Anatomic physeal-sparing MPFL reconstruction in skeletally immature patients shows favourable outcomes at a minimum of 24-month follow-up.

Purpose: Recurrent patellar dislocation is a prevalent orthopaedic issue among active paediatric and adolescent populations. Bony surgical procedures are not recommended in growing patients; therefore, the focus of surgery is on restoring the medial patellar ligaments, with different reconstructive techniques available. This retrospective case series focuses on the 2-year outcomes of medial patellofemoral ligament (MPFL) reconstruction in skeletally immature patients with open physis. Methods: Twenty-four consecutive patients with patellofemoral instability and open growth plates underwent anatomic MPFL reconstruction with a physeal-sparing technique. All subjects have had more than three episodes of true patellar dislocations. Preoperative radiographic examination included anteroposterior and lateral views to assess patella alta and limb alignment. Magnetic resonance imaging was performed to evaluate trochlear dysplasia and tibial tubercle-trochlear groove (TT-TG) distance. The patients were questioned regarding complications and clinical outcomes using the visual analogue scale (VAS), Kujala and Paediatric International Knee Documentation Committee (Pedi-IKDC) score. Variables were evaluated using paired t test with significance at p < 0.05. Results: The mean age at the time of operation was 13.04 years (9-16 years). The cohort was followed for a mean duration of 38.66 months (24-86 months). The mean time from injury to surgery was 50.45 days (16-80 days). No growth arrest, limb-length discrepancies or angular deformities were observed post-operatively during the whole follow-up period. No patellar re-dislocations were recorded throughout the study period. The VAS score improved significantly from 5.67 (4-8) to 1.88 (0-4) (p < 0.01). The Kujala score improved significantly from 64.67 (44-81) preoperatively to 87.58 (77-100) post-operatively (p < 0.01). The Pedi-IKDC also increased significantly from 58.81 (34.80-77.70) preoperatively to 90.64 (70.70-100) post-operatively (p < 0.01). The vast majority of patients (87.5%) returned to their pre-injury activity level. Boys scored better than girls in VAS, Pedi-IKDC and Kujala score post-operatively, but these differences were not statistically significant. Conclusion: Physeal-sparing MPFL reconstruction in children and adolescents yields excellent midterm results and allows patients to return to sports without redislocation of the patella. Boys scored better than girls in VAS, Pedi-IKDC and Kujala score post-operatively, but these differences were not statistically significant. Level of Evidence: IV: case series with no comparative group.

A reduced scapulo-humeral angle contributes to the development of scapular notching in reverse total shoulder arthroplasty.

PURPOSE: Scapular Notching (SN) is one of the most common postoperative complications for a patient after Reverse Total Shoulder Arthroplasty (RTSA). Despite employing various strategies to mitigate SN risk, the overall incidence remains far from zero. This article introduces a new risk factor, the scapulo-humeral angle (SHA), as a key element influencing the risk for SN. METHODS: A retrospective analysis was conducted on all patients who underwent RTSA for rotator cuff arthropathy at the study centre. The preoperative SHA was measured, and the presence of SN was investigated and graded using the Nerot classification at the latest follow-up. RESULTS: 42 patients were included. 12 presented SN (incidence 28.5%). A statistically significant Pearson coefficient correlation between pre-operative SHA and the incidence of SN was observed (r= -0.6954; 95% C.I. -0,8250 to -0,4963; p < 0.0001). A statistically significant Pearson coefficient correlation was also found between the degree of SN and the pre-operative SHA (r= -0,7045; 95% C.I. -0,8306 to -0,5096; P value (two-tailed) < 0,0001, alpha 0.05). CONCLUSIONS: The primary finding is a statistically significant correlation between a reduced preoperative SHA and an increased incidence of postoperative SN. The secondary finding is that a smaller preoperative SHA is associated with a more severe degree of SN A SHA cut-off of 50° distinguished patients at high risk of SN from those at low risk. All patients with an SHA below 50° developed SN (10/10), whereas only 6.25% of patients with an SHA exceeding 50° experienced SN (2/32).

Olecranon Fossa Fenestration Approach to the Coronoid and Anterior Elbow: The Way OFF.

Hypertrophic osteoarthritis of the elbow is a challenging condition that can vary from mild to severe, affecting patients' quality of life due to pain and loss of range of motion. A consensus about its treatment does not exist. Open arthrolysis with capsular release, synovectomy, Outerbridge-Kashiwagi fenestration, and removal of loose bodies and osteophytes demonstrated good results. In more recent times, an arthroscopic procedure has been shown to have the same efficacy as the open one. The aim of this Technical Note is to describe an all-arthroscopic procedure to reach the coronoid tip, in a safe and reproducible manner, through an olecranon fossa fenestration with a direct transtricipital posterior portal and an anterior cruciate ligament guide.

Outcomes of Medial Closing-Wedge Distal Femoral Osteotomy for Femoral- and Tibial-Based Valgus Deformity.

BACKGROUND: In carefully selected patients with an arthritic valgus knee, distal femoral osteotomy (DFO) can improve symptoms at medium- to long-term follow-up, reducing osteoarthritis progression. To date, there is no clear evidence in the current literature regarding the role of postoperative joint line obliquity (JLO) in valgus deformity correction. PURPOSE: To assess the clinical and radiological outcomes of medial closing-wedge DFO (MCW-DFO) for the treatment of valgus knees, considering both tibial- and femoral-based deformities, as well as to verify the efficacy and safety of MCW-DFO according to JLO boundaries (≤4°). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was conducted on a cohort of patients with valgus knees. Patients were divided into 2 groups: femoral-based valgus (FB-V) and tibial-based valgus (TB-V). Knee radiographs were collected before surgery and at the last follow-up. The clinical outcome was evaluated through several validated scores (International Knee Documentation Committee, Knee Society Score, Knee injury and Osteoarthritis Outcome Score, Tegner, Numeric Rating Scale, Crosby-Insall). RESULTS: A total of 30 patients (34 knees) with a mean age of 49.3 ± 9.1 years were included in the study. The overall mean follow-up was 9.4 ± 5.9 years. The mean preoperative hip-knee-ankle angle was 187.6°± 3.3° (range, 181.5°-191°) and the postoperative angle was 180°± 3.1° (range, 176°-185°). Most postoperative JLOs were within the safe zone of ≤4° in both groups (the postoperative JLO was >4° in 4 patients in the TB-V group and 1 patient in the FB-V group), although FB-V knees exhibited significant superior JLO correction (postoperative JLO in the TB-V group: mean, 4.0°± 2.5° [P = .1]; postoperative JLO in the FB-V group: mean, 2.4°± 1.4° [P = .5]). Significant improvements in all clinical scores were observed in both groups (P < .01). Additionally, the severity of the osteoarthritis did not worsen at the last follow-up. CONCLUSION: MCW-DFO is an effective procedure for treating pathological valgus knees, regardless of the site of the deformity. Both FB-V and TB-V groups showed comparable improvements in the clinical scores, development of osteoarthritis, and the restoration of a neutral mechanical axis. Notably, FB-V knees achieved more JLO correction compared with the TB-V ones.

Proximal radioulnar joint, but not posterolateral, instability in patients with symptomatic minor instability of the lateral elbow.

BACKGROUND: The elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like symptomatic minor instability of the lateral elbow (SMILE) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathologic condition. MATERIALS AND METHODS: Twenty-eight patients were included in this study: half of them were operated for suspected SMILE whereas the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, 4 parameters were analyzed: annular drive through (ADT), ulnar-humeral stressed distance (UHSD) at 45° and 30° of flexion, and loose collar sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to take measurements. RESULTS: Statistically significant differences were found for LCS (P = .0003) and ADT (P = .000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly. DISCUSSION AND CONCLUSIONS: Progressive stretching of the RLCL and annular ligament may lead to their elongation, resulting in a pathologic anteroposterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radioulnar instability. The study shows how RLCL and annular ligament are elongated in SMILE patients compared with controls, causing instability of the proximal radioulnar joint and confirming that ligament incompetency is involved in the SMILE condition.

Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications.

PURPOSE: This literature review aims to present evidence-based clinical recommendations for the eight most debated topics related to perioperative management in total knee arthroplasty: counselling, prehabilitation, transfusion risk, tranexamic acid, drainage, analgesia, urinary catheter and compression stockings. METHODS: A multidisciplinary team conducted a systematic review on these topics. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the literature review and result presentation. The research encompassed articles from 1 January 2009 to 28 February 2023, retrieved through the MEDLINE database via PubMed, Embase database and Cochrane Library. RESULTS: Forty-five articles were selected. Preoperative counselling has limited evidence for its impact on postoperative outcomes; yet, it can help alleviate surgery-related anxiety and manage postoperative symptoms. Prehabilitation can also prepare patients for surgery, reducing hospital stays and improving postsurgery functionality. Numerous studies suggest that preoperative Hb levels are independently linked to transfusion risk, with a recommended level of 13 g/dL. Combining intravenous and local tranexamic acid administration is strongly advised to reduce perioperative blood loss, while drainage after primary total knee arthroplasty offers no functional advantages. Employing a multimodal analgesia approach yields better results with reduced opioid usage. Indwelling urinary catheters provide no benefit and avoiding them can lower the risk of urinary tract infections. As for compression stockings, there is insufficient evidence in the literature to support their efficacy in preventing venous thromboembolism. CONCLUSION: The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. It is success relies on a collaborative, resource-adaptive approach led by a multidisciplinary team. Both patients and hospitals benefit from this approach, as it enhances care quality and lowers costs. Several studies have highlighted the significance of a patient-centred approach in achieving high-quality care. Creating a novel treatment protocol could be a prospective goal in the near future. LEVEL OF EVIDENCE: Level III.

Electric scooter-related orthopedic injuries: the experience of an Italian orthopedic center and literature review.

Background: With the increasing prevalence of electric scooters, a concomitant increase in the number of specific injuries, emergency department (ED) admissions and hospital admissions have been reported. Objectives: Analyze patient flow changes in the ED with a focus on e-scooter-related injuries through a case series and a comparison with the contemporary literature. Data sources: A systematic literature review was performed on Medline/PubMed and Embase using terms related to the topic.Data collected from two-wheeled vehicle trauma patients at our Italian ED from May 1 to October 31, 2021, were analyzed for the case series. Study eligibility criteria: Studies were included if they evaluated populations with an e-scooter-related injury referred to the ED with precise localization and nature of the injury reported. Participants and interventions: Data collected from the literature studies and from our case series included overall ED patient numbers, patient demographics, injury mechanism, location of the injury, discharge diagnosis, and performance of surgery. Study appraisal and synthesis methods: All studies were checked in order to establish the coherence with the purposes of this review. Data from the contemporary literature and from this case series were compared. Results: During a 6-month period, 280 patients had e-scooter injuries, resulting in 292 traumas, including 123 fractures, primarily in the elbow. Surgical intervention was necessary for 28 patients. The review included nine papers, highlighting that injuries to the upper and lower extremities and head were frequent in e-scooter-related incidents. The upper extremities were the most common fracture location. Limitations: The study is a retrospective, single-center study without a comparison group, focusing exclusively on orthopedic injuries. Conclusions or implications of key findings: The prevalence of electric scooters, which offer an affordable and eco-friendly mode of transport, is steadily increasing. It is important to focus on injury risk mitigation through effective public health policies, thereby lowering costs to society.

Allografts use in orthopedic surgery: trend change over the past 11 years from a regional tissue bank.

Allografts are the second most transplanted tissue in medicine after blood and are now increasingly used for both primary and revision surgery. Allografts have the advantages of lower donor site morbidity, availability of multiple grafts, and shorter operative time. The Banks represents the bridge between Donor and Recipient and guarantees the quality and safety of the distributed allografts Given the increasing interest in these tissues, a retrospective analysis of data collected from the Regional Musculoskeletal Tissue Bank registry over an 11-year period (2009-2019) was conducted. The statistical analyses used were the Shapiro-Wilk normality test and a Poisson regression model. From January 2009 to December 2019, a total of 14,199 musculoskeletal tissues stored in the Regional Musculoskeletal Tissue Bank were provided for surgical allograft procedures. In 2009, the number of allografts performed was 925; this figure has steadily increased to 1599 in 2019. Epiphyses were taken as the reference tissue with an almost constant trend over the period, while a significant increase was denoted for extensor mechanism allograft, ligaments, tendons and long bone corticals (p < 0.001), processed bone tissues had no change in trend (p = 0.841). There was also a gradual decrease in the rate of microbiological positivity, as determined by bacteriological and serological tests performed on the collected tissues. This phenomenon is due to improved sampling techniques and the training of a dedicated team. Thus, we have seen how the use of allografts in orthopedic surgery has increased over the past 11 years, uniformly in terms of tissue type, except for the noticeable increase in ligamentous tissue.

A 70° Arthroscope Provides Better Visualization of the Medial Side of the Elbow Than a 30° Arthroscope.

Purpose: To assess and quantify the improvement in visualization of humeral insertion of the medial collateral ligament (MCL) using a 70° scope compared with a 30° scope during elbow arthroscopy. Methods: Twenty patients undergoing elbow arthroscopy for different pathologic conditions were enrolled in this single-center study. Visualization of the medial gutter of the elbow was evaluated by using both the 70° and the 30°scope. During the procedure, a needle was inserted at 45° with respect to the axis of the forearm, directed toward the intra-articular humeral emergence of the MCL. Four areas were established: the body (Z1), the lanceolate part (Z2), the tip of the needle (Z3), and the medial portion of the trochlea (Z4). The visible areas during arthroscopy using 2 different scopes were collected. Results: The 70° scope allowed the detection of the first 3 areas in all patients (Z1, Z2, and Z3) and the visualization of the last area (Z4) in 19 patients (95%). On the other hand, the 30° scope allowed the detection of Z1 in 85% of patients, Z2 in 60% of patients, and Z3 in only 5% of patients. The medial portion of the trochlea was never visualized with the 30° scope. These findings were statistically significant. Conclusions: The 70° scope improves visualization of the medial elbow compartment during elbow arthroscopy compared to the 30° scope, enhancing the extent of joint visualization and potentially permitting the detection of otherwise missed injuries in the difficult-to-reach areas of the joint. Level of Evidence: Level II, diagnostic, prospective, cohort study.

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.

Look for the POLESTAR (POsteroLateral Engagement of Soft Tissue And Radial head) while navigating around elbow dislocation.

BACKGROUND: Elbow dislocation is frequently associated with bony and osteochondral posterolateral capitellar lesions that are often under-reported. We aim to examine the radiologic signs of posterolateral lesions on computed tomography (CT). METHODS: A retrospective analysis of CT scans was performed. Patients were classified into 4 groups: (1) simple elbow dislocation, (2) elbow dislocation with a fracture of the coronoid tip, (3) elbow dislocation with coronoid tip fracture and a radial head fracture inferior or equal to the anterior third, and (4) terrible triad defined as elbow dislocation with concomitant coronoid and radial head fracture with a more important involvement. Patients with a more complex fracture pattern were excluded. The presence of POsteroLateral Engagement of Soft Tissue And Radial head (POLESTAR) patterns was analyzed and subclassified as impaction type or fragmentation type. RESULTS: Fifty-one CT scans met the inclusion criteria. POLESTAR lesions were identified in 48 cases (94%): 46% impaction-type and 54% fragmentation-type POLESTAR. Analyzing patients from grade 1 to 4, impaction-type POLESTAR was found, respectively, from 40% to 57%, whereas fragmentation type was present from 60% to 43%. CONCLUSIONS: This study shows a high incidence of POLESTAR lesions (94%) that can be present as impaction type or fragmentation type. Based on our preliminary results, impaction type is more common in grades 3 and 4, whereas fragmentation type is more frequent in grades 1 and 2.

A low carrying angle is measured in elite tennis players just before ball impact during the forehand, suggesting a dynamic varus instant accommodation moving towards full extension.

PURPOSE: The goal of this study was to use image analysis recordings to measure the carrying angle of elite male tennis players during the forehand stroke, with the hypothesis that elite tennis players overstress their elbow in valgus over the physiological degree in the frontal plane just before ball contact on forehand groundstrokes. METHODS: The carrying angle of male tennis players ranked in the top 25 positions in the ATP ranking was measured on selected video frames with the elbow as close as possible to full extension just before the ball-racket contact in forehands. These frames were extracted from 306 videos professionally recorded for training purposes by a high-profile video analyst. All measures were conducted by three independent observers. RESULTS: Sixteen frames were finally included. The mean carrying angle was 11.5° ± 4.7°. The intraclass correlation coefficient value was 0.703, showing good reliability of the measurement technique. The measured carrying angle was lower than what has been observed in historical cohorts using comparable measurement methodology, suggesting a possible instant varus accommodation mechanism before hitting the ball. CONCLUSIONS: The observed decrease in the carrying angle is a consequence of an increase in elbow flexion position dictated by the transition from a closed to open, semi-open stances. As the elbow flexes during the preparation phase, it is less constrained by the olecranon and its fossa, increasing the strain on the medial collateral ligament and capsule structures. Moving towards full extension before the ball-racket contact, the elbow is dynamically stabilised by a contraction of the flexor muscles. These observations could provide a new explanation for medial elbow injuries among elite tennis players and drive specific rehabilitation protocols. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level IV.

Diagnostic and prognostic role of synovial tissue analysis in juvenile idiopathic arthritis: a monocentric study.

OBJECTIVES: This study investigates the diagnostic role of synovial tissue analysis in children presenting with arthritis and assesses its prognostic significance to predict clinical outcome in juvenile idiopathic arthritis (JIA). METHODS: Synovial samples of paediatric patients undergoing synovial biopsy between 1995 and 2020 were analysed histologically and immunohistochemically. Relationships between histological/immunohistochemical parameters and clinical variables were assessed. RESULTS: Synovial biopsy was performed for diagnosis in 65 cases allowing to correctly classify 79% of patients.At histological analysis on 42 JIA samples, any difference in the number of synovial lining layers, subsynovial elementary lesions, fibrin deposit, Krenn Synovitis Score, inflammatory infiltrate score and pattern emerged between JIA subsets or on treatment exposure. Synovial tissue analysis predicted outcome: higher number of synovial layers predicted worse disease course (>4 flares during follow-up; 4.5 vs 3.0, p=0.035), even after adjusting for age at diagnosis and observation time (OR 2.2, p=0.007); subjects who had switched>2 biological disease-modifying antirheumatic drugs had higher prevalence of subsynovial elementary lesions (55.6% vs 10.3%, p=0.005) and fibrin deposits in synovial lining (60.0% vs 22.6%, p=0.049), even after adjustment for observation time and age at diagnosis (OR 8.1, p=0.047). At immunohistochemistry on 31 JIA samples, higher CD3 expression was described in polyarticular compared with oligoarticular subset (p=0.040). Patients with severe disease course had higher CD20+ rate (OR 7, p=0.023), regardless of JIA subset and treatment exposure. CONCLUSIONS: Synovial tissue analysis might support the clinicians in the diagnostic approach of paediatric patients presenting with arthritis and guide the clinical management in JIA.

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations.

BACKGROUND: Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients. METHODS: Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed. RESULTS: A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury. CONCLUSIONS: Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

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.

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.

The meniscal extrusion index is a reliable indirect sign of different meniscal lesion patterns: a classification based on percentage of meniscal extrusion.

PURPOSE: This study's goal is to propose a straightforward classification system based on the MEI (Meniscal Extrusion Index), a measure of meniscal extrusion, that relates to various meniscal lesion patterns and has clinical and biomechanical significance. The study's secondary goal is to determine whether the standard 3 mm meniscal extrusion parameter still has value by correlating the MEI with it. METHODS: 1350 knee MRIs that were performed over the course of 2 years made up the study cohort. Following the application of inclusion and exclusion criteria, 200 of those patients were qualified to participate in the study. All the measurements examined for this study underwent an interobserver reliability test. RESULTS: In the 1350 MRIs that were examined for this study, meniscal extrusion of any grade was present 18.9% of the time. The use of the MEI revealed three groups of patients: those with a MEI < 20%, who are likely para-physiological; those with a MEY between 20% and 40%, who are in a grey area; and those with a MEY > 40%, who have lesions that are impairing the proper meniscal function. According to the authors' findings, the percentage of meniscal extrusion did not correlate with the finite number (3 mm), making the 3 mm parameter an unreliable evaluation method. CONCLUSIONS: This study is clinically relevant, because it proposes a simple and reproducible classification of meniscal extrusion that may aid in evaluating the severity of an extrusion and help in the diagnosis of lesions that might be difficult to identify on MRI. LEVEL OF EVIDENCE: Level IV.

A Worldwide Analysis of Adipose-Derived Stem Cells and Stromal Vascular Fraction in Orthopedics: Current Evidence and Applications.

The biological enhancement of tissue regeneration and healing is an appealing perspective in orthopedics. We aimed to conduct a systematic review to describe the global distribution of studies investigating the use of adipose tissue derivates in orthopedics and to provide information on their quality and on the products available. The quality of the included studies was assessed using the modified Coleman Methodology Score (mCMS) and the Cochrane risk-of-bias tool for randomized trials. Eighty-two studies were included, with a total of 3594 patients treated. In total, 70% of the studies investigated the treatment of knee disorders, predominantly osteoarthritis; 26% of all studies dealt with expanded adipose-derived stem/stromal cells (ADSCs), 72% of which had stromal vascular fraction (SVF); 70% described the injection of adipose tissue derivates into the affected site; and 24% described arthroscopies with the addition of adipose tissue derivates. The mean mCMS for all studies was 51.7 ± 21.4 points, with a significantly higher score for the studies dealing with expanded ADSCs compared to those dealing with SVF (p = 0.0027). Our analysis shows high heterogeneity in terms of the types of performed procedures as well as the choice and processing of adipose tissue derivates.