Good stability and mid-term subjective outcomes after repeated anterior cruciate ligament (ACL) revision surgery using allografts.

PURPOSE: To evaluate the mid-term clinical outcomes of a cohort of patients who underwent multiple ACL revision reconstructions. The hypothesis was that patients with pre-existing meniscal deficiency conditions, malalignment and cartilage degeneration would have obtained lower results. METHODS: All cases of multiple ACL revisions performed with allograft tissue at one single sport-medicine institution were extracted and patients with a minimum 2 years of follow-up were included. WOMAC, Lhysolm, IKDC, and Tegner activity level before the injury and at last follow-up was collected and laxity evaluated with KT-1000 arthrometer and KiRA triaxial accelerometer. RESULTS: From a cohort of 241 ACL revisions, 28 patients (12%) with Repeated ACL Revision reconstructions were included. Fourteen cases (50%) were considered "Complex" due to the addition of meniscal allograft transplantation (8) or meniscal scaffold (3) or high tibial osteotomy (3). The remaining 14 cases (50%) were considered as "Isolate". The mean WOMAC score was 84.6 ± 11.4, Lysholm 81.7 ± 12.3, subjective IKDC 77.2 ± 12.1, and median Tegner score 6 (IQR 5-6) at pre-injury and at final follow-up. Statistically significant inferior values of WOMAC (p = 0.008), Lysholm (p = 0.02) and Subjective IKDC (p = 0.0193) were detected between "Complex" and "Isolate" revision groups. Higher average values of anterior translation at KT-1000 at both 125 N (p = 0.03) and manual maximum displacement test (p = 0.03) were reported in "Complex" with respect to "Isolate" revisions. Four patients were considered as failures and occurred in patients with "Complex" revisions, none occurred in the "Isolate" (30% vs 0%; p = 0.04). CONCLUSION: Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients who experienced multiple failures; however, those who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results. LEVEL OF EVIDENCE: III.

Intra- and inter-operator reliability assessment of a novel extramedullary accelerometer-based smart cutting guide for total knee arthroplasty: an in vivo study.

PURPOSE: The purpose is to verify the intra- and inter-operator reliability of an extramedullary (EM) accelerometer-based smart cutting guide for distal femoral resection during primary total knee arthroplasty (TKA). The hypothesis of the present study was that the use of the device would result in a good correlation between different operators with a difference between repeated measurements of less than 1°. METHODS: Twenty-five not consecutive patients with knee osteoarthritis undergone to primary TKA using an EM inertial-based cutting guide to perform distal femoral resection. In order to assess the agreement in femoral axis definition of the device, two operators performed three time each the manoeuvres necessary to define axis. Inter-rater agreement was evaluated with Bland and Altman agreement test. Intra-rater repeatability was evaluated analysing average results distribution of repeated measurements. Accuracy of the device was evaluated comparing differences between intra-operative device data with final implant alignment measured on post-operative longstanding x-rays using Students' t test. RESULTS: Agreement between the two operators was statistically significant (p < 0.05) with a bias of - 0.4° (95% CI - 0.6° to - 0.2°). Average difference between cut orientation measured with device and final implant position, measured on x-rays, was 0.2° (95% CI - 1.5° to 1.7°) with no statistical difference between the two measurements. Final implant alignment, measured on x-ray, was 90.2°, with 95% of cases distributed within range 88.0° to 92.0° for varus-valgus and 2.8° and with 95% of cases distributed within range 2.0° to 4.0° for flexion-extension. CONCLUSIONS: The EM accelerometer-based smart cutting guide used to perform distal femoral resection during primary TKA demonstrated a good intra- and inter-operator reliability in the present in vivo study.

Adipose-derived Stromal Vascular Fraction Injection in a Competitive High-level Athlete Affected by Insertional Achilles Tendinopathy.

Achilles tendinopathy is one of the most common ankle and foot overuse injuries, especially among athletes. Despite this, the management of this injury lacks an evidence-based support, and patients are at risk of long-term morbidity with unpredictable clinical outcome. Recently, injective approach has gained more and more attention, and in particular the intratendinous injection with adipose-derived stromal vascular fraction. We report a case of an insertional Achilles tendinopathy in a high-level professional athlete, who was treated avoiding surgical treatment in favor of this innovative biological approach. Patient's satisfaction and return to play was prospectively evaluated for a period of 6 months of follow-up. An improvement of all functional scores was yet appreciated after 1 month from the treatment, with a crescent trend until the last 6-month follow-up. The patient was able to return to train after 34 days, and returned to match after 68 days, playing 20 minutes. She returned to the complete full game 72 days after treatment. However subsequent ultrasound and MRI evaluations failed to show any substantial changes in the characteristics of the lesion from the preoperative images. This case report opens a new window for the treatment of insertional Achilles tendinopathy in competitive athletes. The current outcome deserves further investigation with higher quality studies in order to confirm the validity of this fascinating therapeutic option.

The 90-day Readmission Rate after Single-Bundle ACL Reconstruction Plus LET: Analysis of 2,559 Consecutive Cases from a Single Institution.

The aim of the present study is to examine the readmission rate within 90 days of a cohort of patients, who underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with a lateral extraarticular tenodesis, from a single highly specialized sports traumatology department. From our institutional database, we identified 2,559 patients (78.5% males and 21.5% females, with a mean age at surgery of 30.9 ± 11.5 years) who underwent primary ACL reconstruction with the same "over-the-top" technique plus lateral extraarticular tenodesis (LET) from January 2010 to December 2017. From this count, we extracted all patients who were readmitted within 90 days and focused on causes of readmission and reoperation rate. Moreover, a multivariate logistic regression was performed to identify possible variables, such as gender, age, and concomitant meniscus surgery, which could predict the risk of early readmission. From the aforementioned cohort, 58 patients (2.27%) were readmitted within 90 days from surgery after a mean time of 31 ± 23 days. The most common cause of readmission was fever and knee swelling (0.78%), followed by superficial infection (0.63%), deep infection (0.55%), and joint stiffness (0.23%). The patients' age and meniscal lesions requiring concomitant arthroscopic treatment were found to be correlated to an increased risk of early readmission. Superficial infections were more common in female patients (odds ratio [OR] = 3.01), whereas the meniscal treatment was also a significant risk factor specifically for deep infections (OR = 3.56). In conclusion, this technique of arthroscopic ACL reconstruction with LET showed a low readmission rate within 90 days from surgery. However, patients and physicians should be aware of the risk of serious complications, such as deep and superficial infections, mostly in female patients and in cases of concurrent meniscal treatments. This is a Level IV, retrospective case series study.

White Blood Cell Count Is the Most Reliable Test for the Diagnosis of Septic Arthritis After Anterior Cruciate Ligament Reconstruction: An Observational Study of 38 Patients.

PURPOSE: (1) To evaluate the diagnostic testing performance of the synovial white blood cell (WBC) count, polymorphonuclear cell percentage, and synovial glucose, synovial protein, synovial lactate dehydrogenase, and synovial C-reactive protein levels as diagnostic markers for the diagnosis of septic arthritis after anterior cruciate ligament (ACL) reconstruction; (2) to define the ideal thresholds of the aforementioned tests, leading to the optimal sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy; and (3) to define the sensitivity of synovial fluid culture and synovial tissue sample culture, as well as determine whether previous antibiotic treatment may affect the accuracy of these tests. METHODS: We performed a retrospective analysis of all patients readmitted from January 2009 to September 2019 with signs suggestive of septic arthritis and undergoing a knee aspiration for synovial fluid analysis and culture. The receiver operating characteristic curve and the associated area under the curve were constructed for the aforementioned synovial markers. Sensitivity, specificity, PPV, NPV, and accuracy were calculated for the obtained optimal values. Sensitivity was also calculated for synovial fluid culture and synovial tissue sample culture, and the influence of previous antibiotic treatments on culture sensitivity was evaluated. RESULTS: Among 3,408 cases of ACL reconstruction, after the exclusion of 13 patients not meeting the inclusion criteria, 24 infected and 14 uninfected patients were reviewed and included in the analysis. The diagnosis was confirmed by the presence of 2 positive culture findings with the same isolated microorganism or at least 3 of the 4 following criteria: elevated serum C-reactive protein level and erythrocyte sedimentation rate, positive results of histologic analysis of synovial tissue, macroscopic evidence of purulence, and 1 positive culture finding. The receiver operating characteristic curve analysis showed that the most reliable marker for the diagnosis of septic arthritis after ACL reconstruction was the synovial WBC count (area under the curve, 0.89). A cutoff value of 28,100 cells/mL presented the highest accuracy (0.85), highest PPV (0.94), and highest NPV (0.76); moreover, with the threshold set at 40,000 cells/mL, postoperative infection could be diagnosed with 100% specificity. The sensitivity of synovial fluid culture was significantly lower than the sensitivity of synovial tissue sample culture (0.63 vs 0.96, P = .0045); moreover, the sensitivity further decreased if patients took antibiotics before aspiration (0.44 vs 0.73), although this decrease was not statistically significant. CONCLUSIONS: The synovial WBC count is the most reliable test for the diagnosis of septic arthritis after ACL reconstruction. Although the sensitivity of synovial fluid culture is affected by previous antibiotic treatment, the synovial WBC count is not influenced and proves to be useful in the diagnosis of this uncommon complication. LEVEL OF EVIDENCE: Level II, diagnostic study.

Graft-Preserving Arthroscopic Debridement With Hardware Removal Is Effective for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Clinical, Arthrometric, and Magnetic Resonance Imaging Evaluation.

BACKGROUND: Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability. PURPOSE/HYPOTHESIS: The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis. RESULTS: Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases. CONCLUSION: Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis.

Bearing thickness of unicompartmental knee arthroplasty is a reliable predictor of tibial bone loss during revision to total knee arthroplasty.

BACKGROUND: Bone defects during revision procedures for failed UKA represent a challenge even for the most experienced surgeons; therefore, an accurate preoperative planning remains essential to prevent dramatic scenarios in the surgical theatre. HYPOTHESIS: Our hypothesis is that bearing thickness used in original UKA represents a reliable predictor of severe tibial bone loss, requiring a metallic augment or constrained implant, during revision to TKA. PATIENTS AND METHODS: Forty-two patients who underwent a total knee arthroplasty from failed UKA were identified from our institutional database and evaluated clinically using the Knee Society Score (KSS). A multivariate logistic regression analysis was performed using the presence of tibial augments or the need of varus-valgus constrained (VVC) prosthesis as depend variables, and patients' gender, age at revision procedure, side (medial or lateral), UKA tibial tray (all-polyethylene or metal back), bearing thickness (composite thicknesses of the metal-backed tray and insert or all-polyethylene tibial component ≤8mm or more than 8mm) and cause of failed UKA as independent variables. RESULTS: A posterior-stabilized prosthesis was used in 27 cases (64.3%). An augment was necessary in 12 patients (28.6%). Initial bearing thickness greater than 8mm was associated with greater likelihood of a VVC implant (OR=11.78, 95% CI, 1.6583 to 83.6484, p=0.0137) and a tibial augment (OR=9.59, 95% CI, 1.327 to 69.395, p=0.0251). Tibial tray design, patients' gender or age during revision surgery, side or cause of failure were not associated to increased risk of augmentation or constrained implants. DISCUSSION: Surgeons should be aware of the particular challenges that the conversion of a UKA to a TKA presents and be prepared to address them intraoperatively, with particular care to proper bone loss manage. Satisfying results can be achieved at mid-to-long term follow-up, if these procedures are planned accurately, and a precise analysis of failed UKA components, in particular bearing thickness, represents a helpful support in this context. LEVEL OF EVIDENCE: IV, retrospective case series.

Difficult primary total knee arthroplasty requiring a varus-valgus constrained implant is at higher risk of periprosthetic infection.

PURPOSE: The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus-valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs. METHODS: 74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan-Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis). RESULTS: Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209-1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence. CONCLUSIONS: Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Metal-Backed Tibial Components Do Not Reduce Risk of Early Aseptic Loosening in Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis.

Long-term results of unicompartmental knee arthroplasty (UKA) have shown a slightly higher revision rate than total knee arthroplasty (TKA), and implant fixation geometry seems to affect prosthetic survivorship. Whether metal-backed tibial component leads to superior performance over the all-polyethylene design is unclear, and a lack of evidence exists in literature. Our purpose was to demonstrate which implant design of UKA (all-polyethylene or metal-backed tibial component) is clinically superior regarding revision rates and clinical functioning, and investigate the role of potential factors that could affect the revision rate. A systematic review was conducted for clinical studies comparing all-polyethylene and metal-backed tibial components used in primary UKAs in terms of revision rates and clinical scores. Meta-regression techniques were used to explore factors modifying the observed effect. All causes of revision were extracted and analyzed, to find statistically significant differences between the two groups. Our research strategy generated a systematic review of nine studies comprising 1,101 UKAs in 1,088 patients with 87 revisions for any reason. Meta-analysis showed a higher, but not statistically significant, risk of aseptic revision in the all-polyethylene group. Studies with a smaller sample size and higher percentage of female patients were correlated to a higher relative risk of revision in favor of all-polyethylene UKAs. Differently, patients' age and duration of follow-up did not influence the risk ratio. The main cause for revision was aseptic loosening in both implants' component, with no statistically differences in the two groups examined. Our results do not show a superiority of the metal-backed tibial component in UKAs in terms of survivorship, although extreme care must be given for patients with high risk of early failure, such as female patients. However, surgical experience, in combination with careful patient selection, remains paramount and may lead to better long-term outcomes in patients requiring UKA. This is a Level III, therapeutic study.

Knee kinematics after cruciate retaining highly congruent mobile bearing total knee arthroplasty: An in vivo dynamic RSA study.

PURPOSE: This work presents a kinematic evaluation of a cruciate retaining highly congruent mobile bearing total knee arthroplasty design using dynamic Roentgen sterephotogrammetric analysis. The aim was to understand the effect of this implant design on the kinematics of prosthetic knees during dynamic activities. METHODS: A cohort of 15 patients was evaluated at nine month follow-up after surgery. The mean age was 74.8 (range 66-85) years. The kinematics was evaluated using the Grood and Suntay decomposition and the Low-Point (LP) methods. RESULTS: ?tlsb=-0.15pt?>From sitting to standing up position, the femoral component internally rotated (from -11.3 ±â€¯0.2° to -7.0 ±â€¯0.2°). Varus-valgus rotations were very close to 0° during the whole motor task. LP of medial condyle moved from an anterior position of 12.0 ±â€¯0.2 mm to a posterior position of -12.4 ±â€¯0.2 mm; LP of the lateral condyle moved from an anterior position of 8.1 ±â€¯0.2 mm to a posterior position of -12.4 ±â€¯0.2 mm, showing a bi-condylar rollback where both condyles moved parallel backward. Moreover, the femoral component showed anterior translation with respect to the tibia from 80° to 20° (from -4.9 ±â€¯0.2 mm to 3.3 ±â€¯0.2 mm), then a posterior translation from 20° to full extension was identified (from 3.3 ±â€¯0.2 mm to 0.5 ±â€¯0.2 mm). CONCLUSIONS: Paradoxical anterior femoral translation and absence of medial-pivoting motion were recorded, highlighting the role of the symmetric deep dishes insert as main driver of the kinematic of this TKA design.

Age over 50 years is not a contraindication for anterior cruciate ligament reconstruction.

PURPOSE: To report clinical and functional results of ACL reconstruction in patients over 50 years old and investigate the influence of surgery on osteoarthritis progression in this cohort of patients. METHODS: A systematic review was performed on PubMed, Scopus, Google scholar, Cochrane library and EMBASE, using a strategy search design to collect clinical studies reporting outcomes of ACL reconstruction in patients aged 50 years or older. The primary outcome measure was clinical and functional results, including failure rate defined as reoperation for revision ACL surgery or conversion to total knee arthroplasty; secondary outcomes included radiological findings, expressed according to the validated grading score. RESULTS: A total of 16 studies were found suitable and included. Overall, 470 arthroscopic ACL reconstructions were performed in 468 patients (278 males, 190 females), with a mean age of 53.6 years (50-75 years). The total failure rate, described as reoperation for revision ACL surgery was 2.7% (10 knees), ranging from 0 to 14.3% in the selected studies. All papers reviewed showed a statistically significant improvement of clinical and functional scores at final follow-up, comparable to younger control group, when reported. Post-operative objective stability testing with KT-1000 arthrometer device or equivalent was performed in seven studies, with a mean side-to-side difference of 2.2 mm (0.2-2.7 mm). Radiographic signs of progression of osteoarthritis were reported in six studies, where severe signs of degeneration (grade 3 or 4 according Kellgren-Lawrence or Ahlbäck classification) shifted from 4 out of 216 knees (1.9%) before surgery to 28 out of 187 knees (15%) following ACL reconstruction, after a mean period of follow-up ranging from 32 to 64 months. CONCLUSION: ACL reconstruction in patients older than 50 years is a safe procedure with good results that are comparable to those of younger patients previously reported. Age itself is not a contraindication to ACL surgery because physiological age, clinical symptoms and functional requests are more important than chronological age in decision process. Since cohort size in the present study is not large enough, and taking into account the high occurrence of concomitant meniscal and chondral lesions, more high-quality studies are necessary to draw definitive conclusions about development of osteoarthritis of the knee after ACL surgery in these patients. LEVEL OF EVIDENCE: IV.

Return to Sports after Unicompartmental Knee Arthroplasty: Reality or Utopia? A 48-Month Follow-Up Prospective Study.

Unicompartmental knee arthroplasty (UKA) has increased in popularity in the last years, also in younger and more active patients with great expectancies. The purpose of our study was to investigate the change in sports activities before and after medial UKA. We surveyed 53 athletic patients; all underwent cemented medial UKA, to determine not only their subjective and objective evaluation of clinical status with Hospital for Special Surgery (HSS) and visual analog score (VAS) score, but also their sporting and recreational activities at a mean follow-up of 48 ± 6 months (range, 18-56 months). At the last follow-up, 48 of 53 patients were engaged in sports and recreational disciplines, resulting in a return to activity rate of 90%. No early failure and no cases of revision were reported. The frequency of activities (sessions per week) and the time session remained constant at the time of survey. The most common activities after surgery were hiking, cycling, and swimming. Several high-impact activities, as well as skiing and football, had a significant decrease in participating patients. There were no gender-, age- and body mass index (BMI)-related differences. UKA can be considered a viable alternative in relatively young patients with high functional requirements and the correct indications, however, warning the patients about the risks of polyethylene wear and early loosening of the prosthetic components as a result of the resumption of sporting activities in high impact. LEVEL OF EVIDENCE: Prospective case series, level 4.

Early Failure in Medial Unicondylar Arthroplasty: Radiographic Analysis on the Importance of Joint Line Restoration.

Survivorship of unicondylar knee arthroplasty (UKA) remains a drawback, especially compared with the outcome of total knee arthroplasty. This could be improved by identifying and correcting failure mechanisms. To this purpose, this study aimed at exploring failure modalities of UKA, with particular focus on the role of joint line (JL) position and alignment as variable to be optimized for a successful outcome. This study explored modes of failure in 266 medial UKAs. Radiological comparison was performed between 24 failures and 24 matched controls, to determine the importance of UKA positioning in terms of femorotibial angle (FTA), tibial plateau angle, and posterior tibial slope (PTS). Radiographic comparative analysis showed statistically significant differences in the failure group compared with the control group in terms of variation in FTA (p = 0.0222), PTS (p = 0.0025), and JL height (p = 0.0022). Variations not only in FTA but also PTS and JL height were correlated with failures observed in this series. Thus, based on the results of this study, it emerges that JL position should be carefully controlled in all planes while implanting a UKA. This is a Level III, case-control study.

The efficacy of dual-mobility cup in preventing dislocation after total hip arthroplasty: a systematic review and meta-analysis of comparative studies.

PURPOSE: Although long-term reports of total hip arthroplasty (THA) showed successful results, instability remains a major complication. Recently, dual-mobility cups (DMC) have gained more and more interest among clinicians, with encouraging results in terms of lower rate of dislocation associated with good clinical results, but a lack of evidence exists regarding the real efficacy of this implant design compared to traditional fixed-bearing total hip arthroplasties. METHODS: A systematic search was performed in PubMed, Google scholar, Cochrane Library, and EMBASE by two independent reviewers for comparative studies available till December 2017, with the primary objective to demonstrate a real lower dislocation rate of DMC implants compared to unipolar fixed-bearing cup designs. A meta-analysis was conducted with the collected pooled data about dislocation rate, calculating the risk difference (RD) and relative risk (RR) with 95% CI for dichotomous variables. Heterogeneity was tested using the χ2 and Higgins' I2 tests. A fixed-effect model was used because the statistical heterogeneity was below 50%. RESULTS: After performing a critical exclusion process, the number of eligible studies included for final synthesis considered was 15, describing the results of a total of 2408 total hip arthroplasties (50.6% with a dual-mobility acetabular cup design, 49.4% with a standard fixed-bearing design). The fixed-effect meta-analysis showed a slight significant risk ratio of 0.16 (95% CI, 0.09, 0.28; I2 = 0%, p < 0.00001); a statistically significant difference in favor of the DMC group was maintained also considering only primary or revision arthroplasties, traumatic fractures or elective patients with diagnosis of osteoarthritis, avascular osteonecrosis or rheumatic arthritis. CONCLUSIONS: With the intrinsic limitations of our study design and based on the current available data, this study demonstrates that dual-mobility acetabular components decrease the risk of post-operative instability also in high-risk patients, both in primary and revision hip arthroplasties. However, new high-quality studies, possibly with a randomized control design, should be undertaken in order to strengthen the present data. STUDY DESIGN: Level of Evidence III, therapeutic study.

No Effects of Early Viscosupplementation After Arthroscopic Partial Meniscectomy: A Randomized Controlled Trial.

BACKGROUND: The management of the postoperative period after knee arthroscopic surgery may be challenging because surgical trauma deeply alters the joint microenvironment, causing the release of several catabolic molecules and proinflammatory factors that might slow down functional recovery. The possibility of using hyaluronic acid (HA) to promote postoperative pain relief and expedite functional improvement seems attractive, considering its biological properties. PURPOSE: The aim of the present double-blind randomized controlled trial was to evaluate the effects, in terms of pain control and functional recovery, provided by a single HA injection performed at the end of arthroscopic meniscectomy. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 90 patients, 18 to 55 years old, were included according to the following criteria: (1) chronic, symptomatic meniscal tears requiring partial resection; (2) a healthy contralateral knee; (3) no previous surgery on the index knee; and (4) no other concurrent articular lesions requiring surgical treatment (eg, cartilage or ligament injuries). Patients were randomized into 2 treatment groups: one underwent meniscectomy alone, whereas the other also received an injection of 3 mL HA at the end of the procedure. All patients were evaluated at baseline and then at 15, 30, 60, and 180 days using the following tools: International Knee Documentation Committee (IKDC) subjective, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, VAS for general health status, and Tegner scores. The transpatellar circumference and active and passive ranges of motion were also recorded during the follow-up evaluations. RESULTS: No major adverse events were reported using HA postoperatively. A statistically significant increase in all the clinical scores was reported in both treatment groups, but no significant intergroup difference was documented at any follow-up evaluation. No difference was observed also in the objective measurements. The mean time to return to full sports activity was not different between groups, and a comparable satisfaction rate was recorded in both treatment groups. CONCLUSION: Early postoperative viscosupplementation did not provide significant clinical benefits after arthroscopic meniscectomy. Despite the lack of major adverse events, the administration of a single HA injection at the end of the surgical procedure is not a successful strategy to provide either faster functional recovery or symptomatic improvement after meniscectomy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02629380.

Early Viscosupplementation After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial.

BACKGROUND: Hyaluronic acid (HA) has been widely used to treat osteoarthritis given its biological and mechanical properties. Because HA is an "intra-articular" treatment approach that affects the joints, it could be used in the management of acute conditions, such as during the early postsurgical phase, to reduce inflammatory stress and improve articular function. PURPOSE: The aim of the present double-blind, randomized controlled trial was to evaluate pain control and functional recovery provided by a single injection of HA performed the day after anterior cruciate ligament (ACL) reconstruction. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: The study enrolled 60 patients affected by primary, chronic, and symptomatic ACL tear requiring surgical reconstruction. All patients were treated with the same reconstructive technique and rehabilitation protocol. Exclusion criteria were (1) concurrent articular lesion requiring surgical treatment, (2) axial malalignment in the index limb, and (3) functional limitation or pain in the contralateral knee. The day after the procedure, the patients were randomized to receive a single injection of 3 mL HA or 3 mL saline solution after surgical drains were removed. All patients were evaluated at baseline and at 15, 30, 60, and 180 days and 12 months after surgery by use of the following tools: Short Form-36 Health Survey (SF-36), International Knee Documentation Committee (IKDC) subjective score, visual analog scale (VAS) for pain, VAS for general health status, and Tegner score. At each follow-up evaluation, the transpatellar circumference and active and passive range of motion (ROM) of both knees were recorded. RESULTS: No severe adverse events were documented after early viscosupplementation. A significant improvement was documented in both treatment groups. Significant differences were documented in the transpatellar circumference at 60 days and in active ROM at 30 days postoperatively; patients who received HA had better values compared with the placebo group (P = .022 and .027, respectively). No statistically relevant intergroup differences were found in the clinical scores. CONCLUSION: The study documented no adverse events and had some positive findings in terms of active ROM recovery and transpatellar circumference reduction. However, the early postoperative application of viscosupplementation did not lead to significant improvement in clinical scores after ACL reconstruction. REGISTRATION: NCT02630407 (ClinicalTrials.gov identifier).

The adductor tubercle: an important landmark to determine the joint line level in revision total knee arthroplasty.

PURPOSE: The restoration of the physiological femoro-tibial joint line (JL) is important to obtain a good outcome in revision total knee arthroplasty (RTKA). However, its assessment is challenging. The ratio of the distance between the adductor tubercle (AT) JL (ATJL) and the trans-epicondylar femoral width (FW) was proposed as a reliable method. The purpose of this study was to check whether this ratio is a reliable tool to restore the prosthetic JL height in challenging prosthetic revision cases. METHODS: Twenty-one patients (mean age 65.8 years) were recruited. During surgery, FW was measured and ATJL distance was calculated using 0.53 (SD 0.03) as the ratio. After implant positioning, the obtained ATJL line was measured to verify the accuracy of the surgical procedure. Thirteen patients presented a healthy contralateral knee: a comparative radiograph examination was performed to verify the appropriateness of the restored JL height. RESULTS: The intra-operatively calculated ATJL was not significantly different with respect to the measured ATJL obtained after prosthetic component implantation. The comparative analysis between the restored JL and the JL of the contralateral not operated knee was also not statistically significant, thus confirming the appropriateness of the restored JL height. CONCLUSIONS: This study shows that the method which uses an AT to JL distance/FW ratio to determine the JL level, previously applied in primary TKA, is valid when using intra-operatively acquired measurements in RTKA. This is clinically relevant since it represents a reliable tool which helps surgeons to restore the JL level in challenging prosthetic revision cases. LEVEL OF EVIDENCE: Case series, Level IV.

High rate of implant loosening for uncemented resurfacing-type medial unicompartmental knee arthroplasty.

PURPOSE: To determine the medium-term implant survivorship, the clinical results and the failure mechanisms of a novel unicompartmental arthroplasty for uncemented resurfacing of the medial tibio-femoral compartment. METHODS: Seventy-six consecutive patients were prospectively evaluated with a mean final follow-up of 6 years (SD 5.3 months). In 44 patients, the diagnosis was osteoarthritis, and in 32 patients, it was avascular necrosis of the medial femoral condyle. The Hospital for Special Surgery Score was used for objective clinical evaluation, and a self-administered visual analogue scale was used to quantify residual pain at each observation point. Implant survivorship was determined assuming revision for any reason as endpoint. RESULTS: Nineteen patients were revised (6 with osteoarthritis and 13 with avascular necrosis of the medial femoral condyle). The mean interval time from index surgery to revision was 11.2 months (SD 4.66 months). Implant survivorship was higher in patients with osteoarthritis with respect to those with avascular necrosis of the medial femoral condyle (p = 0.018). Aseptic loosening was the most frequent failure mechanism. Femoral component loosening was reported in five patients and tibial component loosening was reported in other six patients. Assuming revision for any reason as endpoint, an implant survivorship of 74.3 % at 6-year follow-up was determined. In the remaining 57 patients, satisfactory clinical results were obtained. Hospital for Special Surgery Score and visual analogue scale for residual pain showed significant improvements (p < 0.03 and p < 0.045, respectively). CONCLUSIONS: At the present time, the standard cemented implants and the conventional designs for unicompartmental knee replacement still represent the optimal solution. The authors do not recommend the widespread use of this technique. LEVEL OF EVIDENCE: IV.

The adductor tubercle: a reliable landmark for analysing the level of the femorotibial joint line.

PURPOSE: The ratio of femoral width and distance from medial epicondyle to joint line helps estimate the femoral joint line position from femoral width. The approximately radial position of the medial epicondyle on femoral condyle spheres is probably responsible for this relationship, The adductor tubercle approximately lies diametrically opposite to the joint line on condylar sphere. Then, a linear correlation could also exist between the femoral width and distance of adductor tubercle to joint line and is the purpose of the current study. METHODS: Femoral width, along with the distance to joint line from the medial epicondyle, the adductor tubercle and fibular pole, was measured on 110 standard antero-posterior knee radiographs. Correlation between femoral width and these measurements was evaluated. The individual ratio of FW with adductor tubercle joint line, medial epicondyle joint line and fibula joint line was calculated using linear regression analysis. Intra-observer and inter-observer reliability was assessed. RESULTS: Linear correlation was found between femoral width and distance of adductor tubercle to joint line (r = 0.83). It was more reliable than the correlation between femoral width and distance from medial epicondyle to joint line (r = 0.52). Inter-observer repeatability was better for distance from adductor tubercle to joint line than for distance from medial epicondyle to joint line. CONCLUSIONS: We conclude that adductor tubercle can be used as a morphologic landmark to determine the knee joint line position, because a linear correlation between femoral width and distance from the adductor tubercle to the joint line was found.