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.

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.

Could anterior closed-wedge high tibial osteotomy be a viable option in patients with high posterior tibial slope who undergo anterior cruciate ligament reconstruction? A systematic review and meta-analysis.

PURPOSE: This study aims to examine the clinical and radiological outcomes of patients who underwent ACL reconstruction (ACLR) combined with anterior closed-wedge high tibial osteotomy (ACW-HTO) for posterior tibial slope (PTS) reduction to investigate the efficacy of this procedure in improving anterior knee stability and preventing graft failure in primary and revision ACLR. METHODS: A literature search was conducted in six databases (PubMed, Embase, Medline, Web of Science, Cochrane, and Scopus). The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The initial screening identified 1246 studies. Each eligible clinical article was screened according to the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence (LoE), excluding clinical studies of LoE V. Quality assessment of the articles was performed using the ROBINS-I methodological evaluation. This systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that were possible to perform a meta-analysis, a p < 0.05 was considered statistically significant. RESULTS: Five clinical studies were included in the final analysis. A total of 110 patients were examined. Pre- and post-operative clinical and objective tests that assess anteroposterior knee stability, PTS, clinical scores, and data on surgical characteristics, complications, return to sports activity, and graft failure after ACLR were investigated. A meta-analysis was conducted using R software, version 4.1.3 (2022, R Core Team), for Lysholm score and PTS outcomes. A statistically significant improvement for both these clinical and radiological outcomes (p < 0.05) after the ACW-HTO surgical procedure was found. CONCLUSION: ACLR combined with ACW-HTO restores knee stability and function with satisfactory clinical and radiological outcomes in patients with an anterior cruciate ligament injury associated with a high PTS and seems to have a protective effect from further ruptures on the reconstructed ACL. LEVEL OF EVIDENCE: Level IV.

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.

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.

Kinetic Sensors for Ligament Balance and Kinematic Evaluation in Anatomic Bi-Cruciate Stabilized Total Knee Arthroplasty.

Sensor technology was introduced to intraoperatively analyse the differential pressure between the medial and lateral compartments of the knee during primary TKA using a sensor to assess if further balancing procedures are needed to achieve a "balanced" knee. The prognostic role of epidemiological and radiological parameters was also analysed. A consecutive series of 21 patients with primary knee osteoarthritis were enrolled and programmed for TKA in our unit between 1 September 2020 and 31 March 2021. The VERASENSE Knee System (OrthoSensor Inc., Dania Beach, FL, USA) has been proposed as an instrument that quantifies the differential pressure between the compartments of the knee intraoperatively throughout the full range of motion during primary TKA, designed with a J-curve anatomical femoral design and a PS "medially congruent" polyethylene insert. Thirteen patients (61.90%) showed a "balanced" knee, and eight patients (38.10%) showed an intra-operative "unbalanced" knee and required additional procedures. A total of 13 additional balancing procedures were performed. At the end of surgical knee procedures, a quantitatively balanced knee was obtained in all patients. In addition, a correlation was found between the compartment pressure of phase I and phase II at 10° of flexion and higher absolute pressures were found in the medial compartment than in the lateral compartment in each ROM degree investigated. Moreover, those pressure values showed a trend to decrease with the increase in flexion degrees in both compartments. The "Kinetic Tracking" function displays the knee's dynamic motion through the full ROM to evaluate joint kinetics. The obtained kinetic traces reproduced the knee's medial pivot and femoral rollback, mimicking natural knee biomechanics. Moreover, we reported a statistically significant correlation between the need for soft tissue or bone resection rebalancing and severity of the initial coronal deformity (>10°) and a preoperative JLCA value >2°. The use of quantitative sensor-guided pressure evaluation during TKA leads to a more reproducible "balanced" knee. The surgeon, evaluating radiological parameters before surgery, may anticipate difficulties in knee balance and require those devices to achieve the desired result objectively.

Should we operate on all patients with COVID-19 and proximal femoral fractures? An analysis of thirty, sixty, and ninety day mortality rates based on patients' clinical presentation and comorbidity: a multicentric study in Northern Italy.

PURPOSE: This study aims to evaluate 30-60-90-day mortality of operated proximal femur fractures (PFFs) suffering from COVID-19 and correlation with patients' clinical presentation and comorbidities. METHODS: Between February 1, 2020, and December 31, 2020, patients with COVID-19 infection and surgically treated PFF were included. Patients' demographic characteristics, oxygen (O2) therapy, comorbidities, and AO type fracture were collected. Chi-square test or Fisher test and hazard ratio were used to assessing the correlation between mortality rate, patient characteristics, and COVID-19 status. Kaplan-Meyer curve was used to analyze 30-60-90-day mortality. Level of significance was set as p < 0.05. RESULTS: Fifty-six patients (mean age of 82.7 ± 8.85 years) were included. Thirty-day mortality rate was 5%, which increased to 21% at 60 days and 90 days. Eleven patients died, eight due to AO type A-like and three due to AO type B-like fractures. No significant difference in mortality rate between patients with cardiopulmonary comorbidity or no cardiopulmonary comorbidity was found (p = 0.67); a significant difference in patients with chronic obstructive pulmonary disease (COPD) or history of pulmonary embolism (PE) and patients without COPD was found (p = 0.0021). A significant difference between asymptomatic/mild symptomatic COVID-19 status and symptomatic COVID-19 status was found (p = 0.0415); a significant difference was found for O2 therapy with < 4 L/min and O2 therapy ≥ 4 L/min (p = 0.0049). CONCLUSION: Thirty-day mortality rate of COVID-19 infection and PFFs does not differ from mortality rate of non-COVID-19 PFFs. However, patients with pre-existing comorbidities and symptomatic COVID-19 infection requiring a high volume of O2 therapy have a higher incidence of 60-90-day mortality when surgically treated.

Effect of polyethylene conformity on total knee arthroplasty early clinical outcomes.

PURPOSE: Total knee arthroplasty is a successful procedure in treating subjects with end-stage knee osteoarthritis. The objective of this matched study was to evaluate subjective patient satisfaction and clinical and radiological outcomes in two groups of patients undergoing primary TKA using an identical third-generation design with different conformity in the polyethylene insert. METHODS: One hundred consecutive patients undergoing TKA because of knee osteoarthritis were randomized in two matched groups. Group A included 50 Posterior-Stabilized (PS) implants, while group B included 50 Medially Congruent (MC) implants. The surgical technique was identical: gap balancing in extension and measured resection in flexion; cruciate ligaments were always removed; the coronal alignment followed the mechanical axis and the tibial slope was set at 3° in the PS group and 5° in the MC. Oxford Knee Score (OKS) and Knee Society Score (KSS) were assessed preoperatively and at 2 year minimum follow-up. Two-sample T test statistical analysis was performed. RESULTS: All patients were available at final follow-up: there were no preoperative statistical differences between the two groups in the average preoperative ROM (PS 112°, MC 108°; n.s.), average preoperative KSS (PS 64.4, MC 63.7; n.s.), average preoperative OKS (PS 19.6; MC 19.0; n.s.), and average BMI (PS 34.40, MC 34.60; n.s.). At final follow-up, there were no statistical differences between the two groups in the average OKS (PS 40,5; MC 41.1; n.s.) and in the average KSS (PS 161,5, MC 165,7; n.s.). We found a statistically but not clinically significant difference at final ROM: the average maximum active flexion was 120° in the PS group and 123° in the MC group (s.s.). CONCLUSION: This study evaluated two biomechanically different polyethylene inserts in the same TKA design, showing that reducing the level of intra-articular conformity had minimal effects on PROMs and objective short-term clinical results but a potentially beneficial effect on ROM. This study suggests that, once a satisfactory intra-operative stability is obtained, the minimal level of constraint should be used. LEVEL OF EVIDENCE: III.

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.

Tibial plateau fractures are associated with ligamentous and meniscal injuries. Preoperative evaluation of magnetic resonance imaging influences surgical treatment.

BACKGROUND: Tibial plateau fractures (TPFs) are usually associated with ligamentous or meniscal injuries that could remain misdiagnosed. An appropriate and early recognition may change the surgical management of these soft tissue injuries (STIs) that could be addressed concomitantly with TPF treatment. Magnetic resonance imaging (MRI) is an efficient diagnostic test to identify all associated STIs in TPFs. This study aims to analyze the MRI impact in identifying and guiding the STIs treatment in TPFs. MATERIAL/METHODS: This retrospective study included a consecutive series of 57 patients with TPFs treated between January 1st, 2022, and December 31st, 2022. All fracture patterns were classified according to the AO/OTA and Schatzker classification. The prevalence of STIs, including medial meniscus (MM), lateral meniscus (LM), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) injuries, was assessed through the MRI evaluation. RESULTS: A statistical significance was found regarding the MRI detection of LM, ACL, PCL and MCL injuries that led to additional surgical procedures at the same time as the TPFs treatment (p < 0.05). In contrast, the amount of additional MM and LCL injuries identified by MRI, which resulted in other surgical procedures, was not statistically significant (p > 0.05). CONCLUSIONS: Preoperative MRI has been demonstrated to be an effective procedure for diagnosing STIs in TPFs, significantly influencing and changing the surgical treatment. LEVEL OF EVIDENCE: IV.

Bi-cruciate retaining total knee arthroplasty is here to stay: A consecutive series transitioning from manual instrumentation to enabling technologies.

BACKGROUND: Bicruciate-retaining (BCR) total knee arthroplasty (TKA) has seen renewed interest due to the potential for more natural knee kinematics with anterior cruciate ligament (ACL) retention. OBJECTIVE: The present study attempts to determine differences in the 2-year survivorship and patient-reported outcomes between two surgical strategies (traditional instrumentation versus robotics) applied to the extensive use of a modern, 2nd generation BCR TKA design. METHODS: We performed a retrospective study with prospectively collected data of 113 patients who underwent primary TKA between 2018 and 2020 using a 2nd generation BCR TKA implant. Patient demographics, PROMS, and intra/post-operative complications were collected. Patients were also evaluated according to the use or not of robotics. A Kaplan-Meier analysis was used to evaluate revision-free survival at follow up. RESULTS: 102 patients were enrolled: 90 received traditional surgery and 12 robotic-assisted surgery. The mean age was 68 years (SD 7.76) with an average BMI of 29.6 kg/m2 (SD 3.56). The mean follow up (FU) was 32.4 ± 6.2 months (range 24-45 months). Survivorship at 2 years was 98% (95% CI: 92.4-99.5). Revisions/reoperations were performed for anterior cruciate ligament (ACL) tear (1/4), pain (1/4), arthrofibrosis (1/4) and acute periprosthetic joint infection (PJI) (1/4). At final FU, 92 patients (90.2%) considered themselves satisfied, showing a mean OKS of 40.6 (SD 5.1) and a mean FKS of 76.7 (SD 11.8). No differences in the outcome were found between traditional and robotic-assisted procedures. CONCLUSION: The modern BCR design evaluated in this study achieved excellent results in terms of implant survivorship, low rate of reoperation and clinical results, independently from the use of enabling technologies.

Direct anterior approach in total hip arthroplasty: influence of stem length on clinical and radiological outcomes at medium-term follow-up.

PURPOSE: To evaluate the influence of short versus long stems implanted through a Direct Anterior Approach (DAA) on clinical and radiological outcomes in THA at medium-term follow-up (average follow-up of 44.8 months). METHODS: 167 consecutive total hip arthroplasties treating patients affected by primary hip osteoarthritis were retrospectively evaluated. A standard-length stem (H-MAXs) was used in 70 patients, while a short metaphyseal-fitting femoral stem (MINIMA) was used in 97 patients. The Harris Hip Score (HHS) and Forgotten Joint Score-12 (FJS) were used as outcomes measurements. Post-operatively, Engh's score and Brooker classification were analyzed at 6 months, 1 year and every 2 years until the final FU. The correct size of the implant was evaluated determining the canal fill index (CFI), and all undersized stems were classified according to Magra classification. RESULTS: The average HHS was 83 ± 13.4 in the standard stems group and 87 ± 14.1 for short stems group (p = 0.148). The average FJS was 87.9 ± 15.2 for patients in the standard stems group and 84.5 ± 17.7 with no significant differences (p = 0.327). None of the stems showed radiographic signs of instability (standard stems mean Engh's score: 19.25 versus short stems mean Engh's score: 19.50-p = 0.41). According to Brooker classification, no significant difference in severity was found using different stems (p = 0.715). A high rate of undersized stems was found (standard stems 24%-short stems 25%) but without statistical difference between groups (p = 0.078), while a different trend in malposition following the recent classification proposed by Magra et al. was observed evaluating all undersized stems (p = 0.0387). CONCLUSIONS: Both groups achieved good and comparable patient-reported outcome measurements (PROMs) and radiographic stability with fixation observed by bone ingrowth. A high rate of undersized stems was found with a correlation between femoral stem length and specific pattern of malposition. Malalignment in Varus was frequent in shorter stems in contact proximally with medial calcar and distally with lateral cortex, while a uniform undersizing was observed for longer ones with a continuous margin around the stem. However, the stems never presented progressive radiolucent lines over the whole surface of the stem.

C-Arm Guidance During Thin Flap Arthroscopic Trochleoplasty for Chronic Patellar Instability.

The purpose of this paper is to provide a complete Technical Note for our treatment of choice for recurrent patellar dislocation in cases of trochlear dysplasia, especially in patients with types B and D trochlear dysplasia according to the Dejour classification. Different surgical procedures have been reported for the treatment of recurrent patellar instability. One of the most important anatomic factors to address when treating a recurrent patella dislocation is trochlear dysplasia. Few types of open trochleoplasty have been classically described to treat a dysplastic trochlea. However, in recent years, arthroscopic techniques have been reported to reduce invasiveness and complications as well as to improve accuracy and clinical outcomes. In this technique is described an arthroscopic thin-flap tracheoplasty with the use of C-arm guidance in order to precisely control the bone resection and to verify intraoperatively the disappearance of the radiologic landmarks used for diagnosis and classification of the dysplasia. The advantage of this technique is the precision in removal of the supratrochlear spur and bump, the accurate and delicate reshaping of the sulcus with preservation of cartilage vitality, combined with increased reproducibility and safety.

Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study.

BACKGROUND: C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality. METHODS: We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio. RESULTS: The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%. CONCLUSIONS: Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.

Is augmentation the best solution in partial anterior cruciate ligament tears? A literature systematic review and meta-analysis.

Purpose: The appropriate management of partial anterior cruciate ligament (ACL) tears is still debated. There is a tendency in orthopedic clinical practice to prefer complete ACL reconstruction, while few surgeons perform ACL augmentation. The purpose of the present study is to evaluate the current evidence on the effectiveness of ACL augmentation compared with standard ACL reconstruction to assess whether ACL augmentation may be the treatment of choice in partial ACL injury. Methods: According to PRISMA guidelines, literature research was performed in PubMed/Medline, Cochrane Library, Embase, Scopus, and Web of Science databases. A PICOS model was used, and a preliminary search resulted in 1101 articles. The methodological quality was assessed through ROBINS-I. A meta-analysis was conducted on postoperative Tegner, Lysholm scores and KT-1000 values between ACL augmentation and ACL reconstruction, and a p < 0.05 has been assumed as statistically significant. PROSPERO, ID: CRD42022343502. Results: Seven papers were included. A total of 472 knees underwent ACL reconstruction, and 311 underwent ACL augmentation. A statistically significant discrepancy was found in the postoperative Tegner score in favor of ACL augmentation compared with ACL reconstruction (p < 0.05). Regarding the postoperative Lysholm score and KT-1000 measurement, no statistically significant difference was shown between ACL reconstruction and ACL augmentation (p > 0.05). Conclusions: ACL augmentation has proved to be an effective and safe procedure and should be preferred to ACL reconstruction in partial ACL tears for the tendency to achieve better functional outcomes.

Biomechanical considerations for an easily-restricted robot-assisted kinematic alignment: a surgical technique note.

BACKGROUND: In total knee arthroplasty, the normal kinematics of the knee may not be restored solely based on preoperative gait, fluoroscopic-based, and dynamic radiostereometric analyses. SURGICAL TECHNIQUE CASE PRESENTATION: This note introduced a 69-year-old male patient who sustained post-traumatic osteoarthritis of his right knee. He underwent robot-assisted total knee arthroplasty based on anatomical reproduction of knee stability during the swing phase of gait. The kinematic alignment was simply achieved within an easy-to-identified range after preoperative radiographic assessment, intraoperative landmarking and pre-validated osteotomy, and intraoperative range of motion testing. CONCLUSIONS: This novel technique allows personalized and imageless total knee arthroplasty. It provides a preliminary path in reproducing the anatomy alignment, natural collateral ligament laxity, and accurate component placement within safe-to-identified alignment boundaries.

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.

Trabecular titanium cups in hip revision surgery: a systematic review of the literature.

Background: Hip revision surgery in extensive acetabular bone defects represents a complex challenge for hip surgeons. The primary goal is to obtain a stable acetabular component and restore the hip biomechanics. Through the years, different prosthetic implants have been developed to perform acetabular revision depending on bone loss location and extension. This systematic review aims to summarize the clinical outcomes and complications reported with trabecular titanium (TT) cups in hip revision surgery. Methods: A literature search of four databases (PubMed, Embase, Scopus and the Cochrane Database of systematic reviews) was performed according to the PRISMA guideline from January 2008 to December 2022. All studies written in English and reporting the clinical outcome of patients undergoing revision total hip arthroplasty using Delta TT cups were included. The initial screening identified 378 studies. Each eligible clinical article was analyzed according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (LoE), and the papers' methodological quality was evaluated using The Methodological Index for Non-Randomized Studies Criteria (MINORS) score. Results: Eight clinical studies were included in the analysis. A total of 523 hip revisions were analyzed. Delta TT cups were used in 3.9%, Delta TT one cups in 46.8%, and Delta TT revisions in 49.3%. Paprosky IIIa was the most frequent acetabular bone defect reported in 26.4% of cases. The overall survival rate of TT cups was 93.4%. The dislocation was the most frequent complication in 4.1% of patients, while the prevalence of aseptic loosening was 1.5. Conclusions: Managing severe acetabular bone defects remains a complex challenge for hip surgeons. Since their introduction, TT cups have exhibited good clinical results, with complication rates in line with or lower than those reported by similar implants.

Should megaprosthesis implants be a viable option in elderly patients after distal femur and periprosthetic distal femur fractures?-a retrospective cohort study.

Background: Distal femur fractures (DFF) and periprosthetic distal femur fractures (PDFF) in elderly patients are challenging to manage, often requiring the use of distal femur replacement (DFR) implants to manage severe bone loss and comminution. The study's main purpose was to analyze outcomes and complications of DFR implant after DFF or PDFF at our institution to understand the feasibility and reliability of this treatment considering a review of the current literature. Methods: Fourteen consecutive patients undergoing total knee replacement with megaprosthesis implant from January 1st, 2017 to January 1st, 2021, at our institution were retrospectively analyzed. Inclusion criteria were age ≥65 years and DFF or PDFF after primary total knee arthroplasties (TKA) implantation. Patient-reported outcome measures (PROMs) such as Knee Society Score (KSS) and Oxford Knee Score (OKS) were analyzed, as well as radiographic pre- and post-operative imaging. Complications were recorded from the early postoperative period to the last follow-up. Results: Nine patients were diagnosed with PDFF and five with DFF. At a mean follow-up of 30.7 months (range, 12 to 69 months), the mean KSS knee score was 79.5±11.2; the mean KSS function score was 69.0±17.9. The mean OKS was 31.6±8.9. The mean age at intervention was 82.1±7.6 years. Two delayed wound closures and one chronic prosthetic joint infection (PJI) were observed. No death was observed at the last follow-up. Conclusions: Megaprosthesis implants could be a suitable option in elderly, arthritic patients diagnosed with complicated DFFs and PDFFs, allowing joint function preservation and a rapid return to daily activities. DFR remains an intervention burdened by devastating complications that must be considered in the treatment choice.

Role of lateral soft tissues release in percutaneous hallux valgus correction: A medium term retrospective study.

BACKGROUND: In the field of minimally invasive surgery (MIS) for the treatment of hallux valgus (HV), different techniques have begun to emerge in the literature concerning the distal osteotomy of the first metatarsal bone, the synthesis or not of the metatarsal head, the possible association with lateral soft tissues release (LSTR) and osteotomy of the base of the first phalanx. AIM: To evaluate the role of LSTR on percutaneous HV correction, evaluating functional and radiographical results. METHODS: From January 2012 to May 2016 a total of 396 patients with mild to moderate symptomatic HV treated with the MIS technique were included in this retrospective study. The technique provides no internal fixation (WOS). Patients were divided into the LSTR group and no LSTR group (LSTR N). This surgical procedure (LSTR) was reserved for insufficient HV angle (HVA) correction during fluoroscopic control. Patients were evaluated at each follow-up by two other authors after appropriate training by senior authors (first practitioners). Clinical evaluation was performed before surgery, 6 mo after surgery, and 48 mo follow-up. American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) score was used to evaluate pain and function, and complications were recorded. In addition, the incidence of relapses and the degree of joint range of motion (ROM) with the association with the LSTR (capsule, adductor tendon, phalanx-sesamoid ligament, and the deep transverse metatarsal ligament) were evaluated. Radiological parameters included HVA and intermetatarsal angle (IMA). Patient satisfaction was assessed. Student t-test and Fisher exact test were used to assess statistical analysis. RESULTS: From our study it is clear that no differences in term of HVA, VAS, IMA correction, rate of complications, and AOFAS score were found between groups, while a significant improvement of the same variables was found in each group between pre and postoperative values. A significant improvement in ROM at 6 mo (P = 0.018) and 48 mo (P = 0.02) of follow-up was found in LSTR N group. Complications were rare in both groups. CONCLUSION: LSTR procedure on percutaneous HV correction seems to increase postoperative joint stiffness with a comparable incidence of relapse and a low incidence of complications.