A fast, easy and reliable method for hamstrings graft size prediction in anterior cruciate ligament reconstruction.

PURPOSE: The aim of this study is to describe and validate a simple and reliable method to pre-operatively predict the size of the ACL graft in the double strand technique with autologous semitendinosus-gracilis tendons on the same MRI used for ACL rupture diagnosis. METHODS: The study included 92 patients, with a median age of 31 years (IQR 26-41 years), 73/92 (79%) of whom were males. All patients that underwent an ACL reconstruction with doubled ST + GT between 2017 and 2022 were counted in the study. RESULTS: Overall, the median predicted graft diameter from MR imaging was similar to the actual graft diameter with no significant differences (n.s.). Regarding the comparison between predicted and actual graft size, concordance was 78/92 (85%, 95% CI 76-91%), with κ = 0.797 which corresponds to a level of agreement defined as "Strong". Tendon sizes calculated on pre-operative MRI were evaluated both with intra-observer and inter-observer reliability demonstrating a statistically reproducible method. The predicted graft was then compared to the reported one with a statistically significant reliability found. CONCLUSION: This study can help the surgeons to perform a fast pre-operative planning of an ACL reconstruction for graft selection. If the planned graft with ST and GT is smaller than 8 mm, the clinician can decide to switch to a different type of graft or plan a different graft preparing technique and, therefore, reduce the risk of post-operative ligament re-rupture. The method proposed is reliable and reproducible. The major strength of the planning technique proposed is that it relies on data that are already available for the clinician before surgery, without the need of further analysis. LEVEL OF EVIDENCE: IV.

Regional migratory osteoporosis of the knee: a literature overview.

The purpose of this article is to review the clinical syndrome of regional migratory osteoporosis (RMO) of the knee and to highlight all the important aspects of diagnosis and management that can be helpful to the physician. RMO is a rare, self-limiting disease characterized by migrating arthralgia, bone marrow edema and osteoporosis. The pathogenesis of RMO remains controversial and is not yet fully elucidated. A thorough presentation of the disease is conducted with presentation of the clinical features (progressive pain and local tenderness), differential diagnosis and appropriate diagnostic criteria. The role of MRI is underlined and strategies for the treatment of RMO are presented.

Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome.

PURPOSE: The medial patello-femoral ligament (MPFL) is considered the primary restraint against patellar dislocation and its reconstruction is indicated in recurrent patellar instability. An anatomical positioning of MPFL femoral insertion is recommended to achieve satisfactory clinical outcomes and prevent osteoarthritis (OA) due to an altered kinematics. The purpose of the study was first to assess the relationship between correct femoral tunnel position and better clinical outcomes and lower patellofemoral osteoarthritis rate. Second, correlation of outcomes with factors potentially affecting the results, such as the type of graft, patellar height and trochlear dysplasia. METHODS: Fifty-three patients (58 knees) who underwent MPFL reconstruction between 2009 and 2018 by a senior knee surgeon were retrospectively evaluated. Knee radiographs were performed before surgery, 12 months later and at last follow-up to assess trochlear dysplasia, patellar height and patellofemoral OA. The tibial tuberosity-trochlear groove (TT-TG) value was measured on a CT scan. The accuracy of graft positioning was evaluated on sagittal radiographs according to Schöttle et al. Subjective outcomes were collected before surgery, at 12 months and at last follow-up using several validated scores. RESULTS: Forty-six patients (51 knees) with a mean age of 24.1 ± 7.4 years were included in the study. Mean follow-up was 8.9 ± 2.1 years. A significant improvement in all clinical scores was observed at 12 months and final follow-up. Anatomic Insertion (AI) of reconstructed MPFL was considered optimal in 33 (64.7%) and sub-optimal in 18 (35.3%) patients. Sub-optimal AI resulted in lower Kujala, IKCD and higher VAS score (p < 0.01); moreover, for every 1 mm distance in any direction from the ideal insertion, a decrease of 0.8 [95% CI (-1.4; -0.2)] in Kujala score and 0.8 [95% CI (-1.3; -0.3)] in IKDC was observed. At final follow-up, 8 patients presented patellofemoral OA Iwano grade 3 (15.7%): although that incidence did not correlate to graft positioning, the use the artificial ligament in all these cases appeared to be significant. CONCLUSION: The present study confirms the importance of an optimal anatomic femoral insertion in MPFL reconstruction, reporting a significant positive correlation between graft positioning and clinical outcome. No significant correlations were found between anatomic insertion and patello-femoral OA development. LEVEL OF EVIDENCE: IV.

Autologous chondrocyte transplantation in the treatment of thumb CMC joint osteoarthritis.

Degenerative thumb carpometacarpal (CMC) joint osteoarthritis is a common disease in women starting at 40-50 years of age. Nevertheless, synovitis and initial cartilage damage start earlier, and then degenerative arthritis develops leading to joint narrowing with progressive exposure of subchondral bone, subluxation, osteophyte formation and joint deformity that can impact the surrounding joints. The aim of this study was to evaluate the outcome of patients treated with autologous chondrocyte transplantation at the thumb CMC joint at early stages. A prospective study on 10 cases of thumb CMC osteoarthritis in 8 patients was done. The thumbs were stage Eaton II (2 cases) and III (8 cases) and were treated by CMC arthroplasty with the implant of autologous chondrocytes by an open or arthroscopic technique. Two patients were treated bilaterally. Preoperatively all patients had persistent pain resistant to various kinds of nonoperative treatments for at least 1 year. Mean preoperative pinch strength was 3.7 Kg pain on VAS was 8, DASH was 55. All patients had limited abduction and flexion at the end range. Ethics committee approval was obtained for this study. Fragments of 3-4 mm of cartilage were harvested by arthroscopy or by an open technique from the wrist or elbow joint. Cartilage cells were sent to the laboratory to be grown on a collagenous biphasic matrix (MACI/Novocart®). After 3 weeks, the chondrocyte augmented scaffold was ready to be implanted in the thumb CMC joint, or frozen for a second operation later. All patients were females aged 42-67 years (mean 52 years). The dominant hand was treated in 6 cases. In 7 cases, the patients were operated with an open technique and in three cases by arthroscopy. Partial trapezium resection and dorsoradial ligament reconstruction was added to stabilize the CMC joint in most cases. Patients were seen in person at 1, 3, and 6, months, 1 year, 2 years, and 5 years after the initial surgery. Patients (nine thumbs) were then reviewed at a mean follow up 8 years (range 4.4-11 years); pain on VAS, Mayo, DASH and PRWE scores were evaluated at follow-up. One patient was lost to follow-up after 2 years. Of those nine hands, seven had an excellent result according to Mayo score, one had a good result. One thumb CMC joint was still painful and was reoperated and converted to arthroplasty after 4.4 years. All patients regained full range of motion. Mean pinch strength increased to 6.25 ± 1.3 Kg, mean DASH score was 7.3 ± 6.7; pain on VAS was 1.0 ± 1.5; these data were statistically significant compared to preoperative values (p < 0.01). Grip strength also increased in all cases, but this was not statistically significant. PRWE was 7.7 ± 6.4. No complications occurred postoperatively. The results obtained are encouraging since the implanted cartilage has lasted a mean of 8 years and up to 11 years. Biological tissue engineering techniques are being developed and could be a new solution to restore normal cartilage in young patients to postpone more aggressive surgical procedures until an older age. In cases of CMC joint instability, a ligament stabilization procedure was added to avoid subsequent damage to the implanted neocartilage. A longer follow-up and a greater number of cases are necessary to definitively establish the usefulness of this procedure, which has the advantage of being completely biological but the disadvantage of being costly.

Direct anterior approach and dual mobility cup: the "head-first" reduction technique: a technical note and early case series.

PURPOSE: Less invasive direct anterior approach (DAA) and dual mobility cup (DMC) are increasingly adopted in practice over the last decade. Their use aims to reduce, as much as possible, soft tissue dissection and dislocation rate. This study aims to present a novel surgical technique to reduce a DMC prosthesis during a DAA easily. METHODS: A mildly modified version of the direct anterior approach is proposed. When leg lengths, stability, impingement, and tension have been checked, the trial stem is disassembled in situ, dislocated, and removed, leaving the space to exchange the trial double mobility head with the definitive one. When the definitive stem is inserted, the surgeon guides and helps the assistant to match the trunnion in the double mobility head. As soon as the components are matched, the traction is released, and the unit is impacted by an alternation of axial traction and release. RESULTS: Of 164 patients who underwent primary total hip arthroplasty (December 2016-May 2017) by a single surgeon, a double mobility cup through DAA and the "head-first" technique was performed in 26 patients (15.8%). The mean operative time was 130 min (85-220 min; SD 34.28). No significant complications occurred during the mean follow-up of 23.6 months. CONCLUSIONS: Specific difficulties can be anticipated when pairing dual mobility cup and direct anterior approach. The "head-first" technique is a useful technique in reducing the possible difficulties related to the reduction of double mobility cup through a less invasive direct anterior approach.

Reliability of anterior medial collateral ligament plication of the elbow.

PURPOSE: The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. METHODS: Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner. RESULTS: In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35-74.5] points; postoperative median OES was 17 [15.5-31.5] points; postoperative median MEPI was 65 [57.5-72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities. CONCLUSIONS: The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension. CLINICAL RELEVANCE: The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.