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Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

To identify prognostic factors significantly associated with rotator cuff repair outcome and define the strength of these associations. 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. 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. 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. Systematic review of level I–IV prognostic studies, Level IV.

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. 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. 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. 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. Systematic review of descriptive and qualitative studies, Level IV.

Generalized joint laxity and shoulder instability are common conditions that exhibit a wide spectrum of different clinical forms and may coexist in the same patient. Generalized joint laxity can be congenital or acquired. It is fundamental to distinguish laxity from instability. Laxity is a physiological condition that may predispose to the development of shoulder instability. A high prevalence of generalized joint laxity has been identified in patients with multidirectional instability of the shoulder. Multidirectional instability is defined as symptomatic instability in two or more directions. The diagnosis and treatment of this condition are still challenging because of complexities in its classification and etiology. These complexities are compounded when multidirectional instability and laxity exist in the same patient. With an improved understanding of the clinical symptoms and physical examination findings, a successful strategy for conservative and/or surgical treatments can be developed. Conservative treatment is the first-line option. If it fails, different surgical options are available. Historically, open capsular shift has been considered the gold standard in the surgical management of these patients. Nowadays, advanced arthroscopic techniques offer several advantages over traditional open approaches and have shown similar outcomes. The correct approach to the management of failed stabilization procedures has not been yet defined.

Purpose: this study was conducted to assess the safety and efficacy of a new surgical technique for anatomical reconstruction of the coracoclavicular (CC) and acromioclavicular (AC) ligaments using one singlestrand semitendinosus tendon graft. Methods: eighteen patients affected by chronic type III-V AC joint dislocations were included in the present study between January 2010 and March 2012. All underwent the same surgical operation and rehabilitation protocol. The semitendinosus tendon was harvested from the ipsilateral knee. The CC and AC ligaments were reconstructed using the graft passed beneath the coracoid and through bone tunnels in the clavicle and in the acromion. The graft was secured with non-absorbable sutures. Radiographic recurrence of AC joint dislocation was the primary outcome. Clinical outcome was assessed using the DASH score and normalized Constant score. Wilcoxon’s signedrank test was used for comparison between pre- and postoperative results. Significance was set at p≤0.05. Results: the mean follow-up duration was 26.4+2.3 months (range: 24-30 months). On X-ray evaluation, only two patients (11%) showed asymptomatic recurrence of AC joint instability. Comparison between pre- and postoperative DASH and Constant scores showed significant clinical improvement (p