Editorial Commentary: The Number One Cause of Anterior Cruciate Ligament Reconstruction Graft Failure Is a Misplaced Femoral Tunnel: Over-the-Top Technique Plus Lateral Extra-Articular Tenodesis Is Recommended.

Patient factors (notably high tibial slope and narrow femoral intercondylar notch width) and surgical factors (including meniscus treatment and anterior cruciate ligament [ACL] tunnel position) contribute to ACL reconstruction failure. The number one cause of failure is a misplaced ACL femoral tunnel. Tunnel malposition leads to a higher incidence of postoperative meniscal lesions, inferior clinical outcomes, and higher revision rates.

Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 ​years.

OBJECTIVES: To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years. METHODS: Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests. RESULTS: 45 QT-A patients were matched to 45 HT-A patients (n â€‹= â€‹90). The mean FU was 78.9 â€‹± â€‹13.6 months. 18 patients (20.0%/QT-A: N â€‹= â€‹8, 17.8%; HT-A: n â€‹= â€‹10, 22.2%; p â€‹= â€‹.60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n â€‹= â€‹9, 20.0%; HT-A: n â€‹= â€‹8, 17.8%; p â€‹= â€‹.79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p â€‹= â€‹.32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 â€‹± â€‹11.6 years, HT-A: 23.3 â€‹± â€‹9.5 years, p â€‹= â€‹.63) or graft thickness (mean graft square area: QT-A: 43.6 â€‹± â€‹4.7 mm2, HT-A: 48.1 â€‹± â€‹7.9 mm2, p â€‹= â€‹.27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 â€‹± â€‹1.2 â€‹mm, HT-A: 2.1 â€‹± â€‹1.5 â€‹mm; p â€‹= â€‹.60), subjective IKDC- (QT-A: 93.8 â€‹± â€‹6.8, HT-A: 91.2 â€‹± â€‹7.8, p â€‹= â€‹.17), Lysholm- (QT-A 91.9 â€‹± â€‹7.2, HT-A: 91.5 â€‹± â€‹9.7, p â€‹= â€‹.75) or any of the five subscales of the KOOS score (all p â€‹> â€‹.05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p â€‹= â€‹.62), VAS for pain (QT-A: 0.5 â€‹± â€‹0.9, HT-A: 0.6 â€‹± â€‹1.0, p â€‹= â€‹.64), Shelbourne-Trumper score (QT-A: 96.5 â€‹± â€‹5.6, HT-A: 95.2 â€‹± â€‹8.2, p â€‹= â€‹.50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 â€‹± â€‹3.2, HT-A: 10.7 â€‹± â€‹4.9, p â€‹= â€‹.24), SSD-DTC (QT-A: 0.5 â€‹± â€‹0.5, HT.- A: 0.5 â€‹± â€‹0.6, p â€‹= â€‹.97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 â€‹± â€‹3.8%, HT-A: 93.7 â€‹± â€‹7.0%) did not differ between groups. Donor-site morbidity (HT-A n â€‹= â€‹14, 46.7%; QT-A n â€‹= â€‹3, 11.5%; p â€‹= â€‹.008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p â€‹= â€‹.29). CONCLUSION: Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft. LEVEL OF EVIDENCE: II.

Comparison of a Minimally Invasive Tissue-Sparing Posterior Superior (TSPS) Approach and the Standard Posterior Approach for Hip Replacement.

Purpose: The purpose of this study is to compare the functional and clinical outcomes, blood loss, complication rate, and hospital length of stay (LOS) of total hip replacement (THR) using a minimally invasive tissue-sparing posterior superior (TSPS) approach and the standard posterior approach. Materials and Methods: This retrospective, observational, double-centered study included 38 patients undergoing hip replacement. The patents were divided into two groups: control group (19 patients), who underwent surgery with the standard posterior approach, and treatment group (19 patients), who received the same type of implant with ceramic-on-ceramic bearing via the TSPS approach. Hemoglobin level was assessed preoperatively, on first and second postoperative days, and on discharge day. Harris hip score and Western Ontario and McMaster Universities Arthritis Index were used to measure the clinical and functional outcomes. Hospital LOS and incidence of early and late complications were assessed in both groups. Postoperative anteroposterior pelvis X-ray was performed to assess the correct positioning of implants. Results: Better early clinical outcomes (p = 0.0155), lesser blood loss (p < 0.0001), and reduced hospital LOS (p < 0.0001) were observed in the TSPS group than in the control group. No major adverse effects occurred in both groups, and a satisfactory implant orientation was achieved in all patients. Conclusions: The TSPS approach is a reliable minimally invasive procedure for THR as it allows an accurate orientation of the components and provides better early postoperative functional outcomes, faster recovery, significantly lower blood loss, and shorter hospital LOS than the standard posterior approach. However, further research is needed to confirm the promising results and cost-effectiveness of the TSPS approach in larger cohorts with a longer follow-up period.

In vivo kinematic comparison between an ultra-congruent and a posterior-stabilized total knee arthroplasty design by RSA.

PURPOSE: The aim of the present study was to compare the in vivo under weight-bearing kinematic behavior of a posterior-stabilized (PS) and an ultra-congruent (UC) total knee arthroplasty (TKA) model during a sit-to-stand motor task, a common activity of daily life. METHODS: A cohort of 16 randomly selected patients (8 PS Persona Zimmer, 8 UC Persona Zimmer) was evaluated through dynamic radiostereometric analysis (RSA) at a minimum of 9 months after TKA, during the execution of a sit-to-stand. The anteroposterior (AP) translation of the femoral component and the AP translation of the low point of medial and lateral femoral compartments were compared through Student's t test (p < 0.05). RESULTS: A significantly greater anterior translation of the femoral component was found for the PS group compared to the UC group. The flexion interval where statistical significance was found was between 30° and 0° (p = 0.017). Both groups showed a significantly greater anterior translation of the low point of the lateral compartment with respect to the medial one (PS: p = 0.012, UC: p = 0.018). This was consistent with a medial-pivot pattern. Furthermore, a significantly greater anterior translation of the medial compartment was found in the PS group compared to the UC group (p = 0.001). The same pattern was observed for the lateral compartment (p = 0.006). CONCLUSIONS: The TKA designs evaluated in the present study showed comparable in-vivo kinematics with regards to medial pivot pattern but differences in absolute AP translation. Specifically, the UC design showed greater AP stability than the PS design. This finding could be positive in terms of implant stability, but negative in terms of premature polyethylene wear and thus implant failure. This remains to be verified in studies with a larger sample size and longer follow-up. LEVEL OF EVIDENCE: IV.

Editorial Commentary: Chronic Anterior Cruciate Ligament Injury Requires Reconstruction Plus Lateral Tenodesis to Control Rotational Instability: Additional Technical Complexity May Result in Complications Without Improved Outcomes.

How to restore native knee kinematics following complex knee injuries is still debated and under investigation. To better reproduce the native anterior cruciate ligament (ACL), surgeons have a host of different options, including graft choice, technique, fixation method, and single-, double-, and triple-bundle techniques, etc. Isolated ACL reconstruction alone is not effective in controlling complex instability patterns, especially regarding internal and external rotations. Several techniques have been described to address such instabilities, like single- or double- bundle ACL reconstruction plus lateral extra-articular tenodesis. In truth, chronic ACL injury requires reconstruction plus lateral tenodesis to control rotational instability. Additional technical complexity may result in complications without improved outcomes. Neither single-bundle nor double-bundle techniques are "truly" anatomic. Keep it simple; keep it safe.

Increased Rotatory Laxity after Anterolateral Ligament Lesion in Anterior Cruciate Ligament- (ACL-) Deficient Knees: A Cadaveric Study with Noninvasive Inertial Sensors.

The anterolateral ligament (ALL) has been suggested as an important secondary knee restrain on the dynamic laxity in anterior cruciate ligament- (ACL-) deficient knees. Nevertheless, its kinematical contribution to the pivot-shift (PS) phenomenon has not been clearly and objectively defined, and noninvasive sensor technology could give a crucial contribution in this direction. The aim of the present study was to quantify in vitro the PS phenomenon in order to investigate the differences between an ACL-deficient knee and an ACL+ALL-deficient knee. Ten fresh-frozen paired human cadaveric knees (n = 20) were included in this controlled laboratory study. Intact, ACL-deficient, and ACL+ALL-deficient knees were subjected to a manual PS test quantified by a noninvasive triaxial accelerometer (KiRA, OrthoKey). Kinematic data (i.e., posterior acceleration of the tibial lateral compartment) were recorded and compared among the three statuses. Pairwise Student's t-test was used to compare the single groups (p < 0.05). Intact knees, ACL-deficient knees, and ACL+ALL-deficient knees showed an acceleration of 5.3 ± 2.1 m/s2, 6.3 ± 2.3 m/s2, and 7.8 ± 2.1 m/s2, respectively. Combined sectioning of ACL and ALL resulted in a statistically significant acceleration increase compared to both the intact state (p < 0.01) and the ACL-deficient state (p < 0.01). The acceleration increase determined by isolated ACL resection compared to the intact state was not statistically significant (p > 0.05). The ALL sectioning increased the rotatory laxity during the PS after ACL sectioning as measured through a user-friendly, noninvasive triaxial accelerometer.

The evaluation of Rolimeter, KLT, KiRA and KT-1000 arthrometer in healthy individuals shows acceptable intra-rater but poor inter-rater reliability in the measurement of anterior tibial knee translation.

PURPOSE: To assess measurement equivalence, inter- and intra-rater reliability, standard error of measurements (SEM) and false positive measurements (FPM) of four different knee arthrometers (KLT,Karl Storz; KiRA, I + ; KT-1000 MEDmetric Corp; Rolimeter, Aircast) in healthy patients. METHODS: Four different investigators (two advanced (AR) and two beginners (BR)) examined 12 participants with healthy knees at two time points with regards to anterior tibial translation (ATT) and side-to-side difference (SSD). Test equivalence was assessed using the TOST (two-one-sided t test) procedure with ± 1 mm equivalence boundaries. Intraclass correlation coefficients (ICCs) were calculated using two-way mixed effects models. Furthermore, false positive-(SSD > 3 mm) and SEMs were assessed. RESULTS: A total of 2304 Lachman Tests were performed. Between-rater SSDs were equivalent between AR and BR raters for the Rolimeter only. Inter-rater ICC values (SSD, ATT) were graded as "poor" to "moderate" for all devices. Equivalent test-retest results were observed for all raters using the Rolimeter, KLT and KT-1000, whereas measurement consistency with KiRA was given in the advanced examiners group only. Intra-rater ICC values (Range: SSD, ATT) were graded as "poor" to "moderate" for SSD values and "moderate" to "good" for ATT. SEMs were lowest for the Rolimeter and highest for KiRA. FPM were never obtained with the Rolimeter (0%), twice (2.1%) with the KT-1000, three times (3.1%) with the KLT and 33 times (34.4%) using KiRA. CONCLUSION: There is acceptable intra-rater but poor inter-rater reliability with all tested arthrometers. Measures of knee laxity are comparable between Rolimeter, KLT and KT-1000 but higher for KiRA. Clinically, the present study shows that repeated arthrometry measurements should always be performed by the same investigators.

In vivo femorotibial kinematics of medial-stabilized total knee arthroplasty correlates to post-operative clinical outcomes.

PURPOSE: To evaluate if there was a correlation between in vivo kinematics of a medial-stabilized (MS) total knee arthroplasty (TKA) and post-operative clinical scores. We hypothesized that (1) a MS-TKA would produce a medial pivot movement and that (2) this specific pattern would be correlated with higher clinical scores. METHODS: 18 patients were evaluated through clinical and functional scores evaluation (Knee Society Score clinical and functional, Womac, Oxford), and kinematically through dynamic radiostereometric analysis (RSA) at 9 months after MS-TKA, during the execution of a sit-to-stand and a lunge motor task. The anteroposterior (AP) Low Point translation of medial and lateral femoral compartments was compared through Student's t test (p < 0.05). A correlation analysis between scores and kinematics was performed through the Pearson's correlation coefficient r. RESULTS: A significantly greater (p < 0.0001) anterior translation of the lateral compartment with respect to the medial one was found in both sit-to-stand (medial 2.9 mm ± 0.7 mm, lateral 7.1 mm ± 0.6 mm) and lunge (medial 5.3 mm ± 0.9 mm, lateral 10.9 mm ± 0.7 mm) motor tasks, thus resulting in a medial pivot pattern in about 70% of patients. Significant positive correlation in sit-to-stand was found between the peak of AP translation in the lateral compartment and clinical scores (r = 0.59 for Knee Society Score clinical and r = 0.61 for Oxford). Moreover, we found that the higher peak of AP translation of the medial compartment correlated with lower clinical scores (r = - 0.55 for Knee Society Score clinical, r = - 0.61 for Womac and r = - 0.53 for Oxford) in the lunge. A negative correlation was found between Knee Society Score clinical and VV laxity during sit-to-stand (r = - 0.56) and peak of external rotation in the lunge motor task (r = - 0.66). CONCLUSIONS: The MS-TKA investigated produced in vivo a medial pivot movement in about 70% of patients in both examined motor tasks. There was a correlation between the presence of medial pivot and higher post-operative scores. LEVEL OF EVIDENCE: IV.

A mid-term follow-up retrospective evaluation of tarsometatarsal joint fracture-dislocations treated by closed reduction and percutaneous K-wires fixation.

INTRODUCTION: Injuries involving the tarsometatarsal (TMT) joint are relatively uncommon, and the surgical treatment is potentially characterized by a high complications rate. The purpose of this study is to evaluate the results of the treatment of Lisfranc fracture-dislocations treated with closed reduction and percutaneous fixation with K-wires, considering complications and re-intervantion rate. MATERIALS AND METHODS: A retrospective review was performed on all patients undergone closed reduction and percutaneous fixation with K-wires of a Lisfranc fracture-dislocation. Patients have been clinically evaluated at last follow up by American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Visual Analogue Scale (VAS), as well as by radiograph assessment. RESULTS: Following inclusion and exclusion criteria, 15 patients have been included, with a mean age of 48.2 ± 5.6 years. Average follow-up was 3.8 ± 1.8 years (range 1-6). 7 fractures analyzed were classified as type A, 7 as type B (3 were B1, 4 were B2) and 1 as type C1. No case of loss of reduction has been observed at radiographic 1-month follow-up. At last follow-up mean AOFAS midfoot score and VAS score were respectively 82.2 ± 10.4 and 1.5 ± 1.3. Registered complications showed one deep vein thrombosis and 2 cases of complex regional pain syndrome (CRPS). One patient subsequently underwent arthrodesis of the tarsometatarsal joint for post-traumatic arthritis. CONCLUSIONS: The treatment of the fracture-dislocations of the Lisfranc joint by percutaneous reduction and fixation with K-wire can achieve good clinical outcomes with a low rate of complications and reoperations. LEVEL OF EVIDENCE: Level IV.

Multi-radius posterior-stabilized mobile-bearing total knee arthroplasty partially produces in-vivo medial pivot during activity of daily living and high demanding motor task.

PURPOSE: The purpose of the present study was to assess the kinematical behavior of a multi-radius posterior-stabilized (PS) mobile-bearing (MB) total knee arthroplasty (TKA) during an activity of daily living (Sit-To-Stand-STS) and a high demanding motor task (Deep-Knee-Lunge-DKL) using model-based dynamic RSA. We hypothesized the achievement of medial pivoting movement in both motor tasks due to the congruent geometry of the inlay with the femoral component, which should allow good stability of the medial compartment, and to the high magnitude of rotations guaranteed by the MB on the tibial side. METHODS: Twenty-two randomly selected patients were recruited and prospectively evaluated. The PS MB cemented TKA was implanted with the standard technique (medial parapatellar approach, adjusted mechanical alignment). At minimum 9-month follow-up, patients were examined with model based Dynamic RSA developed in our Institute (BI-STAND DRX 2) during the execution of two motor tasks: STS and DKL. The motion parameters were evaluated using the Grood and Suntay decomposition and the low-point kinematics methods. RESULTS: In the extension phase of DKL femur performed a greater antero posterior translation of 3.8 mm compared to STS between 0° and 20° of knee flexion (p < 0.05). Low-point analysis showed a medial pivoting movement in both motor tasks: in 62% of patients during STS and 48% during DKL. Varus-valgus rotations were lower than 1° during all the range-of-motion in both motor tasks without differences. CONCLUSIONS: Medial pivot was partially produced by this multi-radius PS MB TKA with some differences during activity of daily living (STS) and high demanding motor task (DKL). LEVEL OF EVIDENCE: IV.

J-curve design total knee arthroplasty: the posterior stabilized shows wider medial pivot compared to the cruciate retaining during chair raising.

PURPOSE: Which total knee arthroplasty (TKA) design represents the better solution to restore a correct knee biomechanics is still debated. The aim of this study was to compare posterior stabilized (PS) and cruciate retaining (CR) version of the same TKA design (femoral component with an anatomic sagittal radius-J-curve design) by the use of dynamic Roentgen stereophotogrammetric analysis (RSA). The hypothesis was that the two models influence differently in vivo knee kinematic. METHODS: A cohort of 16 randomly selected patients was evaluated 9 months after surgery: Zimmer PERSONA® was implanted, eight with CR design and eight with PS design. The kinematic evaluations were performed using a Dynamic RSA (BI-STAND DRX 2) developed in our Institute, during the execution of the sit-to-stand motor task. The motion parameters were obtained using the Grood and Suntay decomposition and the low-point kinematics methods. RESULTS: PS TKA lateral femoral compartment had a wider anterior translation (17 ± 2 mm) than the medial one (11 ± 2 mm), while the two compartments of CR TKA showed a similar anterior translation (medial: 9 ± 2 mm/lateral: 11 ± 2 mm). T test for comparison between CR and PS TKA of antero-posterior translation showed a statistically significant difference (p < 0.05) in the flexion range between 15° and 40°. The CR prosthesis did not anteriorly translate during flexion. The PS design translated anteriorly showing a roll-forward mechanism during extension from 80° to 18° of flexion and a posterior translation from 18° to 0°. The same significant differences (p < 0.05) between the PS and CR groups were found comparing the low-point positions of the femoral condyles in the range of flexion between 25° and 40° for the medial compartment and between 15° and 25° for the lateral compartment. CONCLUSIONS: Dynamic RSA was able to investigate for the first time in vivo the kinematic behaviour of PS and CR version of the same TKA J-curve design. PS type showed a medial pivot during sit-to-stand motion task, while the CR type showed a cylindrical movement. Further studies are needed to evaluate the impact of different TKA designs on clinical results. LEVEL OF EVIDENCE: IV.

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.

ACL reconstruction with lateral plasty reduces translational and rotatory laxity compared to anatomical single bundle and non-anatomical double bundle surgery: An in vivo kinematic evaluation with navigation system.

BACKGROUND: Significantly better stability may be achieved with a Single Bundle Lateral Plasty (SBLP) reconstruction compared with the Single Bundle (SB) and Double Bundle (DB) procedures. METHODS: The study included 42 patients who underwent ACL reconstruction. Patients were randomly selected for one of the following surgical procedure defining three study groups: Single-Bundle-Lateral-Plasty, Single-Bundle and Double-Bundle procedures. Laxity evaluation was performed with an intraoperative navigation system. Lachman test (AP30), Drawer test (AP90), Varus-Valgus stress test at 0° and 30° knee flexion (VV0, VV30), Internal-External rotation (IE30, IE90), and pivot shift (PS) test are the clinical test executed for the laxity evaluation. Laxity reduction was defined as the difference between laxity before the fixation of the graft used for the reconstruction and the laxity just after its fixation. FINDINGS: For all the analyzed surgical techniques, the pre-reconstruction laxity values were statistically higher (P < 0.05) than the post-reconstruction values for all the analyzed tests. The analysis of the Drawer test and Internal-External rotation at 30° and 90° of knee flexion, highlighted a significant difference at time zero after surgery among the three study groups. The results showed that the SBLP technique had the highest reduction values compared to SB (PIE90 = 0.001) and DB (PAP90 = 0.012; PIE30 = 0.021; PIE90 = 0.003) techniques. INTERPRETATION: SBLP technique showed significantly superior results in terms of antero-posterior and internal-external laxity reduction at time-zero after ACL reconstruction.

Triaxial accelerometer can quantify the Lachman test similarly to standard arthrometers.

PURPOSE: To assess the relationship between the KiRA triaxial accelerometer and the KT-1000 measurements in the intact, anterior cruciate ligament (ACL) deficient, and ACL reconstructed knee joint for the quantification of the Lachman test. Moreover, the intra- and inter-examiner repeatability of the KiRA device will be determined. It was hypothesized that the side-to-side difference of the anterior tibial translation as measured by the KiRA device would be equivalent to the one measured by the KT-1000 during the Lachman test. METHODS: Sixty patients were divided into three groups and have been prospectively included in the present study. Group_A composed of 20 patients with a diagnosis of an isolated ACL tear. Group_B composed of 20 patients who underwent ACL reconstruction with a Single-Bundle Lateral Plasty (SBLP) technique with at least 20 years of follow-up. Group_C was the control group and included 20 patients with no history of ACL lesion. Lachman test has been performed at manual-maximum load on both sides, the involved and the contralateral and analyzed with the two different devices. RESULTS: The KiRA device in terms of side-to-side difference resulted not statistically different from the measurement of the KT-1000 arthrometer for the three study groups (n.s): Group_A: (4 ± 2 mm KiRA, 4 ± 2 mm KT1000), Group_B: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), Group_C: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), an excellent intra- (ICC = 0.88-0.89) and inter-examiner (ICC = 0.79) agreement was found for KiRA measurements. CONCLUSION: The KiRA (I+, Italy) device offers a valid method to quantify the Lacham test. LEVEL OF EVIDENCE: II.

Anterior cruciate ligament reconstruction with an all-epiphyseal "over-the-top" technique is safe and shows low rate of failure in skeletally immature athletes.

PURPOSE: The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique. METHODS: Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile]. RESULTS: Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed. CONCLUSION: This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life. LEVEL OF EVIDENCE: Case series, IV.

New design total knee arthroplasty shows medial pivoting movement under weight-bearing conditions.

PURPOSE: To assess, using model-based dynamic radiostereometric analysis (RSA), the biomechanical behaviour of a new design posterior-stabilized (PS) fixed-bearing (FB) total knee arthroplasty (TKA) in vivo while patients performing two common motor tasks. The hypothesis was that model-based dynamic RSA is able to detect different behaviour of the implant under weight-bearing and non-weight-bearing conditions. METHODS: A cohort of 15 non-consecutive patients was evaluated by dynamic RSA 9 months after TKA implantation. The mean age of patients was 73.4 (65-72) years. The kinematic evaluations were performed using an RSA device (BI-STAND DRX 2) developed in our Institute. The patients were asked to perform two active motor tasks: sit-to-stand in weight-bearing condition; range of motion (ROM) while sitting on the chair. The motion parameters were evaluated using the Grood and Suntay decomposition and the low-point kinematics methods. RESULTS: The dynamic RSA evaluation showed a significant difference (p < 0.05) between the biomechanical behaviour of the prosthesis during the two motor tasks. When subjected to the patient weight (in the sit-to-stand) the low point of the medial compartment had a shorter motion (5.7 ± 0.2 mm) than the lateral (11.0 ± 0.2 mm). This realizes a medial pivot motion as in the normal knee. In the ROM task, where the patient had no weight on the prosthesis, this difference was not present: the medial compartment had a displacement of 12.7 ± 0.2 mm, while the lateral had 17.3 ± 0.2 mm. CONCLUSIONS: Model-based RSA proved to be an effective tool for the evaluation of TKA biomechanics. In particular, it was able to determine that the fixed-bearing posterior-stabilized TKA design evaluated in this study showed a medial pivoting movement under weight-bearing conditions that was not present when load was not applied. Under loading conditions what drives the pattern of movement is the prosthetic design itself. By the systematic use of this study protocol future comparisons among different implants could be performed, thus contributing significantly to the improvement of TKA design. LEVEL OF EVIDENCE: IV.

Diagnosis and Treatment of Infected Shoulder Arthroplasty: Current Concepts Review.

Periprosthetic shoulder infection (PSI) is an emerging pathology which requires many improvements in diagnosis and treatment to obtain a satisfying success rate. Different approaches have been described. This article summarizes current concepts of diagnostic process and main treatments described in the literature.

Does Donor Age of Nonirradiated Achilles Tendon Allograft Influence Mid-Term Results of Revision ACL Reconstruction?

Purpose The purpose of the present study was to investigate if the donor age of nonirradiated Achilles tendon allograft could influence the clinical results of revision anterior cruciate ligament (ACL) reconstruction. Methods All patients that underwent ACL revision between 2004 and 2008 with at least 4 years of follow-up were included. For all the patients that met the inclusion criteria, the age of the graft donor was obtained from the tissue bank. Lysholm score was administered to patients that met inclusion criteria. In addition, patients were divided in two groups based on the donor age (<45 years vs. ≥45 years), and the baseline characteristics and outcomes were compared. Results Fifty-two patients were evaluated at a mean 4.8 ± 0.8 years follow-up with Lysholm score. The Lysholm significantly improved from 62.3 ± 6.6 at preoperative status to 84.4 ± 12.3 at final follow-up. The mean donor age was 48.7 ± 8.4 years; a significant difference in Lysholm score was noted between patients that received an allograft with a donor age <45 years (14 patients; 27%) and those receiving an allograft with a donor age ≥45 years (38; 73%) (89.5 ± 3.2 vs. 80.1 ± 11.1, respectively; p = 0.0469). The multiple regression model showed the donor age, the final follow-up, and the preoperative Lysholm score as significant predictors of postoperative Lysholm score ( p < 0.0002). Conclusion Donor age of nonirradiated Achilles tendon allograft influenced the mid-term results of revision ACL reconstruction, thus advising the use of grafts from young donors. Level of Evidence Level III, retrospective comparative study.

Editorial Commentary: The Medial Patellar Ligaments: A Step Closer to the Knee Surgeon's "Rubik's Cube" Solution.

Recent cadaveric research analyzing the medial patellar ligaments and their contribution to patellar stability points out not only the need for reconstruction of the medial patellofemoral ligament, but also the medial tibiofemoral ligament to restore normal patellar stability and biomechanics.

Over-the-top ACL Reconstruction Plus Extra-articular Lateral Tenodesis With Hamstring Tendon Grafts: Prospective Evaluation With 20-Year Minimum Follow-up.

BACKGROUND: There are few published studies with very long-term follow-up of combined intra- and extra-articular anterior cruciate ligament (ACL) reconstruction. PURPOSE: To analyze clinical and radiographic outcomes of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with autologous hamstrings at minimum 20-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 60 originally eligible patients who underwent over-the-top ACL reconstruction with double-stranded hamstring tendon (leaving intact graft tibial insertions) and extra-articular lateral plasty (performed with the remnant part of tendons), 52 were prospectively evaluated at a minimum 20-year follow-up (mean follow-up, 24 years; 41 men, 11 women; mean age at time of surgery, 25.5 ± 7.6 years). Twenty-nine patients were available for prospective evaluations: clinical (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC]), instrumented (KT-2000), and radiographic (standard, long-standing, and Merchant views). Subjective KOOS (Knee injury and Osteoarthritis Outcome Score) and objective inertial sensor pivot-shift analysis (KiRA) were carried out at final follow-up. Twenty-three patients were investigated by phone interview for subjective Tegner score and documented complications, rerupture, or revision surgery. RESULTS: At final follow-up, mean Lysholm score was 85.7 ± 14.6; median Tegner score, 4 (range, 3-5); sport activity resumption, 86.2%; and objective IKDC score, good or excellent in 86% of patients (31%, A; 55%, B). Only 3 of 26 patients (12%) had >5-mm manual maximum KT-2000 side-to-side difference. KiRA system documented positive pivot-shift (>0.9-m/s2 tibial acceleration side-to-side difference) in these 3 of 26 patients (12%). Statistically significant changes were as follows: decrease in Tegner score from 7 (range, 6-8) at 5-year follow-up to 4 (range, 3-5) at 10 years ( P < .0001) and decrease in Lysholm score from 96.1 ± 7.3 at 10-year follow-up to 85.7 ± 14.6 at 20 years ( P = .0003). Radiographic evaluation demonstrated significant difference of medial joint space between injured and healthy knees in patients with concomitant medial meniscectomy (n = 8, 3.2 ± 0.6 vs 5.0 ± 1.8 mm, P = .0114). No significant differences were reported regarding lateral or patellofemoral joint space. One patient (2%) experienced rerupture, with 3 of 52 (5.8%) having a contralateral ACL injury (excluded from KT-2000 and radiographic evaluations). Overall, 4 of 29 clinical failures (objective IKDC, KT-2000) and 1 rerupture among 52 patients were registered at final follow-up. CONCLUSION: Studied surgical technique demonstrated good results in laxity control at 20-year minimum follow-up. The lateral extra-articular plasty associated with ACL reconstruction did not generate lateral knee or patellofemoral osteoarthritis. The factor increasing osteoarthritis was meniscectomy.