Two-stage total joint replacement for hip or knee septic arthritis: post-traumatic etiology and difficult-to-treat infections predict poor outcomes.

PURPOSE: Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients' quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure. METHODS: A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p < 0.05. RESULTS: One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA. CONCLUSIONS: Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.

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.

Nonmetallic tension band fixation is a viable and low-complication surgical technique in patellar fractures: a five-year retrospective study.

BACKGROUND: Traditionally, patellar fractures (PFs) have been managed using metallic tension band fixation, a method often associated with a notable rate of complications. Considering these challenges, this study explores the potential of nonmetallic fixation as a treatment option for PFs. This research aims to provide robust evidence supporting the use of the nonmetallic tension band fixation technique as an effective alternative to conventional metallic tension band fixation, thereby advancing the standard of care in treating these fractures. METHODS: This retrospective study analyzed a consecutive patient series presenting with PFs from 2008 to 2021, treated with a nonmetallic tension band fixation technique. Inclusion criteria were strictly defined to include individuals over 18 years of age with isolated PFs requiring surgical intervention. The study focused on evaluating postoperative complications and clinical outcomes, as measured by standardized scoring systems, at the final follow-up point to assess the efficacy and safety of the employed surgical technique. RESULTS: In this study, with a mean follow-up of 64 ± 7 months, a total of 64 patients who received open reduction and internal fixation (ORIF) for PFs were enrolled. Among these, five cases required additional surgical interventions. Specifically, two cases were due to knee stiffness, while the remaining three involved complications such as superficial infection, skin irritation, or delayed wound healing. The mean postoperative values recorded for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Oxford knee score (OKS), and visual analog scale (VAS) were 20.4 ± 2.3, 35.5 ± 5.3, and 1.6 ± 0.4, respectively. There were no complications related to the nonmetallic fixation technique or instances of loss of reduction. CONCLUSION: This study substantiates that nonmetallic tension band fixation is a safe and effective alternative to traditional metallic tension band fixation for patellar fractures. The study's low-complication rate and reoperation frequency underscore the value of nonmetallic implants in mitigating adverse effects and enhancing clinical outcomes. LEVEL OF EVIDENCE: IV.

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.

Superior outcomes of total hip arthroplasty without prior lumbar arthrodesis: a systematic review and meta-analysis.

PURPOSE: The number of patients undergoing total hip arthroplasty (THA) surgery after previous lumbar arthrodesis (LA) is rising. Literature suggests that LA may significantly impact pelvic biomechanics and potentially compromise the success of prosthetic hip replacement. This study aims to evaluate complication rates, dislocation rates, and revision rates in patients with prior LA undergoing THA surgery compared to those undergoing THA surgery without prior LA. METHODS: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A PICOS template was developed to ensure a structured approach. The search for relevant studies was performed across five databases, including Pubmed, Scopus, Embase, Medline, and Cochrane. The selected articles were evaluated based on the Levels of Evidence (LoE) criteria. The Coleman Methodology Score (mCMS) was employed to analyze the retrospective studies. This systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that allowed for a meta-analysis performed using R software, a p < 0.05 was considered statistically significant. RESULTS: The final analysis included seventeen studies comprising a total of 3,139,164 cases of THA. Among these cases, 3,081,137 underwent THA surgery alone, while 58,027 patients underwent THA with a previous LA. The study investigated various factors, including dislocation rates, revision rates, and complication, as well as the surgical approach and type of implant used, for both the THA-only group and the group of patients who underwent THA with prior LA. The analysis revealed a statistically significant difference (p < 0.05) for all variables studied, favoring the group of patients who underwent THA alone without prior LA. CONCLUSIONS: This systematic review and meta-analysis demonstrated a statistically significant superiority in all analyzed outcomes for patients who underwent THA-only without prior LA. Specifically, patients with isolated THA implants experienced significantly lower incidences of THA dislocation, wound complications, periprosthetic joint infection, revision, and mechanical complications. LEVEL OF EVIDENCE: Level IV.

Platelet-rich plasma for jumper's knee: a comprehensive review of efficacy, protocols, and future directions.

PURPOSE: This comprehensive review evaluates the current state of platelet-rich plasma (PRP) treatment for jumper's knee, also known as patellar tendinopathy. The aim is to assess the efficacy of PRP as a therapeutic option compared to other available procedures, investigate the benefits and potential drawbacks of PRP infiltration, and provide insights into the optimal protocols for PRP preparation and administration. METHODS: A comprehensive literature search of English articles published up to June 2023 was conducted using PubMed and Scopus databases. Studies evaluating PRP for treating jumper's knee or patellar tendinopathy were analyzed to assess the current state of research in this field. RESULTS: PRP has demonstrated promising results in promoting cellular remodeling and accelerating the healing process in the jumper's knee. It shows potential benefits in pain reduction, improved function, and accelerated recovery. However, the efficacy of PRP varies depending on patient characteristics, disease severity, and the specific administration methodology. Establishing standardized PRP preparation and administration protocols are necessary to optimize its effectiveness. Further research is needed to define appropriate patient selection criteria and refine the application of PRP therapy in patellar tendinopathy management. CONCLUSION: Jumper's knee is commonly managed conservatively, but there is a lack of consensus on further treatment options. PRP treatment holds promise in promoting tissue healing and repair. However, standardized protocols for PRP preparation and administration, as well as optimal dosage and number of injections, require further investigation to enhance its efficacy. Continued research efforts are necessary to ascertain the precise role of PRP and its refinement in the management of patellar tendinopathy.

Indications, complications, and clinical outcomes of fixation and acute total hip arthroplasty for the treatment of acetabular fractures: A systematic review.

PURPOSE: Acetabular fracture fixation can be challenging, especially in the elderly. Open reduction and internal fixation (ORIF) alone may not allow for early weight bearing and is associated with a high rate of secondary osteoarthritis; therefore, a combined hip procedure (CHP) or ORIF with acute total hip arthroplasty, may be beneficial in this population. The objective of this study was to perform a systematic review of all reported cases of CHP. METHODS: PubMed, Embase, Scopus, and Cochrane databases were searched for studies analyzing acetabular fractures in the elderly managed with a combined hip procedure (CHP). The research was performed following the PRISMA guidelines. The included studies' methodological quality was evaluated using the MINORS score. The present study was registered on PROSPERO. RESULTS: Eleven clinical studies were included in the final analysis. The mean age was 74.4 (63.2-78) years. Low-energy trauma was the most common mechanism of injury (64%). The most prevalent fracture pattern was the anterior column and posterior hemitransverse (ACPHT) (30.6%). The Kocher-Langenbeck approach was preferred for ORIF of posterior fractures and hip arthroplasty. The ilioinguinal approach and modified Stoppa were generally used for anterior fractures. The overall complication rate was 12.2%, and hip dislocation was the most frequent cause of reoperation (4.4%). The average Harris Hip Score reported postoperatively was 81.6 points, which was considered "good." CONCLUSIONS: CHP is a safe treatment for elderly acetabular fractures with an acceptable complication and reoperation rate that results in good clinical outcomes. LEVEL OF EVIDENCE: Level of evidence IV.

Surgical treatment of popliteomeniscal fascicles tears is associated with better patient-reported outcome measures. A systematic review and meta-analysis.

PURPOSE: Popliteomeniscal fascicles (PMFs) are a component of the popliteal hiatus complex in the knee, and their injury primarily affects young athletes participating in sports activities involving twisting movements. The identification of PMFs tears presents a challenge, often accompanied by lateral pain and a locking sensation. The objective of this systematic review (SR) and meta-analysis is to enhance the suspicion and recognition of PMFs tears, aiming to facilitate the treatment of this condition, particularly in symptomatic young patients. METHODS: A comprehensive search, focused on studies examining PMFs injuries and their treatment, was conducted in four databases, PubMed, Scopus, Embase, and Web of Science. The ROBINS-I tool was used to evaluate the risks of bias. The PRISMA flow diagram was used to conduct the research and select the included studies. A meta-analysis was conducted for the Lysholm score, the Tegner Activity Scale, and the subjective IKDC score. The present SR and meta-analysis was registered on PROSPERO. RESULTS: Five clinical studies were included in the final analysis, comprising 96 patients. All the patients underwent a preoperative MRI assessment and a diagnostic arthroscopy to detect the PMFs tears, with a subsequent surgical procedure either open or arthroscopically performed. Surgery was associated with the resolution of symptoms. A statistically significant improvement in the Lysholm score (p: 0.0005) and the subjective IKDC score (p: 0.003) after the surgical procedure with respect to the preoperative evaluation was found. CONCLUSION: This SR and meta-analysis showed a significant improvement in the Lysholm score and subjective IKDC score following surgery for PMFs tears. However, controversy persists regarding the optimal surgical approach, with current literature favoring arthroscopic procedures. LEVEL OF EVIDENCE: IV.

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.

Treatment of Scaphoid Non-Unions with Custom-Made 3D-Printed Titanium Partial and Total Scaphoid Prostheses and Scaphoid Interosseous Ligament Reconstruction.

PURPOSE: Treatment of scaphoid fracture sequelae is still an unsolved problem in hand surgery. Custom-made 3D-printed titanium partial and total scaphoid prosthesis and scaphoid interosseous ligament reconstruction (SLIL) are performed in cases of non-union and isolated aseptic necrosis of the proximal scaphoid pole and when it is impossible to save the scaphoid bone, respectively. This study aims to evaluate the clinical, functional and radiographic results after these two prosthesis implantations. METHODS: Between January 2019 and July 2020, nine partial and ten total scaphoid prostheses were implanted using custom-made 3D-printed titanium implants. Evaluation criteria included carpal height ratio (CHR), radioscaphoid angle, wrist extension and flexion, radial deviation and ulnar deviation of the wrist, grip strength and pinch strength, Visual Analogue Scale (VAS), the Disabilities of Arm, Shoulder, and Hand (DASH) score, and the Patient-Rated Wrist Evaluation (PRWE). RESULTS: Clinical, functional, and radiographic improvements were found in all outcomes analyzed for both patient groups. The VAS pain scale obtained the most remarkable improvement at the one-year follow-up. The results of the DASH scores and the PRWE were good, with a great rate of patient satisfaction at the end of the follow-up. SLIL reconstruction also provided excellent stability and prevented a mid-carpal bone collapse in the short- and medium-term follow-up. CONCLUSIONS: A custom-made 3D-printed titanium partial or total scaphoid prosthesis is a viable solution for patients with scaphoid non-union and necrosis or complete scaphoid destruction in whom previous conservative or surgical treatment has failed.

Flexor Tendon Pulley Injuries: A Systematic Review of the Literature and Current Treatment Options.

Closed injuries of the finger flexor pulley system are rare among the general population, and most of them occur during rock climbing. During the last few decades, scientific interest on this topic has increased. We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The research was limited from January 2000 to March 2022. PubMed and Scopus databases were investigated for full-text articles published in English, French, and Italian using the following MeSH terms: ([pulley rupture] OR [finger pulley lesion]) AND ([injur*] OR [ruptur*] OR [damage] OR [trauma*]). Initial screening results identified 461 studies, among which 172 were included after including additional records identified through other sources and excluding repeated studies. Finally, four clinical studies were included in the analysis. The methodological quality of the articles was evaluated through the methodological index for nonrandomized studies (MINORS) score. Our search identified four studies that enrolled a total of 189 patients, of whom 164 were male and 25 were female. We finally examined 154 patients with a total of 208 pulleys damaged. Except for the thumb, all fingers were involved. Depending on the type of flexor pulley injury, graded with Schöffl classification, 69 patients underwent a surgical procedure, whereas 85 patients were treated conservatively. Closed finger pulleys injury occurred in rock climbers and non - rock climbers. All patients had excellent results on the Buck-Gramcko score regardless of the return to sports activity. Considering the overall outcomes of the reviewed articles, functional results were satisfactory in both conservative and surgical treatment. Moreover, in grade 3 and 4, surgical results were positive regardless of the specific technique used for finger pulley reconstruction. Only minor complications were reported. Closed flexor tendon pulley injuries require a careful clinical and imaging examination to confirm the diagnosis. In most cases, positive clinical results can be achieved with either conservative or surgical therapy.

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.

Two-stage revision in periprosthetic joint infection of the hip using a new intraoperatively molded articulating spacer design.

Purpose: The treatment of periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is still under debate. Two-stage exchange arthroplasty is the most common surgical procedure performed. This study analyzed a new functional articulating hip spacer called "Spaceflex" regarding the mechanical-related complications, the recurrent/persistent infection during the interval period, the overall infection-free survivorship after reimplantation, the overall complication/reoperation after reimplantation and the evaluation of patient-reported outcome measures (PROMs) at three intervals of time: before the first stage, during the interval period, and at the final follow-up after reimplantation. Methods: A consecutive series of 56 patients with chronic hip PJI undergoing two-stage prosthetic revision using a new intraoperatively molded articulating hip spacer design implanted by the same experienced surgeons was examined from January 2017 to December 2021. The demographic and clinical characteristics of the included patients were analyzed. Specifically, PROMs before the first stage, during the interval period, and at the final follow-up after reimplantation and complications reported during the interval period and after reimplantation were examined. Results: The new functional articulating hip spacer was characterized by a low mechanical complication rate (5.8%) and an overall two-stage procedure success rate of 90.6% at the last follow-up. PROMs improved with the spacer during the interval period and at the final follow-up. Furthermore, the reinfection rate was in line with other case series with different spacer designs. Finally, low postoperative complication rates after reimplantation have been demonstrated. Conclusions: Two-stage revision performed with a modular articulating spacer allows patients to preserve satisfactory functional and quality-of-life outcomes in the postoperative period, with a low risk of mechanical complications and without increasing the reinfection rate.

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.

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.

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.

Reevaluation of the surgical indications for anterior inferior iliac spine avulsion fractures in an acute setting - A narrative review of the current literature.

Purpose: The anterior inferior iliac spine (AIIS) is a frequent site of avulsion fracture in the pelvis, and these lesions could be observed mainly in teenage athletes. The present study aimed to re-evaluate the appropriate acute surgical treatment of AIIS avulsion fractures considering the three-dimensional anatomy of the supracetabular region. Methods: This study evaluated current evidence of AIIS avulsion fracture treatments and outcomes. A literature search was done in the following databases: PubMed, SCOPUS, Embase, and Cochrane Library. All relevant information was used in this review. Results: Several studies have shown how conservative treatment of these injuries lead to excellent outcomes, even when there is radiological evidence of displacement. However, only some surgeons describe clinical and radiological follow-up beyond six months. On the other side, recent studies have demonstrated the efficacy of arthroscopic or open procedures to solve a frequent cause of extra-articular femur-acetabular impingement (FAI) syndrome associated with previous AIIS avulsion fractures, the so-called sub-spine impingement. The acute surgical indication in AIIS avulsion fractures should be considered according to the three-dimensional anatomy of the supracetabular region, especially in young patients with high functional demands. Conclusions: Three-dimensional assessment allows accurate evaluation of the position and dislocation of the fragment, predicting the risk of complications related to conservative treatment and guiding toward surgical indication only when appropriate.

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.

Extended trochanteric osteotomy is a safe procedure in two-stage hip revision: a systematic review of the literature.

BACKGROUND: Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate remains about its safety in periprosthetic joint infection (PJI). The primary aim of this study is to analyze the ETO reinfection and union rate in two-stage hip revision. MATERIAL AND METHODS: A systematic literature review was performed regarding all studies reporting ETO outcomes in the two-stage revision for hip PJI up to October 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search was conducted in the following databases: MEDLINE/EMBASE, Scopus, Web of Science, and Cochrane. Quality assessment of the articles was performed using the Methodological Index for Non-Randomized Studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews. Patient demographic, clinical, and surgical data were collected. RESULTS: This systematic review included and analyzed nine clinical studies with a total of 382 ETO PJI hips in two-stage revision. The overall ETO reinfection rate was 8.9% (34 hips), consistent with the reinfection rate after two-stage revision in patients without ETO. The overall ETO union rate was 94.8% (347 hips), comparable to the ETO union rate in non-septic patients. Compared between a group of patients with ETO PJI and a group of patients with non-PJI ETO, there were no significant differences in postoperative complications, both septic and aseptic, and for postoperative HHS. CONCLUSION: ETO proved to be a safe and effective procedure in PJI revisions. It may be a viable option in challenging femoral stem removal during the two-stage hip revision in PJI. LEVEL OF EVIDENCE: IV.

Highly cross-linked polyethylene versus conventional polyethylene in primary total knee arthroplasty: comparable clinical and radiological results at a 10-year follow-up.

PURPOSE: Highly crosslinked polyethylene (HXLPE) was introduced in total knee arthroplasty (TKA) to reduce wear and consequent revisions for loosening due to conventional polyethylene (CPE) wear. This study aims to analyse whether HXLPE is as safe as CPE and could improve the TKA clinical and radiological results in a long-term follow-up. METHODS: This retrospective study included all consecutive starting series of 223 patients with severe primary knee osteoarthritis (OA), with a minimum follow-up of 10 years treated between July 1st, 2007, and July 31st, 2010. After excluding patients who did not respect the inclusion and exclusion criteria, 128 patients were included in the analysis of this study. The patients were then divided into two groups according to the type of polyethylene (PE) implanted: CPE or HXLPE liners. All patients were evaluated for clinical and radiological parameters, causes and revision rates related to the type of PE implanted. RESULTS: HXLPE appears to be as safe as CPE in TKA, reporting no higher revisions for osteolysis, prosthesis loosening, infection, and mechanical failure. Nevertheless, no statistically significant differences were found between the two groups in the clinical and radiological outcomes evaluated. CONCLUSIONS: Clinical, radiological results, and revision rates are similar between HXLPE and CPE in TKA after 10 years of follow-up, although HXLPE benefits remain controversial. LEVEL OF EVIDENCE: III.