The pie-crust surgical technique for medial collateral ligament release: enhancing visualization of the medial compartment in knee arthroscopy.

This study presents a comprehensive surgical technique for performing a 'pie-crust' release of the medial collateral ligament (MCL) to enhance visualization of the medial compartment during arthroscopic knee procedures. The primary objective of this research is to improve the precision of diagnosis and treatment for injuries specifically affecting the posterior horn and posterior root of the medial meniscus. Arthroscopic knee procedures have become increasingly common in orthopedic surgery, offering the advantage of minimally invasive techniques for treating a wide range of knee conditions. However, accessing and visualizing the posterior structures within the medial compartment can be challenging. To overcome this limitation, the surgical technique presented in this study offers a systematic approach that includes patient positioning, precise identification of anatomical landmarks, and a detailed, step-by-step procedural description. The process begins with meticulous marking of anatomical landmarks to provide reference points. Precisely identifying the location for the MCL release is of utmost importance. This involves making needle punctures with guidance from arthroscopic visualization and applying valgus strain to the knee as necessary. One of the key advantages of this described surgical technique is its focus on safety and efficacy. Surgeons can work more confidently and precisely by reducing the risk of iatrogenic cartilage damage and facilitating access to the posterior structures within the medial compartment. Clinical outcomes from this approach have demonstrated consistently favorable results, leading to improved patient recovery and reduced complications. Furthermore, it is noteworthy that the postoperative use of a brace is not mandatory, adding to the appeal of this technique for both patients and surgeons. This surgical technique's enhanced visualization and optimized treatment outcomes make it a valuable tool in the arsenal of orthopedic surgeons specializing in knee arthroscopy. In conclusion, this study's surgical technique has the potential to significantly improve the diagnosis and treatment of patients with meniscal injuries in the medial compartment, ultimately leading to better clinical outcomes and patient satisfaction.

Bi-cruciate retaining total knee arthroplasty is here to stay: A consecutive series transitioning from manual instrumentation to enabling technologies.

BACKGROUND: Bicruciate-retaining (BCR) total knee arthroplasty (TKA) has seen renewed interest due to the potential for more natural knee kinematics with anterior cruciate ligament (ACL) retention. OBJECTIVE: The present study attempts to determine differences in the 2-year survivorship and patient-reported outcomes between two surgical strategies (traditional instrumentation versus robotics) applied to the extensive use of a modern, 2nd generation BCR TKA design. METHODS: We performed a retrospective study with prospectively collected data of 113 patients who underwent primary TKA between 2018 and 2020 using a 2nd generation BCR TKA implant. Patient demographics, PROMS, and intra/post-operative complications were collected. Patients were also evaluated according to the use or not of robotics. A Kaplan-Meier analysis was used to evaluate revision-free survival at follow up. RESULTS: 102 patients were enrolled: 90 received traditional surgery and 12 robotic-assisted surgery. The mean age was 68 years (SD 7.76) with an average BMI of 29.6 kg/m2 (SD 3.56). The mean follow up (FU) was 32.4 ± 6.2 months (range 24-45 months). Survivorship at 2 years was 98% (95% CI: 92.4-99.5). Revisions/reoperations were performed for anterior cruciate ligament (ACL) tear (1/4), pain (1/4), arthrofibrosis (1/4) and acute periprosthetic joint infection (PJI) (1/4). At final FU, 92 patients (90.2%) considered themselves satisfied, showing a mean OKS of 40.6 (SD 5.1) and a mean FKS of 76.7 (SD 11.8). No differences in the outcome were found between traditional and robotic-assisted procedures. CONCLUSION: The modern BCR design evaluated in this study achieved excellent results in terms of implant survivorship, low rate of reoperation and clinical results, independently from the use of enabling technologies.

No significant clinical differences between native or reduced posterior tibial slope in kinematically aligned total knee replacement with posterior cruciate-retaining.

Aims & objectives: Total knee arthroplasty (TKA) is a common surgical procedure for end-stage knee osteoarthritis. However, conventional alignment techniques may lead to postoperative dissatisfaction in up to 20% of cases. Kinematic alignment (KA) has emerged as a new philosophy to restore the native joint line and achieve more natural kinematics. Preserving the posterior tibial slope (PTS) and posterior cruciate ligament (PCL) is crucial to maintaining the pre-arthritic joint line and improving knee kinematics. This study aimed to assess the prevalence of postoperative PTS changes and their impact on functional outcomes and range of motion. Materials & methods: A retrospective single-center study was conducted on patients who underwent KA-TKA with PCL preservation. The preoperative and postoperative PTS were measured on lateral knee radiographs using the tibial proximal anatomic axis method. Patient-reported outcome measures (PROMs) were collected pre- and postoperatively up to a two-year follow-up. Results: Of the 95 included patients, 62.1% achieved an anatomically similar PTS (within 3° from the preoperative value), while 37.9% experienced noticeable PTS changes. However, no significant associations existed between PTS changes and compromised PROMs (WOMAC, 22.2 and 23.1; FJS, 66.6 and 67.3), ROM (118.5° and 119.4°), or patient satisfaction. No postoperative complications requiring reoperation or component revisions were observed. Conclusion: Preserving or modifying the native PTS during KA-TKA could be confidently undertaken without compromising functional outcomes or patient satisfaction.

Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established surgical procedure, but it may not always restore complete rotational knee stability. Interest is increasing in anterolateral complex (ALC) procedures, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in association with ACLR to overcome this problem. The better ALC procedure, LET or ALLR, remains controversial to date. PURPOSE: To analyze the patient-reported outcome measures and ACL reinjury rate after ACLR with an ALC procedure compared with after isolated ACLR, as well as to analyze the clinical results and graft failure rate of the LET group versus the ALLR group. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 2. METHODS: A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart was used to conduct a comprehensive search of 5 databases: Scopus, MEDLINE, Embase, PubMed, and the Cochrane Database of Systematic Reviews. Only randomized controlled trials were included. Eligible articles were classified according to the levels of evidence of the Oxford Centre for Evidence-Based Medicine. A methodological quality assessment of randomized controlled trials was performed using the Risk of Bias 2 tool. The present systematic review and meta-analysis was registered on PROSPERO. RESULTS: A total of 14 clinical trials were included in the final analysis, with 1830 patients. Isolated ACLR or a combined procedure with LET or ALLR was performed, with several characteristics described, including the surgical technique, additional torn knee structures and their management, graft failure, complications, clinical outcomes, clinical and instrumental examinations to assess knee stability, and postoperative protocols. Regarding clinical outcomes, pivot-shift tests and reduced graft failure, a significant difference was found in the superiority of the combined ACLR associated with the ALC procedure compared with an isolated ACLR (P < .05). No statistically significant difference was found between the 2 ALC procedures. CONCLUSION: This systematic review and meta-analysis reported on the importance of combined ACLR and ALC procedures in patients with a high-grade rotational laxity, as both procedures, LET or ALLR, without superiority of one over the other, are associated with improved pivot-shift tests, patient-reported outcome measures, and reduced graft failure rates.

Irreducible knee dislocation: improved clinical outcomes of open and arthroscopic surgical treatment. A systematic review of the literature.

PURPOSE: Irreducible knee dislocations (IKDs) are a rare rotatory category of knee dislocations (KDs) characterized by medial soft tissue entrapment that requires early surgical treatment. This systematic review underlines the need for prompt surgical reduction of IKDs, either open or arthroscopically. It describes the various surgical options for ligament management following knee reduction, and it investigates their respective functional outcome scores to assist orthopedic surgeons in adequately managing this rare but harmful KD. METHODS: A comprehensive search in four databases, PubMed, Scopus, Embase, and MEDLINE, was performed, and following the PRISMA guidelines, a systematic review was conducted. Strict inclusion and exclusion criteria were applied. Studies with LoE 5 were excluded, and the risk of bias was analyzed according to the ROBINS-I tool system. This systematic review was registered on PROSPERO. Descriptive statistical analysis was performed for all data extracted. RESULTS: Four studies were included in the qualitative analysis for a total of 49 patients enrolled. The dimple sign was present in most cases. The surgical reduction, either open or arthroscopically performed, appeared to be the only way to disengage the entrapped medial structures. After the reduction, torn ligaments were addressed in a single acute or a double-staged procedure with improved functional outcome scores and ROM. CONCLUSIONS: This systematic review underlines the importance of promptly reducing IKDs through a surgical procedure, either open or arthroscopically. Moreover, torn ligaments should be handled with either a single acute or a double-staged procedure, leading to improved outcomes. LEVEL OF EVIDENCE: IV.

C-Arm Guidance During Thin Flap Arthroscopic Trochleoplasty for Chronic Patellar Instability.

The purpose of this paper is to provide a complete Technical Note for our treatment of choice for recurrent patellar dislocation in cases of trochlear dysplasia, especially in patients with types B and D trochlear dysplasia according to the Dejour classification. Different surgical procedures have been reported for the treatment of recurrent patellar instability. One of the most important anatomic factors to address when treating a recurrent patella dislocation is trochlear dysplasia. Few types of open trochleoplasty have been classically described to treat a dysplastic trochlea. However, in recent years, arthroscopic techniques have been reported to reduce invasiveness and complications as well as to improve accuracy and clinical outcomes. In this technique is described an arthroscopic thin-flap tracheoplasty with the use of C-arm guidance in order to precisely control the bone resection and to verify intraoperatively the disappearance of the radiologic landmarks used for diagnosis and classification of the dysplasia. The advantage of this technique is the precision in removal of the supratrochlear spur and bump, the accurate and delicate reshaping of the sulcus with preservation of cartilage vitality, combined with increased reproducibility and safety.

All-Inside Anterior Cruciate Ligament Reconstruction Technique: Tips and Tricks.

The all-inside anterior cruciate ligament reconstruction (ACLR) technique was developed to improve patient outcomes by reducing the procedure's invasiveness, minimizing complications and pain, and enabling faster postoperative recovery. This study presents a detailed description of the all-inside ACLR technique, which involves the use of quadrupled semitendinosus (ST) graft and suspension devices at both tibial and femoral sites, as well as valuable tips for avoiding complications that may arise during the procedure. The surgical procedure employs retrograde drills to create bony sockets for graft passage, which are then fixed with suspension devices at both the tibial and femoral sites. This technique has no specific restrictions and may be applied to all patients with anterior cruciate ligament (ACL) injuries. The literature reports the advantages, good clinical outcomes, and medium- to long-term graft survival achieved with the all-inside ACLR technique. However, the complications and disadvantages associated with the technique must be considered.

A novel geometrical planning method to restore knee joint obliquity in double-level osteotomies.

PURPOSE: Precise preoperative planning is mandatory when a double-level osteotomy (DLO) is required to correct a severe knee deformity. Literature does not report a validated planning method regarding DLO that could be performed directly on digital radiographs using simple measurement tools. This study aims to validate a novel DLO planning method called New Mikulicz-Joint Line (NM-JL) based on essential measurement tools, in which the correction angles are induced by the predicted post-operative joint line obliquity (JLO). METHODS: Twenty-three patients who satisfied the inclusion criteria were enrolled. NM-JL planning method was performed using basic measurement tools to detect corrective angles and gaps. The correction was then simulated using a Virtual Segmentation Software method to obtain the osteotomy fragments. Both planning procedures were performed independently and later repeated by two orthopaedic surgeons to assess the inter and intra-observer reliability. RESULTS: The intraclass correlation coefficient (ICC) regarding corrective angles and gaps showed a significant positive correlation between the values determined using the two procedures by both raters (p < 0.05). Pearson's correlation analysis revealed a significant correlation between the measured results of the two planning methods. (p < 0.05). Finally, the Bland-Altman analysis showed an excellent agreement (p < 0.05) for all measurements performed. CONCLUSIONS: The NM-JL method showed high values of intra and inter-rater reliability. The procedure is built up starting from the predicted value of post-operative joint line obliquity, allowing to maintain this parameter fixed. Other advantages include the quickness, adaptability, and possibility to be performed on any Digital Imaging and Communication in Medicine (DICOM) viewer. LEVEL OF EVIDENCE: Level IV.

Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature.

BACKGROUND: Periprosthetic joint infection (PJI) of the knee represents a severe complication after 1.5% to 2% of primary total knee replacement. Although two-stage revision was considered the gold-standard treatment for PJI of the knee, in the last decades, more studies reported the outcomes of one-stage revisions. This systematic review aims to assess reinfection rate, infection-free survival after reoperation for recurrent infection, and the microorganisms involved in both primary and recurrent infection. MATERIAL AND METHODS: A systematic review of all studies reporting the outcome of one-stage revision for PJI of the knee up to September 2022, according to PRISMA criteria and AMSTAR2 guidelines, was performed. Patient demographics, clinical, surgical, and postoperative data were recorded. PROSPERO ID: CRD42022362767. RESULTS: Eighteen studies with a total of 881 one-stage revisions for PJI of the knee were analyzed. A reinfection rate of 12.2% after an average follow-up of 57.6 months was reported. The most frequent causative microorganism were gram-positive bacteria (71.1%), gram-negative bacteria (7.1%), and polymicrobial infections (8%). The average postoperative knee society score was 81.5, and the average postoperative knee function score was 74.2. The infection-free survival after treatment for recurrent infection was 92.1%. The causative microorganisms at reinfections differed significantly from the primary infection (gram-positive 44.4%, gram-negative 11.1%). CONCLUSION: Patients who underwent a one-stage revision for PJI of the knee showed a reinfection rate lower or comparable to other surgical treatments as two-stage or DAIR (debridement, antibiotics, and implant retention). Reoperation for reinfection demonstrates a lower success compared to one-stage revision. Moreover, microbiology differs between primary infection and recurrent infection. Level of evidence Level IV.

Periprosthetic patella fractures in total knee replacement and revision surgeries: how to diagnose and treat this rare but potentially devastating complication-a review of the current literature.

PURPOSE: Periprosthetic patella fractures (PPPFs) are infrequent but potentially devastating complications after total knee arthroplasty (TKA) and revision TKA (rTKA). These fractures may occur both in resurfaced and un-resurfaced patella. This review summarizes the current literature on PPPFs to help orthopedic surgeons diagnose and treat this uncommon but extremely challenging TKA complication. METHODS: A comprehensive search was performed in three databases: PubMed, SCOPUS, and EMBASE. All relevant information was retrieved and summarized in this narrative review. RESULTS: In the studies analyzed, there is a general trend in favor of nonsurgical treatment, except for implant loosening or extensor lag with extensor apparatus disruption, because surgery is often associated with poor clinical outcomes and high complication rates. CONCLUSION: PPPF is a rare but catastrophic event in TKA and rTKA, occurring mainly in a reconstructed patella. Patient-, implant-, and surgical technique-related factors contribute to its multifactorial etiopathogenesis. Prevention plays a crucial role in reducing the PPPFs rate. Conservative management is the treatment of choice due to high surgery complication rates unless implant loosening, or extensor apparatus disruption occurs.

Comparison between gaits after a medial pivot and posterior stabilized primary total knee arthroplasty: a systematic review of the literature.

BACKGROUND: Total knee arthroplasty (TKA) is one of the most performed orthopedic procedures worldwide. While excellent efficacy has been reported, about 20% of patients are not satisfied with the result. A potential cause is the problematic reproduction of knee kinematics. This systematic review examines gait analysis studies in primary medial pivot (MP) and posterior stabilized (PS) TKAs to investigate the differences between the two prosthesis designs. METHODS: A systematic review was conducted by following PRISMA guidelines. Five databases (PubMed, Medline, Embase, Scopus and the Cochrane Database of Systematic Reviews) were analyzed, and eligible articles were evaluated in terms of the levels of evidence. The methodological quality of the articles was assessed by using the MINORS scoring. This review was registered in PROSPERO. RESULTS: Nine studies were included. Gait analysis was performed in 197 MP TKA and 192 PS TKA patients. PS TKA cases showed (P < 0.05) a significantly higher peak of knee flexion angle during the swing phase, greater knee flexion angle at toe-off, an increased knee adduction angle, higher knee flexion and extension moment, increased anterior femoral roll during knee flexion and anterior translation on medial and lateral condyle during knee flexion compared to MP TKA. MP TKA showed statistically significant (P < 0.05) higher knee rotational moment and greater tibiofemoral external rotation motion during knee flexion than PS TKA. No statistically significant difference (P > 0.05) was reported regarding gait spatial-temporal parameters. The Forgotten Joint Score (FJS) and Western Ontario and McMaster Universities Comparison in terms of Arthritis Index (WOMAC) score (mean stiffness) showed that MP TKA yielded significantly better results than PS TKA. CONCLUSIONS: This systematic review revealed significant kinematic and kinetic differences between MP and PS TKA at all gait analysis phases. Furthermore, the considerable difference between TKA design and the kinematics of healthy knee were highlighted in this study. LEVEL OF EVIDENCE: III.

Primary total knee arthroplasty in tibial plateau fractures: Literature review and our institutional experience.

BACKGROUND: Displaced proximal tibia fractures in the elderly may be very difficult to manage. If osteosynthesis represents the standard of care in the younger patients, in the aged population this solution is controversial because a significant failure rate has been reported after internal fixation. Moreover, osteoarthritis progression following tibial plateau fractures is common, often requiring a subsequent total knee arthroplasty (TKA). In recent years, in order to overcome the fracture healing problems and to allow immediate full weight bearing, primary TKA after tibial plateau fractures in elderly patients has gained popularity. MATERIAL AND METHODS: from 2015 to 2019, 11 tibial plateau fractures in elderly patients with pre-existing osteoarthritis were treated with a primary TKA. Age, gender, mechanism of trauma, pre-operative autonomy level, fractures classification, degree of osteoarthritis and intraoperative data (ligamentous stability and type of implant) were collected. After a mean follow-up of 28 months, Knee Society Score (KSS), post-operative autonomy level and Forgotten Joint Score (FJS) were evaluated. The radiological assessment (signs of loosening, limb axis and patellar height indices) and complications were also recorded. RESULTS: according to fracture type and ligamentous competence, 6 cases of posterior-stabilized (PS) design and 5 cases of semi-constrained TKA were implanted. At the final follow up, mean KSS knee score was 83±16 and mean KSS functional score was 74±15. Mean pre-operative autonomy level assessed with the Parker scale, was significantly higher than the post-operative one (7.5±1.4 vs 5.6 ± 1.3). Mean FJS was 66 ± 14. No lines of radiolucency or limb malalignment were found at the final radiological follow-up. One major complication was recorded: one acute periprosthetic infection. One patient reported a periprosthetic femoral fracture after 26 months. CONCLUSION: Based on our and results and those reported on literature, primary TKA is a suitable option in case of tibial plateau fractures in elderly patients with pre-existing osteoarthritis and poor bone quality, in which osteosynthesis outcome may be poor. Unlike ORIF, primary TKA may allow immediate weightbearing and a faster recovery. Nevertheless, it is a demanding surgery with a significant complications rate and should be reserved for selected patients and experienced surgeons.

Could anterior closed-wedge high tibial osteotomy be a viable option in patients with high posterior tibial slope who undergo anterior cruciate ligament reconstruction? A systematic review and meta-analysis.

PURPOSE: This study aims to examine the clinical and radiological outcomes of patients who underwent ACL reconstruction (ACLR) combined with anterior closed-wedge high tibial osteotomy (ACW-HTO) for posterior tibial slope (PTS) reduction to investigate the efficacy of this procedure in improving anterior knee stability and preventing graft failure in primary and revision ACLR. METHODS: A literature search was conducted in six databases (PubMed, Embase, Medline, Web of Science, Cochrane, and Scopus). The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The initial screening identified 1246 studies. Each eligible clinical article was screened according to the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence (LoE), excluding clinical studies of LoE V. Quality assessment of the articles was performed using the ROBINS-I methodological evaluation. This systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that were possible to perform a meta-analysis, a p < 0.05 was considered statistically significant. RESULTS: Five clinical studies were included in the final analysis. A total of 110 patients were examined. Pre- and post-operative clinical and objective tests that assess anteroposterior knee stability, PTS, clinical scores, and data on surgical characteristics, complications, return to sports activity, and graft failure after ACLR were investigated. A meta-analysis was conducted using R software, version 4.1.3 (2022, R Core Team), for Lysholm score and PTS outcomes. A statistically significant improvement for both these clinical and radiological outcomes (p < 0.05) after the ACW-HTO surgical procedure was found. CONCLUSION: ACLR combined with ACW-HTO restores knee stability and function with satisfactory clinical and radiological outcomes in patients with an anterior cruciate ligament injury associated with a high PTS and seems to have a protective effect from further ruptures on the reconstructed ACL. LEVEL OF EVIDENCE: Level IV.

Is augmentation the best solution in partial anterior cruciate ligament tears? A literature systematic review and meta-analysis.

Purpose: The appropriate management of partial anterior cruciate ligament (ACL) tears is still debated. There is a tendency in orthopedic clinical practice to prefer complete ACL reconstruction, while few surgeons perform ACL augmentation. The purpose of the present study is to evaluate the current evidence on the effectiveness of ACL augmentation compared with standard ACL reconstruction to assess whether ACL augmentation may be the treatment of choice in partial ACL injury. Methods: According to PRISMA guidelines, literature research was performed in PubMed/Medline, Cochrane Library, Embase, Scopus, and Web of Science databases. A PICOS model was used, and a preliminary search resulted in 1101 articles. The methodological quality was assessed through ROBINS-I. A meta-analysis was conducted on postoperative Tegner, Lysholm scores and KT-1000 values between ACL augmentation and ACL reconstruction, and a p < 0.05 has been assumed as statistically significant. PROSPERO, ID: CRD42022343502. Results: Seven papers were included. A total of 472 knees underwent ACL reconstruction, and 311 underwent ACL augmentation. A statistically significant discrepancy was found in the postoperative Tegner score in favor of ACL augmentation compared with ACL reconstruction (p < 0.05). Regarding the postoperative Lysholm score and KT-1000 measurement, no statistically significant difference was shown between ACL reconstruction and ACL augmentation (p > 0.05). Conclusions: ACL augmentation has proved to be an effective and safe procedure and should be preferred to ACL reconstruction in partial ACL tears for the tendency to achieve better functional outcomes.

Outcomes of modular stem for the treatment of periprosthetic femoral fracture: a systematic review of the literature.

Background: Periprosthetic femoral fractures (PFFs) are a frequent complication after total hip arthroplasty (THA). Both modular and non-modular tapered fluted titanium (TFT) stems could be used in total hip revisions (THRs). Nevertheless, the most appropriate femoral stem type is still under debate. The current systematic review aims to analyze the survival rate and all causes of stem revision, the overall complication rate and reason for reoperation, and patient reported outcome measures (PROMs) in THR for PFF using the modular tapered titanium stems (MTTS). Methods: A comprehensive search in four databases, PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews databases, was performed, and following the PRISMA guidelines, a systematic review was conducted. Strict inclusion and exclusion criteria were applied, starting from 1,259 studies. The risk of bias was analyzed according to the MINORS tool system. Descriptive statistical analysis was performed for all data extracted. Results: Eighteen clinical studies were included in the qualitative analysis for a total of 775 patients enrolled. A mean MINORS criteria score of 9.8 [8-12] was reported. The overall survival of MTTS for PFF treatment was 95.4%, with an overall reintervention rate of 10.3% at an average follow-up of 4.5 years. Despite the use of modular components, postoperative hip instability remains the most frequent complication and cause of reintervention in these patients. In addition, a mean postoperative Harris Hip Score (HHS) of 78.1 was reported, which was considered acceptable given the high mean age of 74.1 years at the time of the revision. Conclusions: Several therapeutic approaches and a wide variety of implants have been described in the literature for PFF management; however, no one solution has proven superior to others in the PFF treatment. MTTS has become a commonly used treatment option for Vancouver B2 and B3 fractures because they provide good clinical and radiological results with a reasonable survival rate. However, the complication rate of MTTS is still high.

Should megaprosthesis implants be a viable option in elderly patients after distal femur and periprosthetic distal femur fractures?-a retrospective cohort study.

Background: Distal femur fractures (DFF) and periprosthetic distal femur fractures (PDFF) in elderly patients are challenging to manage, often requiring the use of distal femur replacement (DFR) implants to manage severe bone loss and comminution. The study's main purpose was to analyze outcomes and complications of DFR implant after DFF or PDFF at our institution to understand the feasibility and reliability of this treatment considering a review of the current literature. Methods: Fourteen consecutive patients undergoing total knee replacement with megaprosthesis implant from January 1st, 2017 to January 1st, 2021, at our institution were retrospectively analyzed. Inclusion criteria were age ≥65 years and DFF or PDFF after primary total knee arthroplasties (TKA) implantation. Patient-reported outcome measures (PROMs) such as Knee Society Score (KSS) and Oxford Knee Score (OKS) were analyzed, as well as radiographic pre- and post-operative imaging. Complications were recorded from the early postoperative period to the last follow-up. Results: Nine patients were diagnosed with PDFF and five with DFF. At a mean follow-up of 30.7 months (range, 12 to 69 months), the mean KSS knee score was 79.5±11.2; the mean KSS function score was 69.0±17.9. The mean OKS was 31.6±8.9. The mean age at intervention was 82.1±7.6 years. Two delayed wound closures and one chronic prosthetic joint infection (PJI) were observed. No death was observed at the last follow-up. Conclusions: Megaprosthesis implants could be a suitable option in elderly, arthritic patients diagnosed with complicated DFFs and PDFFs, allowing joint function preservation and a rapid return to daily activities. DFR remains an intervention burdened by devastating complications that must be considered in the treatment choice.

No Significant Differences in Clinical and Radiographic Outcomes between PCL Retained or Sacrificed Kinematic Aligned Medial Pivot Total Knee Arthroplasty in Varus Knee.

In the last decades, several surgical techniques, such as medial pivot (MP) philosophy and kinematic alignment (KA), have been introduced in total knee arthroplasty (TKA) to improve patients' outcomes. This retrospective study aims to evaluate the clinical, radiographic, and functional results of PCL preservation or sacrifice in KA MP-TKA. A consecutive series of 147 patients older than 60, with a minimum follow-up of two years, were treated with TKA for severe primary knee osteoarthritis (OA) at the Department of Orthopedics and Traumatology between 1 January 2019, and 1 July 2020. After excluding those not meeting the inclusion criteria, 64 patients were included in the study analysis. Regarding radiographic outcomes, no statistically significant difference was observed between patients with preserved or sacrificed PCL (p > 0.05). A slight improvement in Knee Society Score (KSS), knee and function score, and FJS was observed for the PCL-preserved group, although this superiority tendency was not statistically significant (p > 0.05). PCL-preserved MA MP-TKA reported a statistically significant result in only two questions on the FJS questionnaire (p < 0.05). A slight, non-statistically significant improvement in active ROM was found in the PCL-sacrificed group (p > 0.05). No interventions or revisions were reported in this case series for all treated patients at the final follow-up. No significant differences were described in clinical, radiographic, and functional outcomes in preserved or sacrificed PCL KA MP-TKA. Although not significant, a slight trend toward better clinical outcomes was reported in PCL-preserved KA MP-TKA.

Anterolateral complex of the knee: State of the art.

Rotatory instability of the knee represents the main reason for failure and poor clinical outcomes regarding anterior cruciate ligament (ACL) reconstruction techniques. It is now clear that the anterolateral complex (ALC) of the knee possesses a fundamental role, in association with the ACL, in controlling internal rotation. Over the past decade, ever since the anterolateral ligament has been identified and described as a distinct structure, there has been a renewed interest in the scientific community about the whole ALC: Lateral extra-articular tenodesis have made a comeback in association with ACL reconstructions to improve functional outcomes, reducing the risks of graft failure and associated injuries. Modern ACL reconstruction surgery must therefore investigate residual instability and proceed, when necessary, to extra-articular techniques, whether functional tenodesis or anatomical reconstruction.This review aims to investigate the latest anatomical and histological descriptions, and the role in rotational control and knee biomechanics of the ALC and its components. The diagnostic tools for its identification, different reconstruction techniques, and possible surgical indications are described.. In addition, clinical and functional results available in the literature are reported.

Restricted kinematic alignment in primary total knee arthroplasty: A systematic review of radiographic and clinical data.

Introduction: Kinematic alignment (KA) has increased in popularity in recent years, becoming a viable alternative to MA with encouraging short- and mid-term follow-up results. Recently, the concept of restricted kinematic alignment (rKA) has been developed to restore native knee kinematics better, avoiding failure of coronal alignment. This systematic review aims to examine whether rKA improves outcome scores (PROMs) compared with MA and to evaluate the radiographic analysis of the lower limb alignment and the causes of complications and reoperations with the rKA approach. Methods: A systematic literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on the Pubmed/Medline, Scopus, Cochrane Library, and Embase databases. The following key terms were used: "restricted kinematic alignment, rKA, kinematic alignment, primary total knee arthroplasty, primary total knee replacement, TKA rKA, and TKR rKA." The initial screening identified 328 studies. Each eligible article was evaluated according to the inclusion criteria: studies with levels of evidence (LoE) 1 to 4, written in English, published through May 2022, and involving human subjects. Criteria from the Methodological Index for Non-Randomized Studies (MINORS) were used to assess the methodological quality of the articles. Results: Six clinical studies were included in this systematic review. The study was registered in the International Prospective Registry of Systematic Reviews (PROSPERO). A total of 574 knees were included. After excluding patients due to loss of follow-up or missing data, 475 knees were analyzed. The following rKA-related data were evaluated: patient-reported outcome scores (PROMs), radiographic analysis of the lower limb alignment, and causes of complications and reoperations. Conclusions: The rKA is an improved concept for restoring native knee kinematics, avoiding excessive coronal varus/valgus alignment. It provides equivalent or slightly better PROMs than MA without increasing the risk of short-middle-term implant failure. Clinical studies with extended follow-up are needed to confirm this trend.

Tibial condylar valgus osteotomy for the treatment of intra-articular varus deformity of the knee.

The increasing incidence and distribution of primary and post-traumatic knee osteoarthritis (OA) in the young, active population has renewed interest in joint-preserving procedures. High tibial osteotomy (HTO) represents the most common treatment for medial knee OA associated with varus tibial deformity. However, deformities may also be related to intra-articular defects that an extra-articular procedure could not correct. The tibial condylar valgus osteotomy (TCVO) represents an intra-articular surgical technique for treating advanced medial knee OA with lateral joint subluxation. Currently, only a few papers with small samples and limited follow-up report the use of TCVO for the treatment of intra-articular deformities. Indications and operative techniques are various and not standardized. After an extensive search of PubMed, Scopus and Cochrane library, the main purpose of this paper is to summarize and discuss the indications, surgical techniques, and outcomes of intra-articular osteotomies while also reporting the preoperative planning and surgical procedure performed at our institution. These characteristics allow earlier weight-bearing and faster complete recovery. TCVO is an effective procedure to correct lower limbs' intra-articular defects from degenerative conditions developmental and post-traumatic deformities. This surgical technique, working at the intra-articular level, leads to some benefits related to restoring joint congruence and stability by realigning the axis of the lower limb and reducing the lateral joint subluxation. Moreover, the improved valgisation and lateralization of the mechanical axis and the limitation of the osteotomy to the medial condyle led to a better load distribution to the not osteotomy-involved compartment.