With Open Physis: Preliminary Results.

BACKGROUND: Juvenile osteochondritis dissecans of the talus (JOCDT) is a focal idiopathic lesion primarily of the subchondral bone leading to subsequent cartilaginous damage. The majority of the papers dealing with JOCDT reported heterogeneous case studies of patients treated with different cartilage repair techniques. The purpose of this paper is to retrospectively review both clinical and radiologic results among 7 patients affected by JOCDT treated with arthroscopic bone marrow aspirate concentrate (BMAC) transplantation with the 1-step technique. METHODS: Both standard anterior-posterior and lateral radiographs and a 1.5 T magnetic resonance imaging of the affected ankle were preoperatively performed in all the patients. The American Orthopaedic Foot and Ankle Society (AOFAS) score and the visual analogue scale were administered to the patients preoperatively and at the final follow-up. RESULTS: Patients were followed up to an average of 48.1±18.4 months. According to the Berndt and Harty classification, 6 lesions were found to be in stage III and 1 lesion in stage IV. The average preoperative AOFAS score was 58.8±7.6 points. At the mean follow-up of 48.1 months the average AOFAS score improved to 95.7±5.4 points (P<0.05). Visual analogue scale improved from 6.3 preoperatively to 0.4 at final follow-up (P<0.05). Complete radiographic healing, in terms of complete bony filling, was observed in 3 of 7 cases. The magnetic resonance imaging analysis showed a complete filling of the osteochondral defect in 4 patients, whereas in 1 patient a hypotrofic tissue was observed. CONCLUSIONS: BMAC transplantation is able to provide good to excellent results in the treatment of JOCDT. The 43% of our patients showed a complete radiographic healing, but all the patients were satisfied with the procedure. Because of the rareness of the lesion, further studies involving more patients and with a longer follow-up are required, to establish the advantage of performing a regenerative procedure like the BMAC transplantation in a pediatric population. LEVEL OF EVIDENCE: Level IV.

Correlation Between Recovery of Triceps Surae Muscle Strength and Level of Activity After Open Repair of Acute Achilles Tendon Rupture.

BACKGROUND: This study aimed to determine whether physical findings reflecting triceps surae strength recovery could predict return to activities such as jogging and sports and whether patients' age and sex would influence recovery of triceps surae strength postoperatively. METHODS: Between 2009 and 2013, 96 consecutive cases of postoperative acute Achilles tendon rupture were reviewed. The postoperative triceps surae strength recovery rate was investigated in all patients by using half body weight 1-time heel rise, full body weight (FBW) 1-time heel rise, FBW 20-time heel rise, jogging, and full return to sports activities. Influence of age and sex on triceps surae strength recovery was also investigated. RESULTS: FBW 1-time heel rise and jogging were achieved at an average of 14 weeks (range, 6-24 weeks) and 15 weeks (range, 8-25 weeks) postoperatively, respectively. FBW 20-time heel rise and full return to sports activities were achieved at a mean of 21 weeks (range, 12-29 weeks) and 22 weeks (range, 13-29 weeks) postoperatively, respectively. Ability to perform FBW 1-time heel rise was directly related to resilience of jogging capability ( R2 = 0.317, P < 0.001), and ability to perform FBW 20-time heel rise was related to full return to sports activities ( R2 = 0.508, P < 0.001). Time to heel rise was not correlated with patient age or sex. CONCLUSION: Postoperative ability to perform FBW 1-time heel rise in patients postoperatively was directly related to resilience of jogging, and ability to perform FBW 20-time heel rise was directly related to full return to sports activities. LEVEL OF EVIDENCE: Level IV, case series.

Treatment Algorithm for Chronic Achilles Tendon LesionsReview of the Literature and Proposal of a New Classification.

Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.

Long-term Results of Combined Epiphysiodesis and Imhauser Intertrochanteric Osteotomy in SCFE: A Retrospective Study on 53 Hips.

BACKGROUND: The management of moderate and severe slipped capital femoral epiphysis is still an issue. The main concern is represented by the choice of an intra-articular or an extra-articular osteotomy to correct the deformity. Theoretically, the intra-articular osteotomy allows the best correction, but it is technically demanding and involves a higher risk of avascular necrosis (AVN); conversely, an extra-articular intertrochanteric osteotomy (ITO) is easier and involves a lower risk of early complications, but may lead to femoroacetabular impingement, resulting in early osteoarthritis and the need for total hip replacement (THR).The aim of this study was to analyze the long-term survivorship free from THR after combined epiphysiodesis and Imhauser ITO. METHODS: From 1975 to 2000, 45 patients (53 hips) underwent a combined epiphysiodesis and Imhauser ITO. There were 27 male and 18 female patients with an average age of 12.8±1.9 years. All cases showed a posterior sloping angle >40 degrees (mean, 69±16 degrees). The cumulative survivorship was determined according to Kaplan and Meier, with the end point defined as conversion to THR. RESULTS: A total of 6 patients (6 hips; 11%) had a follow-up <2 years. Among them, no postoperative complications occurred. For the remaining 39 patients (47 hips, 89%), the mean follow-up was 21±11 years. Four early postoperative complications were reported (2 AVN, 2 chondrolysis). The cumulative 39 years' survivorship free from THR was 68.5% (95% confidence interval, 42.4%-84.7%). The age at surgery (hazard ratio=1.849 per year older, P=0.017) and the postoperative onset of AVN or chondrolysis (hazard ratio=10.146, P=0.010) affected the long-term prognosis significantly. CONCLUSIONS: The combined epiphysiodesis and Imhauser ITO is a valid surgical option in moderate to severe slipped capital femoral epiphysis, preserving the natural hip for at least 39 years in the majority of the patients. Care must be taken to avoid AVN or chondrolysis. The age at surgery affects the prognosis negatively. LEVEL OF EVIDENCE: Level III-a retrospective study.

Treatment of osteochondral lesions of the talus in athletes: what is the evidence?

PURPOSE: ankle injuries make up 15% of all sports injuries and osteochondral lesions of the talus (OLTs) are an increasingly frequent problem in active patients. There exist no widely shared guidelines on OLT treatment in the athletic population. The aim of this paper is to review all the existing literature evidence on the surgical treatment of OLTs in athletes, in order to determine the current state of the art in this specific population, underlining both the limits and the potential of the strategies used. METHODS: a systematic review of the literature was performed focusing on the different types of surgical treatment used for OLTs in athletes. The screening process and analysis were performed separately by two independent researchers. The inclusion criteria for relevant articles were: clinical reports of any level of evidence, written in English, with no time limitation, or clinical reports describing the treatment of OLTs in the athletic population. RESULTS: with the consensus of the two observers, relevant data were then extracted and collected in a single database to be analyzed for the purposes of the present manuscript. At the end of the process, 16 papers met the selection criteria. These papers report a total of 642 athletic patients with OCTs. CONCLUSIONS: the ideal treatment for cartilage lesions in athletes is a controversial topic, due to the need for an early return to sports, especially in elite players; this need leads to extensive use of microfractures in this population, despite the poor quality of repair associated with this technique. None of the surgical strategies described in this paper seems to be superior to the others. LEVEL OF EVIDENCE: systematic review of level IV studies, level IV.

Hamstring graft tibial insertion preservation versus detachment in anterior cruciate ligament reconstruction: a prospective randomized comparative study.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction with hamstring graft (HG) is a commonly performed procedure. Despite the type of reconstruction chosen, the detached HG undergoes a remodeling process known as ligamentization. In order to shorten the ligamentization process, the maintenance of HG tibial insertion, aimed to spare the tendons vascular supply, has been postulated. The aim of this paper is to report the results of a prospective randomized study comparing clinical and MRI results between two different ACL reconstructive procedures with and without HG tibial insertion preservation. METHODS: Forty patients (mean age 27.5 ± 9.5 years) were enrolled and randomly divided into two groups. The study group underwent an ACL reconstruction using a distally inserted HG, while the control group underwent a technique encompassing HG tibial detachment. Subjective and objective IKDC score was administered preoperatively and at 3-, 6-, 12- and 24-month follow-up. Graft morphology was assessed through MRI evaluation performed at 6-month follow-up. RESULTS: Clinical results were excellent in both groups. Regarding MRI results, a better intra-articular graft morphology was observed in the study group (Tau = 0.313, p = 0.024). No differences in graft integration were noticed. CONCLUSION: The main finding of this preliminary study is that preservation of the hamstring tibial insertion seems to enhance graft ligamentization with improved morphology of the intra-articular portion of the graft compared to a detachment of the hamstring tendons from the tibial side. Further well-designed studies with higher number of patients as well as more serial MRI evaluations are required to validate these preliminary findings.

Treatment of Osteochondritis Dissecans of the Talus in Skeletally Immature Population: A Critical Analysis of the Available Evidence.

UNLABELLED: Juvenile osteochondritis dissecans of the talus (JOCDT) is a subchondral bone alteration and a partially or completely detached osteochondral fragment, affecting skeletally immature patients. A review of the English literature on PubMed was conducted. Conservative treatment was applied in patients up to Berndt-Harty stage III. Surgical indications were conservative management failure and loose bodies. The most performed procedures were drilling, subchondral bone grafting, fragment fixation, or excision. High rate of clinical success were achieved, whereas radiographic results were much lower. None of the surgical options demonstrated to be superior. Future long-term qualitative studies focusing on chondral tissue restoration are needed. LEVELS OF EVIDENCE: Therapeutic, Level IV.

High tibial osteotomy for the treatment of medial osteoarthritis of the knee with new iBalance system: 2 years of follow-up.

BACKGROUND: A new system for performing open-wedge high tibial osteotomy (HTO), the iBalance HTO System-Arthrex, has been recently developed in order to make the surgery more reproducible and safe. The aim of this study was to determine the short-term outcomes of the iBalance technique in medial compartment osteoarthritis and varus malalignment of the knee. METHODS: Fifteen patients with a mean age of 50.7 years (SD 5.09), affected by symptomatic varus knee, with medial compartment osteoarthritis (1-2 Ahlbäck degree), were treated with iBalance HTO between July 2011 and February 2012 and evaluated retrospectively. Patients were assessed against the following benchmarks: subjective International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and VAS for pain and Tegner scores, along with X-rays and MRI, before surgery and after a 2-year follow-up. RESULTS: No severe intraoperative complications or implant failures occurred. The mean preoperative scores were as follows: subjective IKDC 66.8 (SD 1.18), KOOS 61.3 (SD 0.86), Vas for pain 8.6 (SD 1.72) and Tegner 4.1 (SD 2.06), while at follow-up the scores were 73.6 (SD 1.01), 88.1 (SD 1.23), 2.9 (SD 2.35) and 3.1 (SD 1.83), respectively. Correction ranged between 3° and 8°. All patients showed complete articular recovery, no loss of correction, no substantial variation in A/P slope and no hardware problems. CONCLUSIONS: iBalance proved to be effective and safe and produced good overall results. Consolidation and osseointegration of the system took place rapidly, while recovery was precocious, comparable with traditional methods and with no severe complications. LEVEL OF EVIDENCE: Case series, Level IV.

Arthroscopic Treatment and Prognostic Classification of Anterior Soft Tissue Impingement of the Ankle.

BACKGROUND: Anterior soft tissue impingement of the ankle has been described based on the etiology and location, but no classification has been reported. Arthroscopic treatment is usually considered effective, even if the behavior of the different forms of impingement is not clear. The purpose of this study was to analyze the factors affecting long-term results. METHODS: Forty-two patients with a mean age of 32.6 years were arthroscopically treated between 2004 and 2008. Impingement lesions were identified according to clinical examination and confirmed by MRI. Soft tissue impingement was detected and classified according to location (anteromedial, anterolateral, syndesmotic or diffuse). Patient data, foot morphology, and previous trauma or surgery were recorded. Patients were evaluated after a mean of 90.1 months' follow-up with the American Orthopaedic Foot & Ankle Society (AOFAS) scoring system. RESULTS: The mean AOFAS score improved from 40.6 preoperatively to 82.6, 78.4, and 74.8, respectively, at the 2-, 4-, and 6-year follow-ups (P < .05). The anterolateral form showed higher scores compared to the diffuse or anteromedial forms. Age, foot morphology, and previous trauma or surgery did not affect the results. Body mass index of more than 26 and male gender were associated with worse outcomes. CONCLUSION: Arthroscopic debridement proved effective in the treatment of soft tissue impingement. Furthermore, we were able to classify the location of the anterior soft tissue impingement of the ankle, which may have prognostic importance. LEVEL OF EVIDENCE: Level IV, case series.

Over-the-Top Anterior Cruciate Ligament Reconstruction Using Single- or Double-Strand Hamstrings Autograft.

The purpose of this study is to (1) report the long-term clinical and radiographic outcomes of a nonanatomical anterior cruciate ligament (ACL) reconstruction using an over-the-top (OTT) femoral route and (2) compare single-strand (1SHG) and double-strand (2SHG) hamstrings graft reconstruction. Fifty-one consecutive patients (mean age, 29.2±3.8 years) underwent nonanatomical ACL reconstruction using OTT femoral passage. Twenty patients underwent 1SHG reconstruction and 31 underwent 2SHG reconstruction. International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner score, and KT-1000 (Medmetric Corporation, San Diego, California) evaluation were recorded at a mean follow-up of 12.1±1.6 years. At final follow-up, radiographic evaluation was performed according to the IKDC grading system. Mean IKDC subjective score at follow-up was 76.6±21.9 in the 1SHG group and 88.9±10.0 in the 2SHG (P=.009). Average KOOS was 82.6±18.7 in the 1SHG group and 92.4±9.2 in the 2SHG group (P=.016). Objective IKDC evaluation showed a higher percentage of normal knees in the 2SHG group (P=.018). Pivot shift testing revealed a significantly higher number of normal knees in the 2SHG group (P=.001). Radiographs showed fewer degenerative changes in the 2SHG group at final follow-up in the medial (P=.01) and lateral (P=.037) compartments. Nonanatomical ACL reconstruction using the OTT technique provided satisfactory results in terms of control of both static and dynamic instability at long-term follow-up, thus preventing degenerative joint disease. The 2SHG group showed better subjective and functional outcomes with fewer degenerative changes compared with the 1SHG group at long-term follow-up.

Regenerative treatment in osteochondral lesions of the talus: autologous chondrocyte implantation versus one-step bone marrow derived cells transplantation.

PURPOSE: Osteochondral lesions of the talus (OLT) usually require surgical treatment. Regenerative techniques for hyaline cartilage restoration, like autologous chondrocytes implantation (ACI) or bone marrow derived cells transplantation (BMDCT), should be preferred. The aim of this work is comparing two clusters with OLT, treated with ACI or BMDCT. METHODS: Eighty patients were treated with regenerative techniques, 40 with ACI and 40 with BMDCT. The two groups were homogenous regarding age, lesion size and depth, previous surgeries, etiology of the lesion, subchondral bone graft, final follow-up and pre-operative AOFAS score. The two procedures were performed arthroscopically. The scaffold was a hyaluronic acid membrane in all the cases, loaded with previously cultured chondrocytes (ACI) or with bone marrow concentrated cells, harvested in the same surgical session (BMDCT). All the patients were clinically and radiologically evaluated, using MRI Mocart score and T2 mapping sequence. RESULTS: Clinical results were similar in both groups at 48 months. No statistically significant influence was reported after evaluation of all the pre-operative parameters. The rate of return to sport activity showed slightly better results for BMDCT than ACI. MRI Mocart score was similar in both groups. MRI T2 mapping evaluation highlighted a higher presence of hyaline like values in the BMDCT group, and lower incidence of fibrocartilage as well. CONCLUSIONS: To date, ACI and BMDCT showed to be effective regenerative techniques for the treatment of OLT. BMDCT could be preferred over ACI for the single step procedure, patients' discomfort and lower costs.