Sulcus Angle, Trochlear Depth, and Dejour's Classification Can Be Reliably Applied To Evaluate Trochlear Dysplasia: A Systematic Review of Radiological Measurements.

PURPOSE: To summarize data on the reliability of available imaging criteria for the assessment of trochlear dysplasia and to assess the methodological quality of the included studies. METHODS: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Search was performed using major electronic databases from their inception to September 2021. All studies enrolling patients of any age who underwent a radiological exam to rule out features related to trochlear dysplasia were included. After the identification of available imaging criteria, reliability studies were analyzed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability studies checklist. RESULTS: A total of 2391 articles were identified, and 33 articles comprising 3036 patients with a mean age of 28.6 years were included. Thirty different measurements were extracted. Magnetic resonance imaging (MRI) was the most used imaging modalities (21 studies), followed by computed tomography (10 studies), conventional radiology (8 studies) and ultrasonography (US) (1 study). Sulcus angle, trochlear depth, and Dejour's classification were the most explored measurements. Overall, sulcus angle can be reliably assessed on radiography, CT and MRI, whereas trochlear depth can be reliably measured only with CT and MRI. Reliability of Dejour's classification ranged from poor or fair to very good for all imaging modalities. Methodological quality of included studies varied from 2 to 9 positive items out of 11 possible. Twenty-four studies (72.7%) were considered at high risk of bias. CONCLUSION: Trochlear dysplasia can be reliably evaluated at least with 3 measurements: sulcus angle, trochlear depth and Dejour's classification. Methodological quality assessment showed high risk of bias in most included studies. LEVEL OF EVIDENCE: Level III, systematic review of Level II-III studies.

BLU-DAT: a new reliable and accurate arthrometer for measuring anterior knee laxity.

PURPOSE: Although many arthrometers have been developed to assess anterior knee laxity, reliability and diagnostic accuracy of these devices are still debated. The aim of the present study was to evaluate the validity of a new arthrometer in the outpatient setting, with the hypothesis that it had good validity in terms of reliability and diagnostic accuracy. METHODS: Seventy-eight subjects (39 with ACL injury and 39 with normal ACL) were tested. ATT was assessed by means of the Lachman test at 30° of flexion with a new testing device (BLU-DAT) under three different loading conditions: 7 kg (69 N), 9 kg (88 N) and maximum (MMT). The tests were performed on both knees to obtain SSD. In the ACL injury group, the tests were performed by two examiners and one of them repeated a second test series. Inter- and intra-observer reliability were assessed with the intraclass correlation coefficients (ICCs) for the average SSD measures. In the normal-ACL group, the analysis was performed with the same testing setup. Side-to-side difference measures of the two groups at every loading condition were compared by Student's t test. Data of test series were dichotomized based on the threshold value of 3-mm SSD as pathological ATT and 2 × 2 contingency tables were used to assess diagnostic accuracy. RESULTS: The ICCs for intra-observer reliability at 7-kg (69 N), 9-kg (88 N) and MMT measurements were 0.781, 0.855 and 0.913, respectively. The ICC for inter-observer reliability at 7-kg (69 N), 9-kg (88 N) and MMT measurements were 0.701, 0.845 and 0.834, respectively. Comparison between the two groups showed a significant mean difference ranging from 3.4 mm for 7-kg (69 N) load to 4.6 mm for MMT. Overall accuracy ranged from 84.6% for 7-kg load to 98.7% for MMT. CONCLUSION: The BLU-DAT has proven to be an instrument with good intra- and inter-observer reliability and very good accuracy in the diagnosis of ACL injuries in the outpatient setting. So, the BLU-DAT can be a new useful tool in everyday clinical practice to assist in the diagnosis of ACL injury. LEVEL OF EVIDENCE: II.

High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach.

PURPOSE: To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques. METHODS: Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient-related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two-thirds agreement on one answer. Descriptive statistic was used to summarize the data. RESULTS: Forty-one shoulder experts were involved. Fifty-six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient-related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo-paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair. CONCLUSION: A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo-paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external-rotation. LEVEL OF EVIDENCE: V.

A new knee arthrometer demonstrated to be reliable and accurate to assess anterior tibial translation in comparison with stress radiographs.

INTRODUCTION: For several years, many arthrometers have been developed to assess anterior knee laxity. The aim of our study was to evaluate the validity of a new practical and handy testing device with the hypothesis that the new arthrometer had good validity in terms of reliability and accuracy. METHODS: Lachman test was performed on five fresh frozen cadaveric knees by five examiners. Anterior tibial translation (ATT) was measured with a new arthrometer (BLU-DAT) and on lateral stress radiographs. Data on ATT were obtained under 7 kg (69 N), 9 kg (88 N), and maximum manual traction (MMT). Tests were performed on the same specimens before and after arthroscopic ACL excision. Inter-rater reliability of the BLU-DAT measures was assessed with the intraclass correlation coefficient (ICC) for single and average measurements. The Bland-Altman method was used to estimate agreement between the BLU-DAT and stress radiographs. RESULTS: ICC values for single measurements were 0.62, 0.54 and 0.58 for 7-kg, 9-kg and MMT assessment, respectively. Overall reliability was good (ICC = 0.63). ICC values for average measurements were 0.89, 0.85 and 0.88 for 7-kg, 9-kg and MMT assessment, respectively. Overall reliability was very good (ICC = 0.90) SEM ranged from 1.4 mm to 1.6 mm for single measurements and was below 1 mm at each testing condition for average measurements. Analysis of agreement between BLU-DAT and radiographic measurements showed a mean difference equal to 0.83 mm ± 2.1 mm (95% CI: 0.55-1.11). Upper LOA was equal to 4.9 mm (95% CI: 5.39-4.41). Lower LOA was equal to - 3.2 mm (95% CI: - 2.71 to - 3.69). CONCLUSION: Measurement of anterior knee laxity with the BLU-DAT testing device has a good to very good inter-rater reliability and good agreement with a gold standard such as stress radiographs. Cadaveric Diagnostic Study, Level of Evidence IV.

Knotless PEEK and double-loaded biodegradable suture anchors ensure comparable clinical outcomes in the arthroscopic treatment of traumatic anterior shoulder instability: a prospective randomized study.

PURPOSE: To compare the clinical outcome of arthroscopic capsulolabral repair for traumatic anterior shoulder instability with PEEK knotless and knotted biodegradable suture anchors. METHODS: Arthroscopic stabilization was performed in 78 patients with recurrent traumatic anterior shoulder instability. They were divided into 2 groups of 39 patients each, according to suture anchors used: knotless PEEK anchors in group 1, and biodegradable anchors in group 2. Exclusion criteria were: instability without dislocation, posterior or multidirectional instability, glenoid bone loss > 20%, off-track lesions, concomitant rotator cuff tears and previous surgery. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) self-administered questionnaire. Secondary outcomes were: Work-DASH, Sport-DASH, Rowe score, recurrent instability and subsequent surgery. The following independent variables were considered: age, gender, dominance, generalized ligamentous hyperlaxity, duration of symptoms, age at first dislocation, number of dislocations, type of work, type of sport, sports activity level, capsule-labral injury pattern, SLAP lesion and number of anchors. Differences between groups for numerical variables were analyzed by use of the Student's t-test or Mann-Whitney U-test. Fisher's exact test was used for analysis of categorical variables. Significance was set at p < 0.05. RESULTS: Seven patients (9%) were lost at follow-up, 5 from group 1 and 2 from group 2. Follow-up ranged from 36 to 60 months (median: 44; IQR: 13). Comparison between groups did not show significant differences for each independent variable considered. No differences could be found either for DASH (n.s.) or Rowe (p = n.s.) scores between the two groups. Overall recurrence rate was 7%. Three re-dislocations were reported in group 1 and two in group 2 (n.s.). Only one patient in each group underwent re-operation. CONCLUSIONS: The study showed no significant differences in clinical outcomes after arthroscopic treatment of traumatic anterior shoulder instability using PEEK knotless or biodegradable knotted anchors at mid-term follow-up. LEVEL OF EVIDENCE: I.

Editorial Commentary: Acromioplasty Does Not Improve Clinical Outcome of Arthroscopic Rotator Cuff Repair: The Game Is Over!

Acromioplasty is a well-known, simple, and reproducible surgical technique that is used in isolation or in combination with other arthroscopic procedures. The clinical value of acromioplasty combined with arthroscopic rotator cuff repair has been largely investigated. Main theoretical benefits lie in the opportunity to improve the visualization, decrease abrasive wear with prominent acromial morphology, and release natural growth factors. On the other hand, acromioplasty and release of the coracoacromial ligament may weaken the insertion of the deltoid muscle, induce scar formation in the subacromial space, theoretically limiting shoulder mobility, and increase risk of anterior-superior humeral escape, especially in patients with large to massive rotator cuff tears. Clinical studies report conflicting results. My results show no differences in clinical outcomes in rotator cuff repairs with or without subacromial decompression, regardless of the acromial morphology. At the same time, I do believe that confirmatory studies are always necessary, especially if the aim is to disprove the usefulness of a common practice.

No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review.

PURPOSE: To conduct a scoping review to clarify the management of acromioclavicular joint osteoarthritis, as well as to identify any existing gaps in the current knowledge. METHODS: Studies were identified by electronic databases (Ovid, Pubmed) from their inception up to April 2nd, 2020. All studies reporting functional outcomes after conservative or surgical treatment of acromioclavicular joint osteoarthritis, either primary or secondary to trauma or distal clavicle osteolysis, were included. Following data were extracted: authors, year of publication, study design (prospective or retrospective), LOE, number of shoulders treated conservatively or surgically, patients' age, OA classification, type of conservative treatment, surgical approach, surgical technique, functional outcomes, complications, revisions, and length of follow-up. Descriptive statistics was used. Quality appraisal was assessed through the Cochrane risk of bias tool for LOE I/II studies, while the MINORS checklist was used for LOE III/IV studies. RESULTS: Nineteen studies were included for a total of 861 shoulders. Mean age of participants was 48.5 ± 7.4 years. Mean follow-up was 43.8 ± 29.9 months. Four studies reported functional results after conservative treatment, whereas 15 studies were focused on surgical management. No studies directly compared conservative and surgical treatment. Seven studies reported a surgical approach after failure of previous conservative treatment. All studies reported functional improvement and pain relief. Complication rate was low. Overall methodological quality of included studies was very low. CONCLUSION: Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. However, available data did not allow to establish the superiority of one technique over another. LEVEL OF EVIDENCE: Level IV.

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members.

PURPOSE: To develop a consensus on diagnosis and treatment of acromioclavicular joint instability. METHODS: A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data. RESULTS: A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar CONCLUSION: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified. LEVEL OF EVIDENCE: Level V.

Anatomic reconstruction of the acromioclavicular joint provides the best functional outcomes in the treatment of chronic instability.

PURPOSE: To systematically review the outcomes of surgical treatments of chronic acromioclavicular joint dislocation. METHODS: Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of chronic acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist. RESULTS: Fourty-four studies were included for a total of 1020 shoulders. Mean age of participants was 38 years. Mean follow-up was 32.9 months. Arthroscopic techniques showed better results than open approach (p < 0.0001). Synthetic reconstructions demonstrated better functional outcomes compared to internal fixation and biologic techniques (p < 0.0001). Among biologic techniques, combined coracoclavicular and acromioclavicular ligaments reconstruction showed better Constant (p = 0.0270) and ASES (p = 0.0113) scores compared to isolated coracoclavicular ligaments reconstruction; anatomic biologic non-augmented graft reconstruction showed better Constant (p < 0.0001), VAS (p < 0.0001) and SSV (p = 0.0177) results compared to augmented techniques. No differences in functional outcomes could be found between anatomic biologic non-augmented graft versus synthetic reconstructions. Overall, methodological quality of the included studies was low. CONCLUSION: Anatomic reconstructions, both synthetic and biologic, showed the best functional results. LEVEL OF EVIDENCE: IV.

Anatomic reconstruction of the coracoclavicular and acromioclavicular ligaments with semitendinosus tendon graft for the treatment of chronic acromioclavicular joint dislocation provides good clinical and radiological results.

PURPOSE: To evaluate clinical and radiographic outcomes of anatomical reconstruction of the coracoclavicular and acromioclavicular ligaments with single-strand semitendinosus tendon graft for the treatment of chronic acromioclavicular joint dislocation. METHODS: Patients affected by chronic type III-V acromioclavicular joint dislocations were included. Exclusion criteria were: age under 18 years, concomitant rotator cuff tears, previous surgery to the same shoulder, degenerative changes of the glenohumeral joint, infections, neurologic diseases, patients with a previous history of ligament reconstruction procedures that had required harvesting of the semitendinosus tendon from the ipsilateral or contralateral knee. All patients underwent the same surgical technique and rehabilitation. Primary outcome was the normalized Constant score. Secondary outcomes were: DASH score, radiographic evaluation of loss of reduction and acromioclavicular joint osteoarthritis. RESULTS: Thirty patients with a mean age of 28.9 ± 8.3 years were included. Mean time to surgery was 12.8 ± 10 months. Mean follow-up was 28.1 ± 2.4 months (range: 24-32). Comparison between pre- and postoperative functional scores showed significant clinical improvement (p < 0.001). Time to surgery was independently associated with a poorer Constant score (p < 0.0001). On radiographs, 4 patients (13.3%) showed asymptomatic partial loss of reduction. CONCLUSION: Anatomic reconstruction of coracoclavicular and acromioclavicular ligaments using a semitendinosus tendon graft for the treatment of chronic acromioclavicular joint dislocation provided good clinical and radiological results at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level III.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation.

PURPOSE: To systematically review the outcomes of surgical treatments of acute acromioclavicular joint dislocation. METHODS: Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications, and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist. RESULTS: One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low. CONCLUSION: Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance. LEVEL OF EVIDENCE: IV.

Satisfactory mid-term outcomes of condylar-constrained knee implants in primary total knee arthroplasty: clinical and radiological follow-up.

BACKGROUND: The purpose of this study was to evaluate (1) the reoperation rates and survivorship for septic and aseptic causes, (2) radiographic outcomes, and (3) clinical outcomes of condylar-constrained knee (CCK) implants used in primary total knee arthroplasty (TKA) with severe coronal deformity and/or intraoperative instability. MATERIALS AND METHODS: A consecutive series of CCK implants in primary TKA was retrospectively evaluated in patients with severe coronal deformities. Forty-nine patients (54 knees) were included with a mean follow-up of 9 years (range 6-12). All patients were treated with a single-design, second-generation CCK implant. The primary diagnosis was osteoarthritis in 36 knees, post-traumatic arthritis in 7 knees, and rheumatoid arthritis in 4 knees. Preoperatively, standing femorotibial alignment was varus in 22 knees and valgus in 20 knees. RESULTS: At a mean follow-up of 9 years, overall survivorship was 93.6%. Two knees (4.3%) required revision for periprosthetic joint infection. One knee (2.1%) required subsequent arthroscopy due to patellar clunk syndrome. At final follow-up, no evidence of loosening or migration of any implant was reported, and the mean Knee Society knee scores improved from 43 to 86 points (p < 0.001). The mean Knee Society function scores improved to 59 points (p < 0.001). The average flexion contracture improved from 7° preoperatively to 2° postoperatively and the average flexion from 98° to 110°. No knees reported varus-valgus instability in flexion or extension. CONCLUSION: CCK implants in primary TKA with major coronal deformities and/or intraoperative instability provide good midterm survivorship, comparable with less constrained implants. In specific cases, CCK implants can be considered a viable option with good clinical and radiographic outcomes. However, a higher degree of constraint should be used cautiously, leaving the first choice to less constrained implants. Level of evidence Therapeutic study, level IV.

Biomechanical Analysis of Latarjet Screw Fixation: Comparison of Screw Types and Fixation Methods.

PURPOSE: To compare the initial fixation stability, failure strength, and mode of failure of 5 different screw types and fixation methods commonly used for the classic Latarjet procedure. METHODS: Thirty-five fresh-frozen cadaveric shoulder specimens were allocated into 5 groups. A 25% anteroinferior glenoid defect was created, and a classic Latarjet coracoid transfer procedure was performed. All grafts were fixed with 2 screws, differing by screw type and/or fixation method. The groups included partially threaded solid 4.0-mm cancellous screws with bicortical fixation, partially threaded solid 4.0-mm cancellous screws with unicortical fixation, fully threaded solid 3.5-mm cortical screws with bicortical fixation, partially threaded cannulated 4.0-mm cancellous screws with bicortical fixation, and partially threaded cannulated 4.0-mm captured screws with bicortical fixation. All screws were stainless steel. Outcomes included cyclic creep and secant stiffness during cyclic loading, as well as load and work to failure during the failure test. Intergroup comparisons were made by a 1-way analysis of variance. RESULTS: There were no significant differences among different screw types or fixation methods in cyclic creep or secant stiffness after cyclic loading or in load to failure or work to failure during the failure test. Post-failure radiographs showed evidence of screw bending in only 1 specimen that underwent the Latarjet procedure with partially threaded solid cancellous screws with bicortical fixation. The mode of failure for all specimens analyzed was screw cutout. CONCLUSIONS: In this biomechanical study, screw type and fixation method did not significantly influence biomechanical performance in a classic Latarjet procedure. When performing this procedure, surgeons may continue to select the screw type and method of fixation (unicortical or bicortical) based on preference; however, further studies are required to determine the optimal method of treatment. CLINICAL RELEVANCE: Surgeons may choose the screw type and fixation method based on preference when performing the Latarjet procedure.

Prognostic factors influencing the outcome of rotator cuff repair: a systematic review.

PURPOSE: To identify prognostic factors significantly associated with rotator cuff repair outcome and define the strength of these associations. METHODS: Search was performed using electronic databases. Studies reporting prognostic factors affecting rotator cuff repair outcome were included. Primary outcomes were: structural integrity, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, and Constant score. Each other outcome was considered as secondary outcome. Descriptive statistics was used. When possible, meta-analyses were performed. Methodological quality was assessed using the Quality In Prognosis Studies Tool. A best evidence synthesis was performed using the Grading of Recommendations Assessment, Development and Evaluation framework adapted to prognostic studies. RESULTS: Sixty-four studies were included. Methodological quality was high only for twelve studies. The overall quality of evidence was low to very low. Meta-analyses were possible only for seven studies. Older age and larger tears size were found to affect retear risk. Results were controversial for fatty infiltration, acromioclavicular joint or biceps procedures, acromiohumeral distance, delamination of tendon edges, musculotendinous junction position, number of tendons involved, and tendon length, quality and retraction. Baseline scores and workers compensation claim predicted functional outcomes. Subjective outcome was also affected by patient's expectations. CONCLUSIONS: Despite the large number of outcomes and prognostic factors evaluated by a relative small number of studies, almost not prognostic in design, it was not possible to reach any definitive conclusion regarding the most relevant predictors of outcome of rotator cuff repair. Moreover, the low methodological quality of the included studies and, subsequently, the low quality of evidence, seriously affected the strength of recommendation of the present review. Based on data available, retear risk is mainly affected by older age and larger tears size. Baseline scores and work compensation claim are the most significant predictors for functional outcomes. LEVEL OF EVIDENCE: Systematic review of level I-IV prognostic studies, Level IV.

Efficacy of intra-articular hyaluronic acid injections and exercise-based rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis.

PURPOSE: To assess the efficacy of intra-articular hyaluronic acid (HA) injections and exercise-based rehabilitation (EBR) programme, administered as isolated or integrated for the treatment of knee osteoarthritis. METHODS: One hundred sixty-five patients affected by moderate degrees of knee OA were randomly divided into three groups. Group 1 (HA) underwent three HA injections (one every 2 weeks); group 2 (EBR) underwent 20 treatment sessions in a month of an individualized programme; and group 3 (HA + EBR) received both treatments simultaneously. Primary outcome was the Italian version of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; secondary outcome was the evaluation of active range of movement (AROM). All patients were evaluated before and 1, 3 and 6 months after treatment. Significance was set at p < 0.05. RESULTS: Two patients in each group were lost to follow-up. No adverse events occurred. All groups experienced improvements at 1-month follow-up. No further improvements could be detected within groups over time. At 1-month follow-up, WOMAC pain subscale showed significant improvement in group 3 compared to group 1 (p = 0.043). WOMAC pain, stiffness and function subscales showed that group 2 significantly worsened between 1 and 6 months after treatment (p = 0.004, p = 0.026 and p = 0.025, respectively). AROM revealed no significant differences between and within groups over time. CONCLUSIONS: Intra-articular HA injections and individualized rehabilitation programmes administered in isolation or in combination are effective in improving knee function and pain relief. The combined treatment showed the greatest pain relief at 1-month follow-up compared to either in isolation. Compared to the previous studies, this is the first study, which proposed an EBR programme tailored to the compartment of the knee joint most involved in the degenerative process. LEVEL OF EVIDENCE: I.

Pectoralis major transfer for treatment of irreparable subscapularis tear: a systematic review.

PURPOSE: Irreparable ruptures of the subscapularis tendon lead to impaired function of the shoulder and presents a surgically complex problem. Transfer of the pectoralis major tendon has been reported as a possible treatment option. The purpose of this systematic review is to critically examine the outcomes of pectoralis major transfers for the treatment of irreparable subscapularis tears. METHODS: A systematic review of the literature was performed using search of electronic databases. No language restrictions were applied. Case reports, review articles, and operative techniques without outcome data were excluded. All the outcomes reported by each study were analyzed and when possible, data were pooled to generate frequency-weighted values to summarize outcomes. RESULTS: Eight studies with a total 195 shoulders were included in this systematic review. The mean age of patients was 58.8 years (range 18-81 years) and the mean follow-up was 33.4 months (range 6-80 months). Constant scores improved from a mean pre-operative score of 37.8 ± 6.8, to a mean postoperative score of 61.3 ± 6.5 (p < 0.0001). Pain scores could not be pooled as different scales were used. Nevertheless, a trend in pain reduction was noted in all papers. Functional outcomes were less favorable in patients with massive rotator cuff tears or previous shoulder replacements. Moreover, the Constant scores were significantly higher in patients following subcoracoid transfer of the pectoralis major tendon compared to patients who received supracoracoid transfer (p < 0.001). The overall reported incidence of postoperative nerve palsy is low (one transient musculocutaneous nerve palsy and one axillary nerve dysfunction out of 195 cases). CONCLUSIONS: The systematic review based on frequency-weighted means demonstrated improvement in shoulder function, strength and pain relief after pectoralis major transfer for irreparable subscapularis tear. LEVEL OF EVIDENCE: IV.

Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis.

PURPOSE: The purpose of this study was to determine the efficacy of surgical and conservative treatment in the prevention of recurrence after primary patellar dislocation. METHODS: Studies were searched on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINHAL from their inception to April 2015. All randomized controlled clinical trials comparing surgical versus conservative treatment after first patellar dislocation were included. Primary outcomes were: recurrent dislocation, subluxation, overall instability and subsequent surgery. Secondary outcomes included imaging, and subjective and objective clinical assessment tools. Methodological quality of the studies was assessed using Cochrane Collaboration's "Risk of Bias" tool. Pooled analyses were reported as risk ratio (RR) using a random effects model. Continuous data were reported as standardized mean difference (SMD) and 95 % confidence intervals (CIs). Heterogeneity was assessed using I². RESULTS: Nine studies were included in the meta-analyses. Methodological quality of the studies was moderate to low. Meta-analyses showed that surgical treatment significantly reduces the redislocation rate (RR = 0.62; 95% CI = 0.39, 0.98, p = 0.04) and provides better results on Hughston VAS score (SMD = -0.32; 95% CI = -0.61, -0.03; p = 0.03) and running (OR = -0.52; 95% CI = 0.31, 0.88; p = 0.01). Conservative treatment showed less occurrence of minor complications (OR = 3.46; 95% CI = 2.08, 5.77; p = 0.01) and better results in the figure-of-8 run test (SMD = 0.42; 95% CI = 0.06, 0.77; p = 0.02) and in the squat down test (SMD = -0.45; 95% CI = -0.81, -0.10; p < 0.00001). No other significant differences could be found. CONCLUSIONS: Based on the available data, surgical treatment of primary patella dislocation significantly reduces the risk of patella redislocation.

The effect of norepinephrine versus epinephrine in irrigation fluid on the incidence of hypotensive/bradycardic events during arthroscopic rotator cuff repair with interscalene block in the sitting position.

PURPOSE: To compare the occurrence rate of hypotensive and bradycardic events (HBEs) during arthroscopic rotator cuff repair performed with interscalene brachial plexus block anesthesia in the sitting position in 2 groups of patients who underwent the procedure with norepinephrine or epinephrine added to the irrigation fluid. The secondary objective was to evaluate the efficacy of norepinephrine in comparison with epinephrine in controlling intraoperative bleeding and maintaining adequate visualization of the arthroscopic field of view during the procedure. We hypothesized that norepinephrine added to the irrigation fluid during shoulder arthroscopy in the sitting position would reduce the occurrence of HBEs, allowing optimal intraoperative bleeding control. METHODS: One hundred twenty patients underwent an arthroscopic rotator cuff repair performed under peripheral anesthesia and in the beach-chair position. Patients were randomly divided into 2 groups of 60 cases each: Norepinephrine (0.66 mg/L) and epinephrine (0.33 mg/L) were added to irrigation bags in group N and group E, respectively. The primary outcome was the occurrence rate of HBEs during surgery. The secondary outcomes were timing of onset of HBEs, accompanying symptoms, and intraoperative bleeding that impaired arthroscopic visualization. The clarity of the visual field was rated postoperatively by the surgeon using a visual analog scale. Comparison between groups for all baseline variables and outcome measurements was performed with the χ(2) or Fisher exact test, as appropriate, for categorical variables and the Student t test or Mann-Whitney U test, as appropriate, for continuous variables. Significance was set at P < .05. RESULTS: One patient was excluded from group E because of block failure; therefore 119 patients were finally included in the study. Comparison between groups showed no significant differences in baseline characteristics. The occurrence rate of HBEs was significantly greater in group E (n = 15) than in group N (n = 5) (P = .02). No differences between groups were found in the average time of onset of HBEs, accompanying symptoms, and clarity of the visual field. CONCLUSIONS: Continuous administration of norepinephrine, 0.66 mg/L, diluted in irrigation fluid during arthroscopic rotator cuff repair with the patient in the beach-chair position reduces the incidence of HBEs and is as effective as epinephrine in controlling intraoperative bleeding and maintaining the visual clarity of the surgical field. LEVEL OF EVIDENCE: Level I, randomized clinical study.

Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review.

PURPOSE: The purpose of this systematic review was to detect the reliability of the currently available magnetic resonance imaging measurements used in the evaluation of repaired rotator cuff. METHODS: Search was performed using major electronic databases from their inception to February 2014. All studies reporting post-operative magnetic resonance assessment after rotator cuff repair were included. After the identification of available magnetic resonance criteria, reliability studies were further analysed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist. RESULTS: One hundred and twenty studies were included in the review. Twenty-six different criteria were identified. Ten studies reported inter-observer reliability, and only two assessed intra-observer reliability of some of the identified criteria. Structural integrity was the most investigated criterion. The dichotomized Sugaya's classification showed the highest reliability (k = 0.80-0.91). All other criteria showed moderate to low inter-observer reliability. Tendon signal intensity and footprint coverage showed a complete discordance. Intra-observer reliability was high for the presence of structural integrity, and moderate to low for all other criteria. Methodological quality was high only for one study and moderate for three studies. CONCLUSIONS: Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. Reliability of most of them has not been analysed yet. With the data available, only the presence of structural integrity showed good intra- and inter-observer agreement. LEVEL OF EVIDENCE: Systematic review of descriptive and qualitative studies, Level IV.

Advances in biology and mechanics of rotator cuff repair.

UNLABELLED: High initial fixation strength, mechanical stability and biological healing of the tendon-to-bone interface are the main goals after rotator cuff repair surgery. Advances in the understanding of rotator cuff biology and biomechanics as well as improvements in surgical techniques have led to the development of new strategies that may allow a tendon-to-bone interface healing process, rather than the formation of a fibrovascular scar tissue. Although single-row repair remains the most cost-effective technique to address a rotator cuff tear, some biological intervention has been recently introduced to improve tissue healing and clinical outcome of rotator cuff repair. Animal models are critical to ensure safety and efficacy of new treatment strategies; however, although rat shoulders as well as sheep and goats are considered the most appropriate models for studying rotator cuff pathology, no one of them can fully reproduce the human condition. Emerging therapies involve growth factors, stem cells and tissue engineering. Experimental application of growth factors and platelet-rich plasma demonstrated promising results, but has not yet been transferred into standardized clinical practice. Although preclinical animal studies showed promising results on the efficacy of enhanced biological approaches, application of these techniques in human rotator cuff repairs is still very limited. Randomized controlled clinical trials and post-marketing surveillance are needed to clearly prove the clinical efficacy and define proper indications for the use of combined biological approaches. The following review article outlines the state of the art of rotator cuff repair and the use of growth factors, scaffolds and stem cells therapy, providing future directions to improve tendon healing after rotator cuff repair. LEVEL OF EVIDENCE: Expert opinion, Level V.