Platelet-rich plasma augmentation in anterior cruciate ligament reconstruction: Evidence is still too scattered. A scoping review of randomised controlled trials.

PURPOSE: Platelet-rich plasma (PRP) augmentation has been proposed to improve the results of anterior cruciate ligament reconstruction (ACLR). The present study aims to quantify the available evidence to support the use of PRP as biological augmentation in ACLR surgery. METHODS: A systematic literature search was conducted on the PubMed, Cochrane, Web of Science and Embase databases on 10 March 2023. Inclusion criteria were randomised controlled trials (RCTs), written in English, addressing PRP augmentation in ACLR surgery, with no time limitation. A scoping review was performed to map the body of literature by examining the evidence related to specific aspects of patients' treatment and evaluation. Risk of bias evaluation was performed with the Cochrane risk-of-bias tool for randomised trials Version 2 (RoB 2), while the quality assessment was performed with the use of the Coleman Score. RESULTS: Out of 983 articles retrieved, 23 RCTs on 943 knees were included in this scoping review. PRP was administered in a liquid form in nine studies and clotted in 11 studies, while in three studies both liquid and clotted PRP were used. Hamstring auto/allografts were used in 14 studies, patellar tendon auto/allografts were used in eight studies and one study described ACLR with peroneus longus allografts. The map of the evidence documented high heterogeneity also in terms of surgical technique, objective and subjective outcome measures and radiological assessment, as well as follow-up times ranging from 1 day to 2 years, with virtually no overlapping data among studies neither in terms of treatments nor evaluations. Risk of bias evaluation showed an overall low quality of the included studies. CONCLUSIONS: The available literature addressing PRP augmentation in ACLR is largely scattered. PRP was produced and applied following different procedures, and high variability was detected across the included studies for every aspect of ACLR surgery and evaluation. Currently, a meaningful comparison of the available studies is not possible as the quantification of the literature results is biased by their heterogeneity. Future studies should provide more standardisation to investigate the benefits of biological augmentation in ACL surgery and confirm the promising yet weak evidence of PRP potential as well as the most suitable application modality, before routine use in clinical practice. LEVEL OF EVIDENCE: Levels I and II, scoping review.

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.

Five-Minute Five-Sequence Knee MRI Using Combined Simultaneous Multislice and Parallel Imaging Acceleration: Comparison with 10-Minute Parallel Imaging Knee MRI.

Background Rapid knee MRI using combined simultaneous multislice (SMS) technique and parallel imaging (PI) acceleration can add value through reduced acquisition time but requires validation of clinical efficacy. Purpose To evaluate the performance of clinical fourfold SMS-PI-accelerated, 5-minute, five-sequence, multicontrast knee MRI protocols compared with standard twofold PI-accelerated, 10-minute knee MRI protocols. Materials and Methods Adults with painful knee conditions were prospectively enrolled from April 2018 to October 2019. Participants underwent fourfold SMS-PI-accelerated, 5-minute, turbo spin-echo (TSE) knee MRI and standard-of-care twofold PI-accelerated, 10-minute, TSE knee MRI at either 1.5 T or 3.0 T. Three radiologists independently evaluated the knee MRI studies for meniscal, tendinous, ligamentous, and osseocartilaginous injuries. Statistical analyses included k-based intermethod agreements and diagnostic performance testing. P < .05 was considered indicative of a statistically significant difference. Results A total of 252 adults were evaluated (mean age ± standard deviation, 47 years ± 17; 134 men). Among the participants, 104 (mean age, 42 years ± 18; 57 women) were in the 1.5-T arm and 148 (mean age, 46 years ± 17; 87 men) were in the 3.0-T arm. Twenty-nine participants (mean age, 38 years ± 12; 15 men) in the 1.5-T arm and 42 (mean age, 41 years ± 16; 24 men) in the 3.0-T arm underwent arthroscopy a mean of 45 days ± 31 and 45 days ± 22 after MRI, respectively. Intermethod agreements were good at 1.5 T (κ >0.71 [95% CI: 0.56, 0.83]) and very good at 3.0 T (κ >0.85 [95% CI: 0.69, 0.96]). The diagnostic performances of corresponding 5-minute and 10-minute MRI protocols were similar for 1.5 T, with areas under the receiver operating characteristic curve (AUCs) greater than 0.78 (95% CI: 0.71, 0.84) (P > .32), and 3.0 T, with AUCs greater than 0.83 (95% CI: 0.78, 0.88) (P > .32). Conclusion Comparisons of 5-minute five-sequence simultaneous multislice- and parallel imaging (PI)-accelerated and 10-minute five-sequence PI-accelerated turbo spin-echo MRI of the knee suggest similar performances at 1.5 and 3.0 T. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Subhas in this issue.

Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis.

PURPOSE: There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications. METHODS: A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines. RESULTS: Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results. CONCLUSION: Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level II.

Use of innovative biomimetic scaffold in the treatment for large osteochondral lesions of the knee.

PURPOSE: Large osteochondral defects involve two different tissues characterized by different intrinsic healing capacity. Different techniques have been proposed to treat these lesions with results still under discussion. The aim of the study is to evaluate the clinical outcome of 19 patients treated with a type I collagen-hydroxyapatite nanostructural biomimetic osteochondral scaffold at minimum follow-up of 2 years. METHODS: Twenty lesions, 19 patients were treated with this scaffold implantation. The lesions size went from 4 to 8 cm(2) (mean size 5.2 ± 1.6 cm(2)). All patients were clinically evaluated using the International Repair Cartilage Society score, the Tegner Score and EQ-VAS. MRI was performed at 12 and 24 months after surgery and then every 12 months and evaluated with magnetic resonance observation of cartilage repair tissue scoring scale. RESULTS: The IKDC subjective score improved from a mean score of 35.7 ± 6.3 at the baseline evaluation to 67.7 ± 13.4 at 12-month follow-up (p < 0.0005). A further improvement was documented from 12 to 24 months (mean score of 72.9 ± 12.4 at 24 months) (p < 0.0005). The IKDC objective score confirmed the results. The Tegner activity score improvement was statistically significant (p < 0.0005). The EQ-VAS showed a significant improvement from 3.15 ± 1.09 to 7.35 ± 1.14 (p < 0.0005) at 2-year follow-up. The lesion' site seems to influence the results showing a better outcome in the patients affected in the medial femoral condyle. CONCLUSIONS: The use of the MaioRegen scaffold is a good procedure for the treatment for large osteochondral defects where other classic techniques are difficult to apply. It is an open one-step surgery with promising stable results at medium follow-up. LEVEL OF EVIDENCE: IV.

Conversion of shoulder arthroplasty to reverse implants: clinical and radiological results using a modular system.

PURPOSE: Revision of a shoulder arthroplasty to a reverse arthroplasty is a highly demanding procedure. The aim of this study is to report the clinical results of hemi and total shoulder prosthesis revisions to reverse implants without removal of the humeral stem, using a modular shoulder replacement system (SMR Lima LTD). We retrospectively reviewed 26 patients who underwent an operation from 2004 to 2009. METHODS: The patients were divided into two groups: in Group I, 18 patients underwent a revision of hemiarthroplasty implanted for fracture; in Group II, eight patients underwent a revision of anatomical total prosthesis. All patients were evaluated at a mean follow-up of 32.3 (±12.7) months using the Constant score rating scale and by range of motion evaluation, EQ-VAS, X-ray and CT scan. RESULTS: The Constant score of each patient was 47.88 (±5.88) after the revision. The EQ-VAS improved from 40 (±20) to 70 (±10). All patients improved in terms of range of motion. The radiographs and CT scans obtained after revision showed good integration and no signs of loosening of the implant. The mean time of surgery was recorded as 62' (±8'), with a maximum blood loss of less than 300 ml in all cases. CONCLUSIONS: Our study demonstrates that using a full modular system at the time of the first implant allows avoidance of the step to remove the humeral stem and metal back in cases of shoulder prosthesis revision to a reverse prosthesis, resulting in a short operative time, few intraoperative complications and a satisfactory clinical outcome at medium-term follow-up.

The use of an eccentric glenosphere compared with a concentric glenosphere in reverse total shoulder arthroplasty: two-year minimum follow-up results.

PURPOSE: The current models of reverse shoulder arthroplasty (RSA) expose the procedure to the risk of scapular notching, possibly leading to loosening of the glenoid. We compared the clinical and radiographic results obtained with a concentric or eccentric glenosphere to assess whether the eccentric design might give better clinical results and avoid or decrease the risk of scapular notching METHODS: Of our patients, 31 underwent RSA using a concentric glenosphere (group A), while 29 had an eccentric glenosphere (group B). Postoperatively, patients were followed-up at one to 12 months and annually thereafter, with the mean being 33 months in group A and 27.5 in group B. In both groups the minimum follow up (F-U) was 24 months. Preoperatively and at each F-U starting from six months, patients were assessed using the Constant score. On radiographs, prosthesis scapular neck angle (PSNA), distance between scapular neck and glenosphere (DBSNG) and peg-glenoid rim distance (PGRD) were calculated. The severity of notching was classified in four grades. RESULTS: In group A the mean Constant score increased by 30 points compared to the preoperative score and the active ROM increased considerably. At latest F-U, the mean PSNA, DBSNG and PGRD were, respectively, 87°, 3.4 mm and 19.8 mm. Glenoid notching was present in 42% of cases. In group A, the mean Constant score increased by 34 points and the mean ROM was better than in group A. The average PSNA, PGRD and DBSNG were, respectively, 92°, 21.2 mm and 4.3 mm. Radiographs showed no inferior scapular notching. CONCLUSIONS: The eccentric glenosphere yielded better clinical results than the concentric glenosphere and was associated with no scapular notching.

The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis.

PURPOSE: The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA). METHODS: A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options. RESULTS: Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects. CONCLUSIONS: This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Recall Bias Affects Pain Assessment in Knee Osteoarthritis: A Pilot Study.

OBJECTIVE: The objective of this study was to evaluate the recall bias of symptoms evaluation in knee osteoarthritis (OA). DESIGN: In this multicentric pilot study, 50 patients with knee OA used a mobile App (Ecological Momentary Assessment [EMA]) to collect pain and function on two 0 to 10 numerical rating scales (NRS) 2 times a day for 2 months. At the 1-month and at the 2-month follow-up visits, patients retrospectively evaluated the mean level of pain/function of the last month. Recall bias was computed as the difference between the mean level of pain/function reported using the App and the level reported with the retrospective assessment. The correlation between the recall bias and patients' characteristics, as well as pain/function trajectories, was analyzed. RESULTS: A statistically significant recall bias was documented with higher pain reported at 1-month with the retrospective assessment (P < 0.001). These results were confirmed also at the 2-month follow-up (P = 0.002). For function, no significant recall bias was documented. During the first and second months, 47 and 31 patients showed pain peaks, respectively. The number of pain peaks during the first month was correlated with the magnitude of the recall bias (P = 0.02). CONCLUSIONS: The recall bias influences the retrospective self-assessment of pain at the follow-up visits and the presence of pain peaks, a common event in the patients with OA, increases the magnitude of recall bias. The EMA performed with a mobile App is a useful tool to limit the influence of recall bias in the clinical and research setting evaluation of knee OA.

Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: from early degeneration to osteoarthritis.

PURPOSE: The aim of our study is to compare the efficacy of platelet-rich plasma (PRP) and viscosupplementation (hyaluronic acid [HA]) intra-articular injections for the treatment of knee cartilage degenerative lesions and osteoarthritis (OA). METHODS: The study involved 150 patients affected by cartilage degenerative lesions and early and severe OA. Fifty symptomatic patients were treated with 3 autologous PRP intra-articular injections and were evaluated prospectively at enrollment and at 2- and 6-month follow-up. The results obtained were compared with 2 homogeneous groups of patients treated with HA injections. One group was treated with injections of high-molecular weight HA; the other group was treated with low-molecular weight (LW) HA. International Knee Documentation Committee and EQ VAS scores were used for clinical evaluation; adverse events and patient satisfaction were also recorded. RESULTS: At 2 months' follow-up, the PRP and LW HA groups showed a similar improvement, with higher results compared with the high-molecular weight HA group (P < .005). At 6 months' follow-up, better results were observed in the PRP group (P < .005). PRP and LW HA treatments offered similar results in patients aged over 50 years and in the treatment of advanced OA. PRP showed a better performance compared with HA in younger patients affected by cartilage lesions or early OA. CONCLUSIONS: Autologous PRP injections showed more and longer efficacy than HA injections in reducing pain and symptoms and recovering articular function. Better results were achieved in younger and more active patients with a low degree of cartilage degeneration, whereas a worse outcome was obtained in more degenerated joints and in older patients, in whom results similar to those of viscosupplementation have been observed. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Home-Based vs Supervised Inpatient and/or Outpatient Rehabilitation Following Knee Meniscectomy: A Systematic Review and Meta-analysis.

Importance: Arthroscopic meniscectomy is one of the most common orthopedic procedures. The optimal postoperative approach remains debated. Objective: To compare outcomes associated with home-based rehabilitation programs (HBP) vs standard inpatient and/or outpatient supervised physical therapy (IOP) following arthroscopic isolated meniscectomy (AM). Data Sources: A systematic literature search was conducted on PubMed, Web of Science, Cochrane Library, and Scopus databases on March 15, 2021. The included studies were published from 1982 to 2019. Study Selection: Randomized clinical trials of patients treated with HBP vs IOP after AM were included. Data Extraction and Synthesis: Data were independently screened and extracted by 2 authors according to the Preferred Reporting Items for Systematic Reviews (PRISMA) reporting guideline. The meta-analysis was performed using a random-effect model; when an I2 < 25% was observed, the fixed-effect model was used. The Hartung-Knapp correction was applied. Main Outcomes and Measures: The primary outcome was the Lysholm score (scale of 0-100 with higher scores indicating better knee function) and secondary outcomes were subjective International Knee Documentation Committee (IKDC) score, knee extension and flexion, thigh girth, horizontal and vertical hop test, and days to return to work, as indicated in the PROSPERO registration. Outcomes were measured in the short-term (ranging from 28 to 50 days) and the midterm (6 months). Results: In this meta-analysis of 8 RCTs including 434 patients, IOP was associated with a greater short-term improvement in Lysholm score compared with HBP, with a mean difference of -8.64 points (95% CI, -15.14 to -2.13 points; P = .02) between the 2 approached, but the sensitivity analysis showed no difference. Similarly, no statistically significant difference was detected at midterm for Lysholm score, with a mean difference between groups of -4.78 points (95% CI, -9.98 to 0.42 points; P = .07). HBP was associated with a greater short-term improvement in thigh girth, with a mean difference between groups of 1.38 cm (95% CI, 0.27 to 2.48 cm; P = .01), whereas IOP was associated with a better short-term vertical hop score, with a mean difference between groups of -3.25 cm (95% CI, -6.20 to -0.29 cm; P = .03). No differences were found for all the other secondary outcomes. Conclusions and Relevance: No intervention was found to be superior in terms of physical and functional outcomes as well as work-related and patient-reported outcomes, both at short-term and midterm follow-up. Overall, these results suggest that HBP may be an effective management approach after AM in the general population.

Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction can be performed with different techniques for independent and transtibial (TT) drilling of femoral tunnels, but there is still no consensus on which approach leads to the best outcome. PURPOSE: To assess whether the independent or TT drilling approach for ACL reconstruction leads to the best functional outcomes. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic literature search was conducted on July 1, 2020, using the PubMed, Web of Science, Cochrane Library, and Scopus databases. The influence of different femoral drilling techniques was analyzed through a meta-analysis in terms of patient-reported outcome measure scores, risk of complications, range of motion limitations, graft failure, and differential laxity. Subanalyses were performed to compare the different independent drilling techniques considered. Linear metaregression was performed to evaluate if the year of study publication influenced the results. The risk of bias and quality of evidence were assessed following the Cochrane guidelines. RESULTS: A total of 22 randomized controlled trials including 1658 patients were included in the meta-analysis. Both International Knee Documentation Committee (IKDC) subjective score and Lysholm score were higher with the independent drilling approach (mean difference [MD], 1.24 [P = .02] and 0.55 [P = .005], respectively). No difference was documented in terms of the risk of reinjury, but independent drilling led to reduced KT-1000 arthrometer-assessed anterior tibial translation (MD, 0.23; P = .01) and a higher probability of a negative postoperative pivot-shift test finding (risk ratio, 1.13; P = .04). There were no significant differences in IKDC objective or Tegner scores. A P value of .07 was found for the association between the year of the study and IKDC objective scores. CONCLUSION: Independent femoral tunnel drilling provided better results than the TT approach, although the difference was not clinically significant. No difference was observed in the risk of reinjury. Increasingly better results were seen among surgical procedures performed in more recent years. Among the independent drilling options, the anteromedial portal technique seemed to provide the most favorable outcomes. The lack of clinically significant differences and the promising outcomes reported with new modified TT techniques suggest the importance of correct placement, rather than the tunnel drilling approach, to optimize the results of ACL reconstruction.

Improving cell seeding efficiency through modification of fiber geometry in 3D printed scaffolds.

Cell seeding on 3D scaffolds is a very delicate step in tissue engineering applications, influencing the outcome of the subsequent culture phase, and determining the results of the entire experiment. Thus, it is crucial to maximize its efficiency. To this purpose, a detailed study of the influence of the geometry of the scaffold fibers on dynamic seeding efficiency is presented. 3D printing technology was used to realize polylactic acid porous scaffolds, formed by fibers with a non-circular cross-sectional geometry, named multilobed to highlight the presence of niches and ridges. An oscillating perfusion bioreactor was used to perform bidirectional dynamic seeding of MG63 cells. The fiber shape influences the fluid dynamic parameters of the flow, affecting values of fluid velocity and wall shear stress. The path followed by cells through the scaffold fibers is also affected and results in a larger number of adhered cells in multilobed scaffolds compared to scaffolds with standard pseudo cylindrical fibers. Geometrical and fluid dynamic features can also have an influence on the morphology of adhered cells. The obtained results suggest that the reciprocal influence of geometrical and fluid dynamic features and their combined effect on cell trajectories should be considered to improve the dynamic seeding efficiency when designing scaffold architecture.

Platelet autologous growth factors decrease the osteochondral regeneration capability of a collagen-hydroxyapatite scaffold in a sheep model.

BACKGROUND: Current research aims to develop innovative approaches to improve chondral and osteochondral regeneration. The objective of this study was to investigate the regenerative potential of platelet-rich plasma (PRP) to enhance the repair process of a collagen-hydroxyapatite scaffold in osteochondral defects in a sheep model. METHODS: PRP was added to a new, multi-layer gradient, nanocomposite scaffold that was obtained by nucleating collagen fibrils with hydroxyapatite nanoparticles. Twenty-four osteochondral lesions were created in sheep femoral condyles. The animals were randomised to three treatment groups: scaffold, scaffold loaded with autologous PRP, and empty defect (control). The animals were sacrificed and evaluated six months after surgery. RESULTS: Gross evaluation and histology of the specimens showed good integration of the chondral surface in both treatment groups. Significantly better bone regeneration and cartilage surface reconstruction were observed in the group treated with the scaffold alone. Incomplete bone regeneration and irregular cartilage surface integration were observed in the group treated with the scaffold where PRP was added. In the control group, no bone and cartilage defect healing occurred; defects were filled with fibrous tissue. Quantitative macroscopic and histological score evaluations confirmed the qualitative trends observed. CONCLUSIONS: The hydroxyapatite-collagen scaffold enhanced osteochondral lesion repair, but the combination with platelet growth factors did not have an additive effect; on the contrary, PRP administration had a negative effect on the results obtained by disturbing the regenerative process. In the scaffold + PRP group, highly amorphous cartilaginous repair tissue and poorly spatially organised underlying bone tissue were found.

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears. PURPOSE/HYPOTHESIS: The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction. STUDY DESIGN: Meta-analysis. METHODS: A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines. RESULTS: Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis (P > .05). The level of evidence was moderate to low for the outcomes of the 3-week cutoff analysis and low to very low for the outcomes of the 10-week cutoff analysis. CONCLUSION: This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications. STUDY REGISTRATION: CRD42019119319 (PROSPERO).

Arthroscopically assisted and three-dimensionally modeled minimally invasive rim plate osteosynthesis via modified anterolateral approach for posterolateral tibial plateau fractures.

AIM: The aim of this study was to describe a new, closed, arthroscopically-assisted reduction of posterolateral tibial plateau fractures with minimally invasive plate osteosynthesis using a plate pre-contoured over a 3D-model based on a CT-scan of the injured tibial plateau and positioned by using a minimal anterolateral approach. METHODS: A five to six centimeter long curvilinear incision was made over the Gerdy's tubercle. After subcutaneous dissection, the fascia was incised, the ileo-tibial band was split, and the dissection was extended posteriorly. The knee was flexed to 90° and the space between the fibular collateral ligament and the posterolateral plateau rim (para-FCL space) was created. A variable-angle locking compression plate contoured on a 3D-model was inserted flush to the tibial plateau rim. Two cortical screws were placed to ensure support under the area of depression as far posteriorly as possible. Two additional screws were implanted, and a cortical screw was used for the most anterior screw hole. The custom pre-contoured plate based on a person-specific 3D-model, associated with arthroscopy reduction, provides a supporting and containing effect to the posterolateral periarticular fragments and allows a minimally invasive plate osteosynthesis fixation to be performed. This guarantees a proper reduction and fixation without the described limitations and risks associated with the classic approaches. CONCLUSIONS: This approach should be considered to treat fractures of the posterolateral plateau, isolated or associated with medial tibial plateau fractures, as it could improve the outcome in terms of lower associated risks, better reduction and fixation, and faster and improved patient recovery.

Fully Automated 10-Minute 3D CAIPIRINHA SPACE TSE MRI of the Knee in Adults: A Multicenter, Multireader, Multifield-Strength Validation Study.

OBJECTIVES: The aim of this study was to test the hypothesis that magnetic resonance imaging (MRI) of the knee with 10-minute 3-dimensional (3D) controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) sampling perfection with application optimized contrast using different flip angle evolutions (SPACE) turbo spin echo (TSE) protocols can replace 20-minute 2-dimensional (2D) TSE standard-of-reference protocols for the diagnosis of internal derangement. MATERIALS AND METHODS: After internal review board approval and prospective informed consent, 100 symptomatic subjects underwent MRI of the knee at 3 T and 50 symptomatic subjects at 1.5 T, consisting of 10-minute 3D CAIPIRINHA SPACE TSE and 20-minute standard-of-reference 2D TSE protocols. Two fellowship-trained musculoskeletal radiologists assessed the studies in an anonymized and randomized fashion for structural abnormalities. Descriptive statistics, interreader reliability, intermethod concordance, diagnostic definitiveness, and interchangeability tests were applied. P values equal to or smaller than 0.01 were considered significant. RESULTS: The interchangeability analysis showed that the 3D MRI can replace the 2D MRI protocols, whereas a superiority of 3D MRI was suggested statistically for the detection of medial and lateral meniscal tears, cartilage defects, and bone marrow edema by significantly higher common pair exact match proportions of readers (P < 0.01, respectively).The overall interreader reliabilities were 89% of exact matches for 2D TSE (κ, 0.842) and 96% of exact matches for 3D TSE (κ, 0.941) (P < 0.01). There was good intermethod concordance (κ, 0.736; range, 0.579-1.000). The interreader reliability (2D TSE: κ, 0.748 [0.603-1.000]; 3D TSE: κ, 0.901 [0.797-1.000]) and diagnostic definitiveness were significantly higher for the 3D than 2D MRI (P < 0.01). CONCLUSIONS: 10-minute 3D CAIPIRINHA SPACE TSE MRI protocols can replace 20-minute 2D TSE standard-of-reference MRI protocols for the evaluation of internal derangement of the knee by producing similar results in individual patient diagnoses, whereas interpretations of 3D CAIPIRINHA SPACE TSE MRI examinations resulted in an overall higher interreader reliability, intermethod concordance, and reader definitiveness.

Isolated Knee Arthritis as Early and Only Symptom of Whipple's Disease.

We report a case of isolated Whipple's disease involving the knee of a 64-year-old female patient who presented recurrent monoarthritis whose origin was not clear. Initially, the cause of the gradually invalidating symptoms was related to a meniscal lesion and a diffuse minor grade chondropathy, but pain and functional impairment suggested that more exams were needed. Biopsies were performed during arthroscopy. The histology showed highly inflammatory infiltrates with PAS staining negative for Tropheryma while PCR revealed the infection with Tropheryma whipplei. This, following the recommendation of a rheumatologist and infectious disease specialist, led to biopsies of the gastrointestinal tract and analysis of the cerebrospinal fluid that showed no other organ involvement. This confirms the scientific literature that an isolated monoarthritis without involvement of the gastrointestinal tract caused by this bacterium is rare but can occur as an early manifestation of potentially fatal systemic disease. Moreover, a review of the scientific literature showed the uncertainty about epidemiology of this rare disease, suggesting that more and specific data are required.

Posterior pelvic ring fractures: Intraoperative 3D-CT guided navigation for accurate positioning of sacro-iliac screws.

INTRODUCTION: Posterior pelvic ring fractures frequently pose a problem of stability with an elevated risk of complications. The traditional method of percutaneous sacroiliac (SI) stabilization with the use of fluoroscopic image amplifiers demands a high degree of experience and has an elevated risk of screws' malpositioning. HYPOTHESIS: Intraoperative 3D-CT scan coupled with a navigation system (O-Arm©) can allow screw fixation accuracy while limiting the risk of complications for the treatment of posterior pelvic ring fractures. MATERIAL AND METHODS: Patients with posterior pelvic ring fractures stabilized with percutaneous SI screws through O-Arm© navigation from August 2008 to December 2017 were analyzed. A modified Gras classification was used to determine screws' positioning under CT visualization, and intraoperative and early postoperative complications were documented. RESULTS: Among the 21 patients evaluated, 14 men and 7 women with a mean age of 57.8 years (range 25-91), receiving 39 screws, the rate of misplacement was low: 82% grade I, 15.4% grade II, and only 2.6% grade III. Only one patient underwent revision surgery, not because of misplacement but rather for a secondary implant loosening. No complications occurred in this series. DISCUSSION: This study documented a large series of patients treated for pelvic ring fractures using the intraoperative 3D-CT O-Arm© guided navigation. This surgical approach provided a precise and safe SI screw positioning with no complications. LEVEL OF EVIDENCE: IV, Retrospective study.

Femoral Tunnel Positioning in Anterior Cruciate Ligament Reconstruction: Anteromedial Portal versus Transtibial Technique-A Randomized Clinical Trial.

Purpose The purpose of this study was to investigate, through three-dimensional computed tomography (3D-CT), the accuracy of femoral tunnel positioning in patients undergoing anterior cruciate ligament (ACL) reconstruction, comparing transtibial (TT) and anteromedial (AM) techniques. Methods We evaluated postoperative 3D-CT scans of 26 patients treated with ACL reconstruction with hamstrings autograft using a low accessory AM portal technique and 26 treated with the TT technique. The position of the femoral tunnel center was measured with the quadrant method. Results Using quadrant method on CT scans, femoral tunnels were measured at a mean of 32.2 and 28.1% from the proximal condylar surface (parallel to Blumensaat line) and at a mean of 31.2 and 15.1% from the notch roof (perpendicular to Blumensaat line) for the AM and TT techniques, respectively. Conclusion The AM portal technique provides more anatomical graft placement than TT techniques. Level of Evidence Level I, randomized clinical study.