Unbalanced metaphyseal fixation is associated with an increased aseptic loosening of revision total knee arthroplasty at mean 4-year follow-up.

INTRODUCTION: The total number of total knee arthroplasty performed is rising, and the number of revisions is rising accordingly. Periprosthetic joint infection emerged in recent years as a leading cause of total knee revisions. Bone loss is a real challenge when facing septic knee revisions since radical debridement is crucial to overcome infection. Many devices have already demonstrated to reliably address bone loss and guarantee enhanced fixation. However, the role of balancing metaphyseal fixation and its interplay with the level of constraint has not been elucidated yet. MATERIAL AND METHODS: An institutional arthroplasty registry was retrospectively reviewed looking for patients who underwent two-stage revision of the knee and metaphyseal cones implantation. Patients were divided into two groups based on the presence of cones only on one side (femoral or tibial, Group U) or both femoral and tibial side (Group B). Failure, aseptic loosening, and revision rates were compared between groups, as were values of patient-reported outcome measure. Kaplan-Meier analysis was used to assess survival of implants. RESULTS: A total of 65 patients were included in the analysis and were evaluated at a mean final follow-up of 4 years (range, 2-7). Mean age was 67 (range, 43-81) years. Mean BMI was 27.4 (range, 20-37) kg/m2. The overall mean KSS, OKS, ROM significantly increased from baseline values to last follow-up (p < 0.001). Kaplan-Meier analysis demonstrated that patients included in Group U had a significantly lower rate of implant survival compared to those included in Group B. CONCLUSIONS: Patients undergoing revision total knee arthroplasty for periprosthetic infection present considerable rates of complication and failure. Management of bone loss represents a concern for the surgeon, who must achieve a stable fixation. Our study demonstrated that implants characterized by an unbalanced metaphyseal fixation are at higher risk of aseptic loosening and consequent revision, especially when coupled with hinged inserts.

Total knee arthroplasty after anterior cruciate ligament reconstruction: a narrative review.

Background and Objective: Knee replacement following anterior cruciate ligament (ACL) reconstruction can be demanding due to altered anatomy, soft tissue scars, bone loss, extensor mechanism complications, and knee instability. This narrative review summarizes the strategies and approaches to managing operative challenges in total knee arthroplasty (TKA) following ACL reconstruction. Methods: Studies reporting outcomes of patients who underwent TKA after ACL reconstruction were retrieved and assessed to be included in this review that synthesizes the available evidence highlighting the pitfalls encountered during surgery, the intraoperative challenges posed by ligament balancing and exposure, and the leading role of modular and retained implants. Key Content and Findings: TKA following ACL reconstruction has a high rate of intra-operative complications such as instability, bone loss, difficult exposure and demanding soft tissue balancing, representing a revision surgery rather than routine primary knee arthroplasty and a revision-oriented skill set and modular components are recommended to significantly optimize both surgical strategy and patient outcomes. With a rising incidence of ACL injuries and growing reconstructions, anticipating an increase in TKA procedures, this review aims to provide a call for rethinking clinical approaches to ensure effective and patient-centric care. Conclusions: This narrative review seems to indicate that TKA after ACL reconstruction should be considered as revision surgery and modular components should be used. However, future prospective and high-quality studies are required to better clarify risk factors and give strong recommendations for this complex surgery.

Direct anterior approach with conventional instruments versus robotic posterolateral approach in elective total hip replacement for primary osteoarthritis: a case-control study.

BACKGROUND: The purpose of this study is to compare peri-operative and short-term outcomes in patients who underwent elective total hip replacement (THA) for primary osteoarthritis (OA) with direct anterior approach (DAA) versus a pair-matched cohort of patients who underwent robotic-assisted THA with posterolateral approach. MATERIALS AND METHODS: Data from consecutive patients who underwent elective hip replacement from 2021 to 2023 for primary OA were retrospectively retrieved and divided into two groups: the DAA group, who underwent THA with the DAA approach using conventional instruments, and the robotic posterolateral (R-PL group), who underwent robot arm-assisted THA with the posterolateral approach. Comparative assessed outcomes were: operative time, radiographical implant positioning, intake of rescue analgesics, blood loss, transfusion rate, leg length discrepancy and functional outcomes (Harris hip score and forgotten joint score). RESULTS: A total of 100 pair-matched patients were retrieved with a mean age of 66.7 ± 10.7 (range: 32-85) years and a mean follow-up of 12.8 ± 3.6 (range: 7-24) months. No differences in patients' characteristics were detected. Patients in the R-PL group required less rescue tramadol (p > 0.001), ketorolac (p = 0.028) and acetaminophen (p < 0.001). There was no significant difference in the operative time between (MD = 5.0 min; p = 0.071). Patients in the DAA group had significantly lower Hb levels at day 1 (p = 0.002) without significant differences in transfusion rate (p = 0.283). Patients in the R-PL group had shorter length of stay (LOS) with a mean difference of 1.8 days [p < 0.001; 95% confidence interval (CI) 1.4-2.3]. No difference in clinical outcomes was found [leg length discrepancy (LLD), p = 0.572; HHS, p = 0.558; forgotten joint score (FJS), p = 0.629]. No radiographical differences were measured in cup inclination (MD = 2.0°, p = 0.069), malpositioning [odd ratio (OR) = 0.2; p = 0.141], stem alignment (OR = 0.3; p = 0.485) and stem sizing (OR = 1.5; p = 1.000). There was no difference in complication rate except for lateral femoral cutaneous nerve damage, which was higher in DAA group (p < 0.001). CONCLUSIONS: R-PL and DAA THA had comparable short-term clinical and radiological outcomes along with similar complication rates. The R-PL group showed significantly lower Hb drop, rescue analgesic consumption and shorter LOS. This is a preliminary study and no strong recommendation can be provided. Further prospective randomized trials are requested to further investigate the cost-effectiveness of robotic surgery in THA. LEVEL OF EVIDENCE: Level IV, case-control study.

Autologous microfragmented adipose tissue treatment of knee osteoarthritis demonstrates effectiveness in 68% of patients at 4-year follow-up.

BACKGROUND: Adipose tissue-derived stem cells are an interesting therapeutic option for early knee osteoarthritis (OA) treatment due to their high plasticity, easiness of harvesting and rapidity of administration. The aim of this study was to evaluate the medium-term effectiveness and safety of Microfragmented Autologous Fat Tissue (MFAT) injection treatment at 4-year follow-up and to investigate potential correlations among patients' pre-treatment clinical condition and clinical outcomes to identify possible predicting factors for procedure success or failure. PATIENTS AND METHODS: This is a prospective trial enrolling 46 patients with diagnosis of symptomatic knee OA and failure of previous conservative measures who underwent diagnostic arthroscopy and single autologous MFAT injection between June 2017 and July 2018. Patients were assessed with repeated clinical scoring systems at baseline, 6 months, 1 and 4 years after surgery. The evaluation included demographic characteristics, arthroscopic findings, and stem cell number from injected tissue. RESULTS: No major complications were reported during follow-up period and there was a significant increase of Lysholm knee score from baseline value of 61.7 ± 13.8 to 79.5 ± 16.9 at 4 years (p < 0.001). The WOMAC score increased from a baseline value of 66.5 ± 14.7 to 82.8 ± 15.7 at 4 years (p < 0.001) and there was a significant decrease of VAS pain score from baseline value of 6.3 ± 1.5 to 3.5 ± 2.6 at 4-year follow-up (p < 0.001). ROM improved significantly from 118.4 ± 2.6 to 122.5 ± 2.5 at 12 months (p < 0.001), but did not improve at 4 years (p > 0.05). 15 patients (32.6%) were considered treatment failures, because they required secondary surgery, further injection therapy or experienced symptoms persistence. Patient with synovitis had 75% failure rate, although synovitis did not result as a statistically significant factor influencing clinical outcome up to 4-year follow-up (p = 0.058). Age, cartilage defects severity, BMI, concomitant procedures, and stem cell number from injected MFAT did not show any significant correlation with the results. CONCLUSIONS: MFAT intra-articular injection is a safe procedure with positive improvements up to 4-year follow-up in patients with early knee OA. These findings suggest MFAT could be a minimally invasive treatment of early knee OA with durable benefits at mid-term evaluation. TRIAL REGISTRATION: IRB number ID-3522.

Previous anterior cruciate ligament reconstruction influences the complication rate of total knee arthroplasty: a systematic review and meta-analysis.

Purpose: The results of total knee arthroplasty (TKA) following anterior cruciate ligament (ACL) reconstruction are still under-investigated. The purpose of this research is to investigate the differences between TKA after ACL reconstruction and TKA for primary osteoarthritis through a review and meta-analysis of the literature. Methods: Case-control and cohort studies reporting outcomes of TKA following ACL reconstruction were considered eligible for inclusion. The primary endpoint was to systematically review and meta-analyze the reported complications of TKA following ACL reconstruction. The outcomes have been compared with a group of patients who underwent TKA for primary knee osteoarthritis (OA) with any previous ACL surgery. Secondary endpoints were to assess and compare technical difficulties and results including the operative time, the use of revision components, the request for intraoperative release or additional procedures, the revision rate, and the clinical outcomes. Results: Seven studies were included involving 1645 participants, 619 of whom underwent TKA in previous ACL reconstruction and 1026 TKA for primary OA with no previous ACL reconstruction. Meta-analysis showed that TKA in previous ACL reconstruction had a significantly higher complication rate (OR = 2.15, P < 0.001), longer operative times (mean differences (MD): 11.19 min; P < 0.001) and increased use of revision components (OR = 2.16; P < 0.001) when compared to the control group without differences of infection, and revision rate. Conclusions: TKA in a previous ACL reconstruction has a significantly higher complication rate, longer operative times, and a higher need for revision components and intraoperative soft tissue releases in comparison to TKA for primary OA without previous ACL reconstruction.

Surgical treatment of critical size bone defects with Masquelet technique versus bone transport: a systematic review and meta-analysis of comparative studies.

INTRODUCTION: To date, the management of critical-sized bone defects lacks a universally accepted approach among orthopedic surgeons. Currently, the main options to treat severe bone loss include autologous grafting, free vascularized bone transfer, bone transport and induced-membrane technique. The purpose of this study is to critically compare the outcomes of Masquelet technique and bone transport to provide a higher level of evidence regarding the indexed techniques. MATERIAL AND METHODS: The authors conducted a systematic search on several databases according to the PRISMA guidelines. English-written reports comparing outcomes of the Masquelet technique versus the bone transport technique in patients with critical-sized defects in lower extremities were included. RESULTS: Six observational studies involving 364 patients were included. The systematic review and meta-analysis of pooled data showed no significant difference in most outcomes, except for ASAMI bone outcomes and residual deformity, which showed better results in the bone transport group. The 64% of patients treated with Masquelet technique obtained excellent/good bone ASAMI results compared to 82.8% with bone transport (p = 0.01). Post-operative residual deformity was 1.9% with the bone transport method versus 9.7% with the Masquelet technique (p = 0.02). CONCLUSIONS: Both the Masquelet technique and bone transport showed comparable results for the management of critical-sized bone defects of the lower limb. However, these findings must be carefully interpreted due to the high risk of bias. Further prospective randomized controlled trials are necessary to better clarify the strengths and limitations of these two techniques and to identify the variables affecting the outcomes.

Ultrasound-Guided Autologous Platelet-Rich Plasma Injections Versus Focal Ultrasound-Guided Extracorporeal Shockwave Therapy for Plantar Fasciitis in Athletes and Nonathletes: A Retrospective Comparative Study With Minimum 2-Year Follow-Up.

Plantar fasciitis is often cause of heel pain, especially in sporting-related activities. Different conservative measures for the management of plantar fasciitis were compared in several researches. The purpose of this retrospective study was to evaluate and compare clinical outcomes of chronic plantar fasciitis treated with ultrasound-guided platelet-rich plasma (PRP) and focal ultrasound-guided extracorporeal shockwave therapy (ESW). Secondarily, results on subpopulation of athletes were recorded. Fifty-five patients treated for plantar fasciitis were included, 24 among them were competitive or recreational athletes. Treatment outcomes were assessed using Visual Analog Scale and Foot Function Index before and after treatment. Time to return to sport among patients practicing sporting activities was recorded. Before treatment, no differences were observed between groups in terms of age, gender, body mass index, and months of follow up. From baseline to final follow-up assessment, significant improvement was observed in all the outcomes measures. The subgroup analysis showed no differences between patients stratified for type of treatment and sport/nonsport practitioners. The overall failure rate was higher, although not significant, in patients who underwent ESW therapy and they required a higher number of orthopedic visits. Among sports practitioners the mean time to return to sport (months) was faster in PRP group than ESW group (p = .044). PRP and ESW represent both reliable solutions for plantar fasciitis leading to good results in terms of patients' satisfaction, pain, and clinical outcomes. However, after treatment with PRP injections less recurrences in overall population and faster return to sporting activities in sports practitioners were observed.

The management of healthcare-related infections through lean methodology: systematic review and meta-analysis of observational studies.

Introduction: Lean is largely applied to the health sector and on the healthcare-associated infections (HAI). However, a few results on the improvement of the outcome have been reported in literature. The purpose of this study is to analyze if the lean application can reduce the HAI rate. Methods: A comprehensive search was performed on PubMed/Medline, Scopus, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: "lean" and "infection". Inclusion criteria were: 1) research articles with quantitative data and relevant information on lean methodology and its impact on healthcare infections; 2) prospective studies. The risk of bias and the study quality was independently assessed by two researchers using the "The National Institutes of Health (NIH) quality assessment tool for before-after (Pre-Post) study with no control group". The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines has been used. 22 studies were included in the present meta-analysis. Results: Lean application demonstrated a significant protective role on healthcare-associated infections rate (RR 0.50; 95% C.I.: 0.38-0.66) with significant impact on central line-associated bloodstream infections (CLABSIs) (RR 0.47; 95% C.I.: 0.28-0.82). Conclusions: Lean has a positive impact on the decreasing of HAIs and on the improvement of compliance and satisfaction of the staff.

Interposition arthroplasty with bovine collagenous membrane for hallux rigidus: A long-term results retrospective study.

BACKGROUND: Hallux rigidus (HR) is a degenerative arthritis of the first metatarsophalangeal joint (MTP1) with progressive loss of range of movement (ROM). Interposition arthroplasty (IA) is a technique widely used for the treatment of HR;however, few studies reported long-term clinical results. This study aims to report the clinical results of IA using a bovine pericardium collagen matrix for HR with a minimum 10-years follow-up. METHODS: Thirty patients (31 feet) who underwent IA using a bovine pericardium collagen matrix from 2001 to 2009 were retrospectively evaluated with a mean follow up of 154.1 ± 28.6 (range 124-218) months. All HR ranged from grade II to grade III, according to Regnauld classification. All patients were clinically assessed with the American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal- Interphalangeal Scale, a pain Visual Analog Scale, and the Foot and Ankle Disability Index. Scores before and after treatment, respectively achieved from clinical records and clinical evaluation at final follow-up were compared. RESULTS: At final follow-up, an improvement of all the considered scores (p < 0.01) was recorded. The overall rate of unsatisfying results was 16.1 %. Two (6.4 %) patients complained discomfort due to first ray shortening and 3 (9.7 %) cases of persistent metatarsal pain. There was one (3.2 %) case of Complex Regional Pain Syndrome (CPRS). No revision surgeries, infection, or other adverse events were reported. CONCLUSION: Interposition arthroplasty using bovine collagenous membrane is a reliable solution for high-grade HR with durable results over 10 years in more than 80 % of patients.

Dynamic hip screw versus intramedullary nailing for the treatment of A1 intertrochanteric fractures: A retrospective, comparative study and cost analysis.

OBJECTIVES: This study aims to compare sliding hip screw and intramedullary nail perioperative results and costs in two-part femoral fractures. PATIENTS AND METHODS: Between January 2015 and December 2019, a total of 85 patients (70 males, 15 females; mean age: 85.6±9.5 years; range, 33 to 99 years) who were treated for intertrochanteric two-part femoral fractures were retrospectively analyzed. The patients were stratified and divided into two groups according to type of implant used for surgical fixation: one group treated with intramedullary proximal femoral nail (EBA) and the other with sliding hip screw (DHS). Comorbidity, hemoglobin (Hb) level, hematocrit (hct) level, number of transfusions, and days of hospitalization details were evaluated. Postoperative X-rays were analyzed to assess the quality of reduction and to identify non-union, malunion, mechanical failures, and heterotopic ossifications. The modified Harris Hip Score, fracture mobility score, and Parker Mobility Score were calculated. Cost analysis considered the orthopedic device, operating room, transfusion, and hospital costs for the primary hospital stay. RESULTS: Of the patients, 44 were treated with DHS and 41 were treated with EBA nail by a single surgeon. No significant differences were found in the baseline demographic data. There was a significant increased operative time (p<0.001) and decreased fluoroscopy X-ray exposure time (p=0.031) in the subgroup of patients who underwent DHS fixation. The patients who underwent EBA nail fixation had a significantly higher transfusion rate during hospitalization (p=0.001) and a significantly lower Hb level and hct level on postoperative Day 1 and Day 3 (p<0.05). There were no significant differences in the clinical and functional scores, radiographic outcomes and mortality (p>0.05). The patients who underwent intramedullary nail fixation had higher costs. CONCLUSION: Sliding hip screws showed decreased postoperative anemization, lower transfusion rates, and similar clinical outcomes compared to the intramedullary nail for two-part femoral fractures. Sliding hip screws should be preferred for A1 intertrochanteric fractures.

Efficacy of Autologous Platelet-Rich Plasma Injections for Grade 3 Symptomatic Degenerative Meniscal Lesions: A 1-Year Follow-up Prospective Study.

BACKGROUND: Platelet-rich plasma (PRP) injections have been proposed as a biologic option to provide symptomatic relief and delay surgery in patients with degenerative joint disease of osteoarthritis (OA). The efficacy of autologous PRP on symptomatic degenerative meniscal lesions (DMLs) has never been investigated. HYPOTHESIS: We hypothesized that patients with symptomatic DMLs without OA undergoing autologous PRP injections experience a significant clinical improvement at 12 months. STUDY DESIGN: Prospective case series. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 69 patients with symptomatic DMLs without radiographic evidence of knee OA (Kellgren-Lawrence radiographic grading scale 0-1) received 4 autologous PRP injections once a week. Patients were prospectively evaluated before the injection and then at 1, 3, 6, and 12 months. Evaluation was based on Lysholm knee scoring scale (primary outcome), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Tegner activity scale, and visual analogue scale scores. RESULTS: Patients treated with PRP injections demonstrated an improving knee function and symptoms over the duration of the study. A significant improvement from baseline to 12 months was observed in all the outcome measures, and no patients experienced failure or required surgery during the follow-up. Patients younger than 50 years reported lower subjective level of pain and higher Tegner activity scale at baseline and had significantly better Lysholm knee scoring scale (P = 0.03) and WOMAC (P = 0.03) scores at 6 months, as well as better range of motion at 3, 6, and 12 months (P < 0.001). Thirty-three (47.8%) patients were very satisfied, 26 (37.7%) satisfied, 8 (11.6%) partially satisfied, and 2 (2.9 %) not satisfied, with 62 (89.8%) patients willing to repeat the same treatment. No patient was lost to follow-up and no patient experienced adverse reaction, infection, failure, recurrence or underwent further surgery. CONCLUSION: PRP injections provide short-term benefits in symptomatic DMLs. Although promising results were evident at 12 months, this is a preliminary study and no definitive recommendation can be made based, for example, on longer follow-up. CLINICAL RELEVANCE: This research supports the use of autologous PRP injections for symptomatic DMLs.

Two-stage arthroplasty for septic arthritis of the hip and knee: A systematic review on infection control and clinical functional outcomes.

INTRODUCTION: Septic arthritis of the native hip and knee joint poses particular challenges to orthopedic surgeons. Patients often suffer from several comorbidities, and it could be challenging to find a balance between infection control and adequate function. Two-stage arthroplasty has been addressed as a reliable solution, however the literature on the topic is composed of case series with small sample size. This systematic review aimed to analyze data on infection control and clinical functional outcomes of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee. METHODS: An electronic search of studies published from January 1st, 2000, to June 1st, 2021, was conducted using eight different databases. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Revies and Meta-analysis two authors reviewed the available literature and reference lists to identify papers eligible for inclusion. RESULTS: A total of 21 studies were included, involving 435 procedures. The mean age was 57.3 ± 6.2 (45.8-71.8) years. The mean follow-up was 53.7 ± 18.6 (12-86.7) months. The mean infection eradication was 93.3 ± 6.4%. Mean Harris Hip Score improved from 32.1 ± 10.6 (11.5-42.9) to 87.5 ± 5.7 (80.6-97.8). Mean Knee Society Score improved from 42.9 ± 7.6 (35.9-58.0) to 86.1 ± 5.4 (80.1-96.0). CONCLUSIONS: Two-stage arthroplasty for hip and knee septic arthritis provided high infection control rate and excellent function. Further high-quality studies should be oriented on providing a validated algorithm for diagnosis and treatment of this condition. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Predictors of failure of two-stage revision in periprosthetic knee infection: a retrospective cohort study with a minimum two-year follow-up.

PURPOSE: Despite the standardization of two-stage knee revision protocols, a high percentage of failures still occurs. Identifying the predictors of failure is necessary to determine appropriate management and counsel for patients with a periprosthetic knee infection. This study aimed to identify risk factors predicting the failure, to describe implant survival, and to report the mid-term clinical outcomes of patients undergoing two-stage revision for periprosthetic knee infection. METHODS: Data of patients who underwent two-stage knee revision from 2012 to 2016 were analyzed, and 108 patients were included. The mean age was 66.6 ± 9.2 years. The mean follow-up was 52.9 ± 15.6 months. Logistic regression was conducted to identify predictors of treatment failure. Kaplan-Meier curves were generated to assess implant survival. Preoperative functional outcomes were compared to those registered at the final follow-up. RESULTS: Difficult-to-treat infections (OR = 4.2, 95% CI 1.2-14.5, p = 0.025), the number of previous surgeries (OR = 1.8, 95% CI 1.2-2.6, p = 0.005), and the level of tibial bone defect (OR = 2.3, 95% CI 1.1-4.7, p = 0.027) significantly predicted the failure of two-stage knee revision. Survivorship of implants was significantly lower for patients presenting these risk factors (p < 0.05). Mean Knee Society Score improved from 49.0 ± 12.0 to 80.2 ± 13.6 (p < 0.001). Mean Oxford Knee Score improved from 22.2 ± 4.9 to 36.1 ± 6.0 points (p < 0.001). CONCLUSION: Difficult-to-treat pathogens, the number of previous surgeries, and the level of tibial bone defect were independent risk factors of two-stage knee revision failure. Overall, the two-stage protocol provided a good survival rate and functional outcome.

Clinical radiographic outcomes and survivorship of medial pivot design total knee arthroplasty: a systematic review of the literature.

BACKGROUND: Total knee arthroplasty is a reliable procedure able to reduce pain and disability in patients suffering from osteoarthritis. However, a considerable percentage of patients still experiences unsatisfactory results. Medial pivot total knee arthroplasty has been introduced in the clinical practice to overcome problems related with classic design implants and better mimic native knee kinematics. The aim of this study was to analyze survivorship and clinical and radiographic outcomes of medial pivot implants. METHODS: A systematic research was conducted in eight different databases. Thirty-four studies met the inclusion criteria and were included in the analysis. Data on objective and patients-reported outcomes, radiographic alignment, and survivorship were collected and analyzed. Revision rate was expressed as revision per 100 components years. RESULT: A total of 3377 procedures were included. Mean follow-up was 85.7 months (range, 12-182). The revision per 100 components years was 0.19, which corresponds to a revision rate of 1.9% after 10 years. Mean post-operative range of motion was 117.3 ± 0.4°. Mean clinical and functional Knee Society Score were, respectively, 85.9 ± 1.1 and 84.7 ± 3.5 at final follow-up. Post-operative femorotibial alignment was 177.1 ± 0.5°. Alfa and beta angles were 95.7 ± 0.1° and 89.2 ± 0.1°, respectively. Gamma and delta angles were 2.3 ± 0.6° and 86.7 ± 0.4°. CONCLUSION: Medial pivoting implants provided excellent survivorship and low revision rate, as well as good-to-excellent results in term of objective and patient-reported clinical outcomes, and reliable correction of radiographic parameters. More high-quality studies with long-term follow-up are needed to clarify the role of medial pivoting implants.

Home Se-Cure: A Home Care Service for Cancer Patients during the COVID-19 Pandemic.

Cancer patients are exposed to a greater risk of COVID-19 infection, resulting in treatment delays and unnecessary hospitalizations. International authorities have suggested reducing visits to hospitals and guarantee continuity of care. We developed a home care project called Home Se-Cure (HSC) to guarantee the continuity of oral, intramuscular, and subcutaneous cancer therapy during COVID-19. The Home Se-Cure project included cancer patients living near Galliera Hospital. Patients received home visits by registered nurses (RNs), whoperformed blood tests and delivered cancer therapies. Patients were instructed to take drugs after blood test results and therapy confirmation by oncologists. Sixty-six patients decided to participate and 38 declined the service. A customer satisfaction questionnaire was administered to a subgroup of patients participating in the project. The most prevalent disease in the HSC group was prostate cancer. The mean age of the patients in HSC was 78.4 years and 68.9 in the decliner group. The majority of the HSC participants appreciated the project because they could stay at home (71%) and reduce the risk of COVID-19 contagion (67.7%). Compared to decliners, the time the study group saved was 2033 hours. HSC guaranteed the continuity of care during the COVID-19 pandemic by reducing the number of patients in the hospital and avoiding crowds in the waiting room.

Clinical outcome and risk factor predictive for failure of autologous PRP injections for low-to-moderate knee osteoarthritis.

PURPOSE: To report the 5-year clinical efficacy of PRP intra articular injections in knee osteoarthritis (OA) and to investigate the risk factors predictive for treatment failure and poor clinical outcome. METHODS: We retrospectively evaluated 118 patients treated for low to moderate knee OA demonstrated by X-Ray and magnetic resonance imaging (MRI) with autologous PRP injection from 2014 to 2018 with a mean 51.1 ± 14.8 (range 29 to 89) months follow-up. All the patients were evaluated with Lysholm and WOMAC score. The role of Kellgren Lawrence (KL) grade, patello-femoral (PF) degeneration, age, body mass index (BMI), relevant comorbilities, smoking status, gender, previous surgery or conservative measures were analyzed with univariate and multivariate analysis. RESULTS: There was a significant improvement of all outcome measures at final follow-up and high satisfaction rate (79.7%). The overall failure rate was of 15.3% after a mean of 57.7 ± 15.1 (range 33 to 85) months. The BMI and the KL grade were identified as significant independent risk factor related to failure of autologous PRP injection. Patients under 60 reported significantly higher Tegner activity scale (p = 0.032) at final follow-up. Patients with KL grade 3 and patients with PF MRI-KL grade 3 had significantly lower Lysholm scores (p = 0.026 and p = 0.042 respectively) at final assessment. Younger patients with lower BMI and lower grade of radiographic OA had significantly longer therapeutic benefit (p < 0.05). CONCLUSION: Intra articular PRP injections led to a significant clinical improvement in middle-aged adults with a low to moderate knee OA. BMI and high KL grade have been identified as significant risk factors predictive for failure at mid-term follow-up.

Anatomy and biomechanics of the medial patellotibial ligament: A systematic review.

BACKGROUND: The knowledge of the anatomy and biomechanics of patellar stabilizers is mandatory to achieve good clinical results with surgical reconstructive procedures. Few articles provide clear anatomical and biomechanical picture of medial patello-tibial ligament (MPTL). METHODS: After a systematic review of the literature we selected in vivo or ex vivo studies providing anatomical or biomechanical measurements. We included 7 studies about MPTL anatomy for a total of 96 knees and 4 biomechanical studies. RESULTS: The MPTL is a true ligament and important component of the medial patellar stabilizers, together with the medial patello-femoral ligament (MPFL) and medial patello-meniscal ligament. The contribution of MPTL on restriction forces of the patello-femoral joint is still unclear. Quadriceps, patellar, semitendinous and gracilis tendons are adequate grafts for surgical MPTL reconstruction. CONCLUSIONS: MPTL is a well defined anathomical structure and histologically can be considered a ligament. It plays an important role in patellar stability especially it has a main role on patellar rotation and tilt instead on shift.

Endoscopic calcaneoplasty for the treatment of Haglund's deformity provides better clinical functional outcomes, lower complication rate, and shorter recovery time compared to open procedures: a systematic review.

PURPOSE: The aim of this research is to report the clinical outcome following surgical correction of Haglund's deformity summarising different surgical strategies and comparing clinical outcomes, failures, complications and return to activities of patients underwent open and endoscopic techniques. METHODS: A systematic search of the literature was conducted using eight different databases. Thirty-five studies were included in the systematic review. A total of 1260 ankles of 1147 patients were grouped in accordance with the surgical approach (open, endoscopic, or percutaneous). RESULTS: The overall mean age was 44.8 ± 8.2 (range 14.9-82) years with a mean follow-up of 30.9 ± 17.1 (range 3-132) months. Analysis of clinical outcomes of open and endoscopic techniques demonstrated significant differences of AOFAS (87.1 ± 5.9 versus 90.7 ± 4.2 points; P < 0.001), complications (15.5% versus 4.1%; P < 0.001), failures (6.0% versus 1.2%; P < 0.001), time to return to daily activities (17.2 ± 9.3 versus 6.3 ± 1.0 weeks; P < 0.001) and time to return to sport (20.7 ± 3.3 versus 11.9 ± 0.3 weeks; P < 0.001) in the studies that reported these specific outcome measures. CONCLUSION: Surgical correction of Haglund's deformity provides overall good clinical results and high subjective satisfaction. Endoscopic procedures demonstrated better final AOFAS, a lower rate of complications and failures, and shorter recovery time when compared to open techniques. LEVEL OF EVIDENCE: Level IV.

Conservative two-stage revision with primary components of infected total hip arthroplasty: An analysis of survival, clinical and radiographic outcomes.

Few studies provide an analysis of conservative two-stage revision of hip periprosthetic joint infection (PJI) and its impact on final outcome. A conservative revision is defined when soft tissues and bone quality enable the use of primary prosthetic components. Data of patients treated for chronic hip PJI who underwent two-stage revision between 2009 and 2016 and had a minimum of 2 years of follow-up were collected. Oxford Hip Score (OHS), Harris Hip Score (HHS) and radiological and microbiological data were retrieved and analysed. Clinical and functional outcome, survival, mortality, eradication, reinfection and re-revision rates within subgroups of patients with primary components and revision components are reported herein. A total of 148 patients underwent two-stage hip exchange with a mean follow-up of 55.6 ± 23.1 months and a mean age at surgery of 64.3 ± 12.7 years. Forty-four percent of patients underwent conservative revision. The mean HHS significantly improved from 40.6 ± 9.4 points to the final value of 87.8 ± 10.5 points (p = .002), and the mean OHS went from 20.3 ± 3.8 points to 40.3 ± 5. points (p< .001). Patients who were treated with primary components or isolated revision stems in the second stage had a significant reduction in surgical times (p< .001). The mortality rate for all causes of death was 6.8%, the eradication rate was 89.9%, the reinfection rate was 4.7% and the reoperation rate was 7.4% without differences between conservative and non-conservative revisions. Two-stage exchange arthroplasty for total hip arthroplasty (THA) PJI is a good strategy that provides satisfactory results, high eradication rates and no further need for revision. The conservative two-stage revision in patients with adequate bone stock represents a feasible option with good results and survival rates.

Permanent Spacers Are a Reliable Solution for Peri-prosthetic Shoulder Infection: A Systematic Review.

BACKGROUND: Peri-prosthetic shoulder infection (PSI), a highly disabling complication of shoulder arthroplasty, often requires additional surgery and prolonged antibiotic therapy. Of strategies proposed to manage this devastating condition, the use of cement spacers, perhaps even as a definitive treatment, is debated. QUESTIONS/PURPOSES: We sought to systematically review the literature on antibiotic-loaded cement spacers as a viable, perhaps definitive, treatment for PSI, evaluating the eradication rates, mechanical reliability, and functional results related to its use. METHODS: We conducted a systematic review of studies published from January 1, 1980, through September 1, 2019. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Review and Meta-analysis, we searched for studies reporting functional and clinical outcomes in patients with PSI treated with a permanent spacer of the shoulder. Two independent reviewers searched eight databases, as well as reference lists of the retrieved articles. RESULTS: After exclusion criteria were applied, 12 studies were included, involving a total of 143 patients. The mean age was 65.8 years; the mean follow-up was 37.4 months. A total of 133 patients (93%) were free from infection at latest follow-up. The mean post-operative active elevation of the shoulder ranged from 48.6 to 90°, the mean abduction ranged from 51 to 75°, and external rotation ranged from 3.6 to 29°. The mean Constant-Murley score ranged from 20.6 to 42 points (out of 100, from worst to best). CONCLUSION: The use of a permanent cement spacer is a reliable solution to PSI in low-demand, older patients with comorbidities, a population in whom it is desirable to avoid additional surgery. Our review found a high rate of infection eradication and moderate-to-good objective and subjective results. However, the overall level of evidence of included studies was very low, and higher-quality studies are needed to clarify the role of permanent spacers in the treatment of PSI.