All-Inside Arthroscopic Meniscus Repair for Patients Over 40 Years of Age: Is Forty the New Twenty?

INTRODUCTION: Meniscal injuries are a common challenge in orthopedic surgery. For decades, partial or total meniscectomy has been the primary surgical treatment for meniscal tears. In recent years, the increased recognition of menisci's biomechanical importance has progressively shifted the paradigm towards meniscus repair. However, meniscus-sparing surgery remains the treatment of choice for selected lesions in young and active patients, especially for young and active patients. In this study, we evaluated the effectiveness of all-inside sutures in treating meniscus tears in patients over 40. METHODS: In our retrospective evaluation, we evaluated the clinical and functional outcomes of cases over 40 years of age with post-traumatic acute meniscus tears that received meniscus repairs using the all-inside technique. The pre-operative and post-operative functionality of treated patients were assessed using the knee injury and osteoarthritis outcome score (KOOS) score. Major complications were recorded. RESULTS: Twenty-three cases met our inclusion criteria. Eight females and fifteen males with a mean age of 44.9 were included in our study. Their mean follow-up was 35.1 months. Before surgery, our patients' mean KOOS score was 55.4 (18-80). At the patients' latest follow-up, the value had risen to 87.4 (63-100). There was no statistical correlation between patients' age and their functional recovery. No surgical failure was recorded at the latest follow-up. CONCLUSION: The all-inside suture technique can represent a suitable and reliable solution for suturable meniscal tears, even for patients over 40. Preserving the meniscus and restoring patients' functionality allows patients to return to their daily activities and promote their quality of life.

Design, Fabrication, and Preliminary Validation of Patient-Specific Spine Section Phantoms for Use in Training Spine Surgeons Outside the Operating Room/Theatre.

Pedicle screw fixation (PSF) demands rigorous training to mitigate the risk of severe neurovascular complications arising from screw misplacement. This paper introduces a patient-specific phantom designed for PSF training, extending a portion of the learning process beyond the confines of the surgical room. Six phantoms of the thoracolumbar region were fabricated from radiological datasets, combining 3D printing and casting techniques. The phantoms were employed in three training sessions by a fifth-year resident who performed full training on all six phantoms; he/she placed a total of 57 pedicle screws. Analysis of the learning curve, focusing on time per screw and positioning accuracy, revealed attainment of an asymptotic performance level (around 3 min per screw) after 40 screws. The phantom's efficacy was evaluated by three experts and six residents, each inserting a minimum of four screws. Initial assessments confirmed face, content, and construct validity, affirming the patient-specific phantoms as a valuable training resource. These proposed phantoms exhibit great promise as an essential tool in surgical training as they exhibited a demonstrable learning effect on the PSF technique. This study lays the foundation for further exploration and underscores the potential impact of these patient-specific phantoms on the future of spinal surgical education.

Ultrasound and Clinical Alterations in the Foot of Children with Obesity and Diabetes.

BACKGROUND: Alterations in plantar soft tissues are often reported in adults with diabetes, whereas data on children are conflicting. Also, the extent of foot damage caused by excess body fat in children has not been fully characterized yet. This study aimed to address the relationship between body mass and structural changes of the foot in children and adolescents with and without diabetes. METHODS: In a case-control study, 43 participants (age 13 ± 2.6 years) were recruited, 29 (67%) with type 1 diabetes (T1D) and 14 (33%) controls. Anthropometric parameters [body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR)], foot posture index-6 (FPI-6) for static foot posture, and navicular drop test (NDT) for medial longitudinal arch height (MLA) were measured in all participants. The thickness of the midfoot plantar fascia (MPF) and medial midfoot fat pad (MMFP) were quantified using ultrasound. RESULTS: No differences in clinical and ultrasonographical parameters were observed between the study groups. MMFP thickness was correlated with MPF thickness (p = 0.027). MMFP and MPF thicknesses were positively associated with BMI (p < 0.001 and p = 0.013, respectively), WC (p < 0.001 and p = 0.013), and WHtR (p < 0.001 and p = 0.026). The NDT measured on the right and left foot correlated with WHtR (p = 0.038 and p = 0.009, respectively), but not with WC and BMI. CONCLUSIONS: Children with T1D show structural alterations of plantar soft tissues which seem related to body mass increase rather than diabetes pathology. Ultrasound is a valuable tool to assess early structural changes of the foot in young people with an elevated BMI.

Is the Combination of Platelet-Rich Plasma and Hyaluronic Acid the Best Injective Treatment for Grade II-III Knee Osteoarthritis? A Prospective Study.

Background: Knee osteoarthritis is a common disease with increasing incidence and prevalence in western countries. It can cause severe pain and functional limitations, thereby representing a threat for patients' quality of life and a burden for national health systems. Intra-articular injections with hyaluronic acid (HA) and platelet-rich plasma (PRP) have been used for decades in order to reduce the symptoms caused by osteoarthritis. In recent years, a combination of HA and PRP has been introduced in clinical practice with the aim to minimize the clinical presentation of osteoarthritis and potentially delay articular degeneration. Materials and Methods: Sixty cases with grade II-III knee osteoarthritis according to the Kellgren-Lawrence classification were included in a prospective study, focused on the evaluation of clinical and functional outcomes after intra-articular knee injections. Cases were randomly divided into three groups. Twenty cases (Group A) were injected with HA, 20 (Group B) had PRP, and the remaining 20 (Group C) received a combination of HA and PRP. Basal WOMAC score and VAS score were recorded before the treatment and repeated within 3 and 6 months after the treatment. Results: At 6-month follow-up, Group C (PRP + HA) was the one with the lowest WOMAC and VAS mean values. It was also the only group that reported a reduction in the two values both in the first three months and in the following three months. No major complication was recorded. Conclusion: The combination of platelet-rich plasma and hyaluronic acid can be effective in the treatment of grade II-III knee osteoarthritis in a short-to-mid-term scenario. It represents an innovative and valuable alternative to the administration of its two components alone.

Femoral neck fractures treated with cannulated screws: can surgeons predict functional outcomes and minimize the risk of necrosis?

BACKGROUND AND AIM: Femoral neck fractures are among the most frequent in mankind. Screw fixation is considered a suitable approach specially for undisplaced or slightly displaced fractures that occur to young patients. We conducted our study in order to evaluate both functional outcomes and complication rates of patients who received this treatment in our institution. A particular focus was given to the aseptic necrosis of the head, trying to identify if anamnestic, clinical or radiological data could play a significant role as prognostic factors. METHODS: For each case who was treated with screw fixation due to a femoral neck fracture, we recorded data regarding, among the others, BMI and whether they used tobacco products or corticosteroids on a regular basis. Necrosis of the femoral head and mechanical complications were recorded. Functional outcome was evaluated using the Harris Hip Score.      Results: 74 cases were included in our study. The mean Harris Hip score was 89.5. Aseptic necrosis of the femoral head occurred in 9 cases (12.2%). Regular use of tobacco was associated with a higher risk to develop necrosis (p=0.007). The Body Mass Index was significantly higher in cases who had necrosis compared to the rest of our population (p=0.043) and was inversely proportional to the post-operative Harris hip score (p=0.001). CONCLUSIONS: While considering screw fixation to treat cases with femoral neck fractures, patient's weight and use of tobacco should be considered as prognostic factors.  (www.actabiomedica.it).

Impending atypical femoral fractures associated with bisphosphonates: postoperative diagnosis after hip prosthesis. Clinical cases presentation.

BACKGROUND AND AIM: Number of hip prosthesis implants in arthritis, number of patients treated with bisphosphonates to prevent fragility fractures and, together, number of atypical femoral fracture's cases are increasing. CASE SERIES: This article describes two cases of hip arthritis, treated with hip replacement, in patients using bisphosphonates for a long time; in both cases an incomplete atypical femoral fracture was misdiagnosed before the surgery. Authors describe the importance to carry out a complete osteometabolic and radiographic pre-operative examination of patients in treatment with bisphosphonates going to hip replacement, to check the possible presence of incomplete atypical femoral fracture and to optimize surgical and pharmacological treatment. CONCLUSIONS: In hip prosthesis surgery, prior diagnosis of incomplete atypical femoral fractures can indicate the choice of a different kind of prosthesis stem to optimize surgical results. This can also positively impact to rehabilitation in term of duration and daily activities recovery.

Multifocal Humeral Fractures: Clinical Results, Functional Outcomes and Flowchart of Surgical Treatment.

Aim and objective: Multifocal fractures of the humerus are rare. The aim of our study is to evaluate the effectiveness of surgical treatment and propose a modification to the Maresca-Pascarella classification. A flowchart for surgical treatment is provided. Materials and methods: Thirty-one patients with multifocal humeral fractures were treated and evaluated. The Maresca-Pascarella classification was used. All were treated using with either plates and screws, external fixation or intramedullary nailing. Functional outcomes were evaluated using the QuickDASH test, the University of California - Los Angeles (UCLA) shoulder score and the Mayo elbow performance score (MEPS). Results: There were 12 Type A, 17 Type B, 1 Type C and 1 of combined fractures of the proximal and distal epiphysis. Of the 31 patients, 5 were lost to the follow-up (FU), 1 died of pulmonary embolism (PE) and the remaining 25 had a mean FU of 19.8 (7-35) months. Three patients had radial nerve damage and 1 went to a non-union that required further surgical intervention. The mean QuickDASH score was 15.7, the average UCLA shoulder score was 26.3 and the mean MEPS elbow score resulted to be 83.0. Conclusion: Although multifocal fractures are severe injuries, patients are able to recover good functionality if treated judiciously. Clinical significance: We proposed a standardised surgical approach based on the fracture characteristics, site and a modified Maresca-Pascarella classification. How to cite this article: Scaglione M, Casella F, Ipponi E, et al. Multifocal Humeral Fractures: Clinical Results, Functional Outcomes and Flowchart of Surgical Treatment. Strategies Trauma Limb Reconstr 2022;17(2):81-87.

Intraoperative Load Sensing in Total Knee Arthroplasty Leads to a Functional but Not Clinical Difference: A Comparative, Gait Analysis Evaluation.

INTRODUCTION: Although Total Knee Arthroplasty (TKA) is a successful procedure, a significant number of patients are still unsatisfied, reporting instability at the mid-flexion range (Mid-Flexion Instability-MFI). To avoid this complication, many innovations, including load sensors (LS), have been introduced. The intraoperative use of LS may facilitate the balance of the knee during the entire range of motion to avoid MFI postoperatively. The objective of this study was to perform a Gait Analysis (GA) evaluation of a series of patients who underwent primary TKA using a single LS technology. METHODS: The authors matched and compared two groups of patients treated with the same posterior stabilized TKA design. In Group A, 10 knees were intraoperatively balanced with LS technology, while 10 knees (Group B) underwent standard TKA. The correct TKA alignment was preoperatively determined aiming for a mechanical alignment. Clinical evaluation was performed according to the WOMAC, Knee Society Score (KSS) and Forgotten Joint Score, while functional evaluation was performed using a state-of-the-art GA platform. RESULTS: We reported excellent clinical results in both groups without any statistical difference in patient reported outcome measurements (PROMs); from a functional standpoint, several GA space-time parameters were closer to normal in the sensor group when compared to the standard group, but a statistically significant difference was not reached. CONCLUSIONS: Gait Analysis represents a valid method to evaluate TKA kinematics. This study, with its limitations, showed that pressure sensitive technology represents a valid aid for surgeons aiming to improve the postoperative stability of TKA; however, other factors (i.e., level of intra-articular constraint and alignment) may play a major role in reproducing the normal knee biomechanics.

Preventive bilateral femoral nailing in atypical femoral fracture non responder to anabolic therapy: case report and mini-review.

Currently bisphosphonates are the main antiresorptive medications used in osteoporosis. However, a prolonged use of these drugs is associated to an increased risk of atypical femoral fractures, especially in patients suffering from others predisposing clinical conditions. This report describes a case of a woman presenting bilateral impending femoral fracture initially treated with bisphosphonates suspension and intramedullary nailing of right femur. Despite anabolic therapy, the patient presented progression of incomplete contralateral femoral fracture which required a second surgical treatment.

Instability Severity Index Score Does Not Predict the Risk of Shoulder Dislocation after a First Episode Treated Conservatively.

The first purpose of this study was to verify the association between Instability Severity Index Score (ISIS) and Recurrent Shoulder Dislocation (RSD) after a first episode treated conservatively. The second aim is to identify the risk factors associated with RSD after a primary acute shoulder anterior dislocation treated conservatively. A total of 111 patients with first traumatic anterior shoulder dislocation treated at a single trauma centre between January 2014 and March 2016 were enrolled. The main predictive variables of risk factors and the ISIS score were calculated. Among the 85 patients included, 26 cases of RSD were observed (30.6%). Considering the whole population, no significant association between ISIS and RSD were reported. Regarding other risk factors, high-risk working activities and rotator cuff injury had a significantly higher RSD risk. Sex, dominant limb, familiar history, hyperlaxity, contact or overhead sports, competitive sport, post-reduction physiokinesitherapy, return to sports activity time, Hill-Sachs lesion, bony Bankart lesion and great tuberosity fracture did not seem to influence the risk of RSD. No correlation between ISIS score and RSD in patients treated conservatively after a first episode of shoulder dislocation were reported. The only risk factors with a significant association to RSD were high-risk working activities and rotator cuff injury.

Use of a Plasma-Sprayed Titanium-Hydroxyapatite Femoral Stem in Hip Arthroplasty in Patients Older than 70 Years. Is Cementless Fixation a Reliable Option in the Elderly?

BACKGROUND: Although cementless implants are increasing in popularity, the use of cementless femoral stems for total hip arthroplasty (THA) and hip hemiarthroplasty (HH) in elderly patients remains controversial. The aim of this study was to report the outcomes of a cementless stem used in a large multicentric cohort of elderly patients receiving elective THA and HH for displaced femoral neck fracture. METHODS: A total of 293 patients (301 hips) aged 70 years or older (mean age, 78 years; range, 70-93) who received the same cementless plasma-sprayed porous titanium-hydroxyapatite stem were retrospectively evaluated after primary THA and HH to investigate stem survival, complications, and clinical and radiographic results. RESULTS: Cumulative stem survival was 98.5% (95% CI, 96.4-99.4%; 91 hips at risks) with revision due to any reason as the end-point at 10-year follow-up (mean 8.6 years, range 4-12). No stem was revised due to aseptic loosening. The mean Forgotten Joint Score was 98.7. Radiographically, the implants showed complete osseointegration, with slight stress-shieling signs in less than 10% of the hips. CONCLUSION: The use of cementless stems was proven to be a reliable and versatile option even in elderly patients for elective THA and HH for femoral neck fracture.

A Novel Capacitive Measurement Device for Longitudinal Monitoring of Bone Fracture Healing.

The healing process of surgically-stabilised long bone fractures depends on two main factors: (a) the assessment of implant stability, and (b) the knowledge of bone callus stiffness. Currently, X-rays are the main diagnostic tool used for the assessment of bone fractures. However, they are considered unsafe, and the interpretation of the clinical results is highly subjective, depending on the clinician's experience. Hence, there is the need for objective, non-invasive and repeatable methods to allow a longitudinal assessment of implant stability and bone callus stiffness. In this work, we propose a compact and scalable system, based on capacitive sensor technology, able to measure, quantitatively, the relative pins displacements in bone fractures treated with external fixators. The measurement device proved to be easily integrable with the external fixator pins. Smart arrangements of the sensor units were exploited to discriminate relative movements of the external pins in the 3D space with a resolution of 0.5 mm and 0.5°. The proposed capacitive technology was able to detect all of the expected movements of the external pins in the 3D space, providing information on implant stability and bone callus stiffness.

ACL Replacement with Synthetic vs. Biological Tendon Grafts: Long-Term Follow-Up Comparison Using Objective Evaluations.

BACKGROUND AND AIM OF THE STUDY: Anterior cruciate ligament (ACL) tears are among the most common articular injuries in sports and can be responsible for knee instability and reduced articular performance. Treatment can be either conservative or operative, and ligament reconstruction may be carried out using biological autologous grafts or synthetic materials. Several studies have sought to evaluate and compare functional results in treated patients. However, there is still very limited information available on long-term follow-up and clinical outcomes are generally evaluated only using subjective scores. In this study, we assessed long-term functional and biomechanical results in patients treated with biologic and synthetic ligaments using objective measures. MATERIALS AND METHODS: Patients were divided according to whether ACL reconstruction was biologic or synthetic. The Tegner activity scale was used before and after surgery. Post-operative subjective scores such as the IKDC Questionnaire and the Tegner-Lysholm score were also recorded. The Y Balance Test was used to assess global stability and mobility of the lower limb. Kinematic Rapid Assessment (KiRA) was used to evidence and estimate ligamentous laxity during the Pivot Shift and Lachman tests. RESULTS: Clinical subjective patient and operator-dependent scores as well as objective biomechanical findings were similar and comparable in patients treated with biologic and synthetic reconstructions after more than 10 years of use. CONCLUSIONS: Both synthetic and biological tendon grafts may represent good reconstructive approaches to treat torn ACLs, and remain effective even for a long period of time if implanted in suitable target patients.

The New Challenge in the Management of Proximal Femur Fractures during SARS Cov-2 outbreak.

The aim of this study is to evaluate how the spread of Sars-Cov-2 has changed the epidemiology of proximal femur fractures in two major trauma centers in Italy, understanding the workload and the best allocation of the resources for the orthopedics department in such an emergency situation. The rate of patients from January 2019 to April 2020 hospitalized with femoral neck fractures (group A) and trochanteric fractures (group B) were recorded. Demographic data, timing of surgical treatment and the length of stay were recorded. Data show that the number of proximal femur fractures has remained unchanged in the COVID and pre-COVID era (ranging from an average of 91.14/month in the pre-COVID era to 76/month in March and 80/month in April). In our trauma centers, the rate of patients operated on within 48 hours has remained stable (78.19% vs 77.92%), while the length of stay has decreased during the COVID period (8.9 days vs 6.5 days in March and 6.8 days in April). Proximal femur fractures, even during the COVID period, are a constant issue and a new challenge for the healthcare system. The main goals of management are to preserve patients from viral infection, to provide early surgical treatment and fast track protocol for discharge.

Bibliometric trend analysis in a decade of European Orthopaedic literature.

Purpose The purpose of this bibliometric study was to summarize European orthopedic literature produced by EFORT memberships between 2009 and 2019 and to identify the 100 most cited articles, analyzing the characteristics that made them so interesting for the orthopedic scientific world. Method A search of the literature was conducted using Clarivate Analytics Web of Science in the subject category "orthopaedics"; then the results were summarized using Web of Science tools. Results A total of 160.375 articles were found: most of these were produced by England. In particular the most prolific institution was the University of London. Analyzing in detail the 100 most cited publications emerged that most of them were review published in journal with high impact factor (Q1). The University of Oxford was the institution with the greatest number of contributions (13%). The most cited topics were osteoarthritis (24%), followed by orthopedic basic science (22%). Biomaterials was the most common topic by ordering the 100 analyzed articles according to "usage count", a recent indicator of the level of interest in a specific item. Conclusion This bibliometric study can be useful to identify topics of interest for future scientific research and to outline the features that make some publications more interesting than others.

Mesangiogenic Progenitor Cells Are Tissue Specific and Cannot Be Isolated From Adipose Tissue or Umbilical Cord Blood.

Mesangiogenic progenitor cells (MPCs) have been isolated from human bone marrow (BM) mononuclear cells. They attracted particular attention for the ability to differentiate into exponentially growing mesenchymal stromal cells while retaining endothelial differentiative potential. MPC power to couple mesengenesis and angiogenesis highlights their tissue regenerative potential and clinical value, with particular reference to musculoskeletal tissues regeneration. BM and adipose tissue represent the most promising adult multipotent cell sources for bone and cartilage repair, although discussion is still open on their respective profitability. Culture determinants, as well as tissues of origin, appeared to strongly affect the regenerative potential of cell preparations, making reliable methods for cell isolation and growth a prerequisite to obtain cell-based medicinal products. Our group had established a definite consistent protocol for MPC culture, and here, we present data showing MPCs to be tissue specific.

All-Inside Arthroscopic Repair For Longitudinal Meniscal Tears: Clinical and Functional Results.

Meniscal injuries are a common challenge in orthopaedic surgery. Depending on their location and the patient's age and functional needs, they can be treated either conservatively or surgically. A surgical approach can consist of arthroscopic meniscectomy or meniscal suture. The latter is the treatment of choice in case of lesions involving the red-red or red-white areas of the meniscus, especially for young high-demanding patients. We report here our experience with the repair of longitudinal meniscal tears using the all-inside technique with the Fast-Fix™ 360 Meniscal Repair System (Smith & Nephew Endoscopy, Andover, MA). We retrospectively evaluated 20 consecutive cases of longitudinal meniscal tears. In 4 cases, concomitant ACL rupture was diagnosed and treated alongside the meniscal repair. All patients underwent periodic clinical evaluations. At the latest check-up, their functional outcomes were rated according to the Tegner-Lysholm Knee and KOOS scoring scales. The mean Tegner-Lysholm Knee score was 84.85 (44-100) and the mean KOOS score was 88.58. No failure or major complications were observed. Furthermore, a negative statistical association was observed between age at surgery and the post-operative Tegner-Lysholm Knee score (coef. = -1.01189 [-1.942073,-0.0817063], p = 0.035). This relation, independent of gender, meniscus involved, eventual associated ACL reconstruction, and chondral injury, suggests that functional outcomes worsen with increasing patient age. Our results suggest that the arthroscopic all-inside suture is both safe and effective in cases of longitudinal meniscal tear, considering the good post-operative functionality and low rates of local complications and surgical failures.

Synthetic Bone Grafting in Aseptic Loosening of Acetabular Cup: Good Clinical and Radiological Outcomes in Contained Bone Defects at Medium-Term Follow Up.

Restoring bone loss is one of the major challenges when facing hip revision surgery. To eliminate the risk of disease transmission and antigenicity of allografts and donor-morbidity of autografts, the use of synthetic bioceramics has become popular in the last decade. Our study investigated the effectiveness of impaction bone grafting (IBG) of contained acetabular defects (Paprosky 2 and 3a) using a porous ceramic-based hydroxyapatite bone substitute (Engipore, provided by Finceramica Faenza S.p.A., Faenza, Italy) mixed with a low percentage of autologous bone (obtained from reaming when available). We retrospectively assessed 36 patients who underwent acetabular revision using IBG using a porous ceramic-based hydroxyapatite bone substitute with cementless implants with a mean follow-up of 4.4 years. We evaluated, at regular intervals, patients clinically (using the Hip Harris Score and Oxford Score) and radiologically to evaluate the rate of incorporation of the graft, the presence of radiolucent lines or migrations of the cup. Clinical scores significantly improved (WOMAC improved from 49.7-67.30, and the HSS from 56-89). The rate of implants' survival was 100% at our medium follow-up (4.4 years). We reported five cases of minor migration of the cup, and radiolucent lines were visible in seven patients at the last-follow up. The graft was well-incorporated in all patients. The results presented in this study suggest the HA bone substitute is an effective and safe bone graft when facing hip revision surgery; thus, longer follow-up studies are required.

Lessons learnt from COVID 19: An Italian multicentric epidemiological study of orthopaedic and trauma services.

INTRODUCTION: The Pandemic caused by the SARS-CoV-2 has put a strain on the most of health systems all over the world. Many hospitals had to re-organize to deal with the emergency, so that the non-core activities have been suspended or cancelled, raising management problems. The aim of this multicentre study is to report the epidemiological orthopaedic and traumatological data between COVID and pre-COVID era and to analyse patients' needs and their management. METHODS: We reported and compared traumatological and elective orthopaedic surgeries performed in three of the main hospital centres in Tuscany during COVID (March 2020) and pre-COVID (March 2019) era. We also reported the epidemiological data about the number of orthopaedic first aid visits at the main hub, analysing the main differences. For each centre, we reported the number, diagnosis, co-morbidities, treatment, hospital course, complications and outcomes of confirmed COVID 19 patients. We also indicated what kind of PPE were used by medical staff and patients at any visit. RESULTS: The scheduled surgery drastically decreased in all the centres and the most of procedures were carried out for tumours, infections and implant mobilizations during the COVID time, delaying all the other ones. Trauma activities slightly decreased between the two time points: proximal femur fractures continued to engage our hospitals at the same pre-COVID volumes, while minor traumas drastically decreased. We report a decrease of 70.95% in orthopaedic first aid, with first-aid-visits/hospitalization ratio of 13.8 in the pre-COVID time vs 5.8 in the COVID time. A total of 5 confirmed COVID patients were treated for fractures and 4 of them healed without complications. We report just one case of death among COVID patients. All the medical staff members have worn the PPE and no one have developed COVID symptoms. CONCLUSIONS: The COVID-19 raised many important issues, such as the optimal management of patients requiring the treatment of conventional diseases during a pandemic. The flow of patients changes from one area to another during a pandemic and an integrated approach within the same geographical area could be useful to better allocate resources and manage the patients' needs. The preventive measures put in place in our country seem to work, but this first experience with COVID-19 crisis highlighted the chronic problems of our health system and we believe that we have to "learn the lesson" to be better prepared in the future.

Which role for synthetic ligaments in the reconstruction of patellar tendon chronic rupture after TKA? Mid-term outcomes using LARS ligament.

BACKGROUND AND AIM OF THE WORK: Patellar tendon rupture is a rare complication after Total Knee Arthroplasty (TKA) which often requires surgical treatment. Patients with chronic lesions or tendon degenerations showed good results when treated using autografts or allografts, but these techniques showed poor outcomes at long-term follow-up (FU). Moreover, allografts have high costs and limited availability, not to mention the increased risk of immune reactions and infections. Recently, the use of synthetic ligaments for patellar tendon reconstruction has taken hold with encouraging results. We report our experience in the treatment of patellar tendon ruptures after TKA using the Ligament Advanced Reinforcement System-LARS®. METHODS: Clinical evaluation was performed using the Knee Society Score and recording extensor lag. Instrumental evaluation was performed using ultrasound imaging to assess patellar tendon thickness and using conventional x-rays to assess prosthesis' mobilization signs and patella's height. RESULTS: At the final FU, 6 knees were included in our study. Patient's mean age was 66.7. Patellar tendon reconstruction occurred after a mean time of 4 months from the previous surgery. The mean FU was 44,2 months. The mean Knee Score was 63.3 and the mean Function Score was 35. In 4 knees the extensor lag was < 10° while in 2 knees it was > 20°. The mean ISI was 1.16, while the average increment in tendon thickness was 127.12%. CONCLUSIONS: In our opinion, synthetic ligaments can be successfully employed for the reconstruction of patellar tendon breakage after TKA and rTKA in selected patients, in order to quickly return them to their activity of daily living.