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Abstract The clinical evaluation of the knee is a fundamental tool to correctly address diagnosis and treatment, and should never be replaced by the findings retrieved by the imaging studies carried on the patient. Every surgeon has his own series of exams with whom he is more confident and on whom he relies on for diagnosis. Usually, three sets of series are used: one for patello-femoral/extensor mechanism pathologies; one for meniscal and chondral (articular) lesions; and one for instability evaluation. This review analyses the most commonly used tests and signs for knee examination, outlining the correct way to perform the test, the correct interpretation of a positive test and the best management for evaluating an injured knee both in the acute and delayed timing.

Importance: Tibial tubercle osteotomy (TTO) is indicated to treat patellofemoral (PF) malalignment and chondral disease refractory to conservative treatment. However, there are no systematic reviews describing TTO outcomes in chondral damages without instability., Aim: The aims of this study were to (1) assess the quality of the published studies, (2) identify indication for TTO to treat PFP with chondral disease without instability, (3) evaluate the most common TTO techniques, (4) evaluate the clinical outcomes, and (5) evaluate TTO's complication and failure rates., Evidence Review: In December 2020, a literature search was performed applying the following criteria: (1) peer-reviewed Level 1-4 studies; (2) English language; (3) human subjects with clinical and/or radiological outcomes; (4) TTO alone or associated with minor cartilage procedure (only drilling, no instability); (5) minimum follow-up 12 months, minimum 10 patients; and (6) no more than 20% of drop-out rate. Data from studies were collected and described with weighted averages and standard deviations., Findings: A total of 18 Level 4 studies were included. The average Coleman Methodology Score was 61.5 points (range 48-81). A total of 851 patients (892 knees) were included, with 64.8% of female patients. The weighted average follow-up was 49.1 months (range 12-128.5). Indication for TTOs was poorly described. The main technique used was anteromedialisation (60.4%). In 27.7% of the cases, TTO was associated with lateral release. Different scoring systems were used to evaluate outcomes, with significant improvements. The average rate of good/excellent results was 78.7% (range 57%-100%). Fifteen studies described the complication rate (9.9%), whereas only four reported the failure rate (6.2%)., Conclusion and Relevance: TTOs performed to treat PF malalignment associated with chondral disease without instability provided good clinical outcomes, with acceptable complication/failure rates. However, high-level studies are necessary because of studies' heterogeneity regarding patellofemoral malalignment and chondral disease treatment., Study Design and Level of Evidence: Systematic review., Level of the Study: Level IV, systematic review of Level IV studies., Competing Interests: Competing interests R.R. is a teaching consultant for Arthrex®, Zimmer Biomet®, Depuy Mitek®, Medacta®, Lima Corporate® and Smith and Nephew®. D.E.B. is a paid teaching consultant for Arthrex and Zimmer Biomet. He received editorial royalties for Elsevier and Springer, and he is in the editorial board “The Knee” journal, Elsevier. The other authors certify that they have no commercial associations that might pose a conflict of interest in connection with the submitted article. Conflict of interest is described in the appropriate uploaded document., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Patellar instability is a common cause of knee disability in children and adolescent, with a high recurrence rate. When conservative treatment fails, surgical options should be considered. The femoral insertion of the medial patellofemoral ligament (MPFL) is in close proximity to the distal femoral growth plate and precautions should be taken to avoid injuries to the physis. Anatomical features of the MPFL complex, with focus on the relationship between femoral MPFL attachment and femoral physis, are discussed together with surgical tips to avoid injuries to the growth plates. The aim of this article is to review the recent literature regarding MPFL reconstruction and other stabilization techniques for patellofemoral instability in skeletally immature patients, focusing on the different surgical options available. These can be classified as anatomical versus nonanatomical, proximal versus distal realignments, or based on the graft used: free graft and pedicled graft (quadriceps, patellar tendon, hamstring, and adductor magnus)., Competing Interests: Conflict of Interest D.B. and R.R. report other from Zimmer Biomet, outside the submitted work. All the other authors report no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Infection after total hip arthroplasty (THA) is a devastating complication with significant consequences for patients. In literature, single and two-stage revision, irrigation and debridement, Girdlestone resection arthroplasty, and arthrodesis and amputation are reported as possible treatments. Recently, two-stage revision has become popular as the gold standard treatment for chronic hip joint infections after THA. In this review, we evaluate the current literature about microbiology of periprosthetic joint infections and the use of antibiotic-loaded cement spacers. We aim to give an overview about indications, clinical results, and mechanical complications for spacers implantation, evaluating also selection criteria, pharmacokinetic properties, and systemic safety of the most frequently used antibiotics., Competing Interests: Conflict of Interest None declared.

Background: Revision total knee arthroplasty (rTKA) is a demanding procedure, with a high complication and failure rate and a high rate of bone losses and poor bone quality. Different classifications for bone losses have been proposed, but they do not consider bone quality, which may affect implant fixation. The aim of this study is to describe the outcomes of a consecutive series of rTKA. Furthermore, a modified bone loss classification will be proposed based also on bone quality. Finally, the association between radiolucent line (RLL) development and different risk factors will be evaluated., Methods: All the patients who underwent rTKA between 2008 and 2016 in the same institution were included. rTKAs were performed by the same surgeon according to the three-step technique. Bone losses were classified according to the proposed classification, including bone quality evaluation. The Knee Scoring System (KSS), the Hospital for Special Surgery Knee Score (HSS), and the SF-12 were used for the clinical evaluation. Radiological evaluation was performed according to the Knee Society Roentgenographic Evaluation System. Different possible risk factors (i.e., gender, age, amount of bone losses) associated to RLL development were identified, and this association was evaluated using logistic regression., Results: Fifty-one patients (53 knees) were included (60.8% female, average age 71.5 years). The average follow-up was 56.6 months (range 24-182). The most frequent cause of failure was aseptic loosening (41.5%). 18.9% of the cases demonstrated poor bone quality. Bone losses were treated according to the proposed algorithm. In all the cases, there was a significant improvement in all the scores (P < 0.05). The average post-operative range of motion was 110.5° (SD 10.7). At the radiological evaluation, all the implants resulted well aligned, with 15.1% of non-progressive RLL. There were 2 failures, with a cumulative survivorship of 92.1% at the last follow-up (SD 5.3%). At the logistic regression, none of the evaluated variables resulted associated to RLL development., Conclusion: rTKA is a demanding procedure, and adequate treatment of bone losses is mandatory to achieve good results. However, also bone quality should be taken into consideration when approaching bone losses, and the proposed classification may need surgeons after an adequate validation., Level of Evidence: Level IV.

Total knee arthroplasty (TKA) is a valuable treatment option for advanced osteoarthritis in patients unresponsive to conservative treatments. Despite overall satisfactory results, the rate of unsatisfied patients after TKA remains high, ranging from 5 to 40%. Different modifiable and nonmodifiable prognostic factors associated with TKA outcomes have been described. The correction, whenever possible, of modifiable factors is fundamental in preoperative patients' optimization protocols. Nonmodifiable factors can help in predicting the outcomes and creating the right expectations in the patients undergoing TKA. The goal of this review is to summarize the modifiable and nonmodifiable prognostic factors associated with TKA outcomes., Competing Interests: Conflict of Interest None declared.

Large osteochondral allograft (OCA) transplant has become a valid alternative to restore articular surface in challenging articular lesions in young and active patients, either in primary or in revision procedures. Several studies support the effectiveness and safety of OCA, but costs and graft availability limit their use. The indications are the treatment of symptomatic full-thickness cartilage lesions greater than 3 cm 2 , deep lesions with subchondral damage, or revision procedures when a previous treatment has failed. The goal of the transplant is to restore the articular surface with a biological implant, allow return to daily/sports activities, relieve symptoms, and delay knee arthroplasty. Grafts can be fresh, fresh-frozen, or cryopreserved; these different storage procedures significantly affect cell viability, immunogenicity, and duration of the storage. Dowel and shell technique are the two most commonly used procedures for OCA transplantation. While most cartilage lesions can be treated with the dowel technique, large and/or geometrically irregular lesions should be treated with the shell technique. OCA transplantation for the knee has demonstrated reliable mid- to long-term results in terms of graft survival and patient satisfaction. Best results are reported: in unipolar lesions, in patients younger than 30 years, in traumatic lesions and when the treatment is performed within 12 months from the onset of symptoms.

Purpose  To analyze the prognostic factors influencing subjective and objective outcomes and return to play (RTP) after anterior cruciate ligament reconstruction (ACL-R). Methods  Primary ACL-Rs using a transtibial technique performed between 2008 and 2012 were included. Data regarding patients, surgery, sports, and rehabilitation, including an on-field rehabilitation (OFR) and duration of the rehabilitation program, were collected. The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms, and the Knee Injury and Osteoarthritis Outcome Score and Lysholm questionnaires were used for the assessment of subjective and objective outcomes. The Subjective Patient Outcome for Return to Sports and ACL-return to sport after injury (RSI) scores were used for RTP evaluation. Several potential predictors of outcome were tested with a univariate analysis. All the variables with p  < 0.1 were retested in a logistic regression model to evaluate their association with the outcomes. Results  In total, 176 cases were included with an average follow-up of 44.1 months. Of the patients, 92.2% were rated as normal or nearly normal at the IKDC evaluation. In addition, 90.1% of the patients returned to sport, with 57.6% returning to the same preinjury level. Objective outcomes were negatively influenced by late rehabilitation (odds ratio [OR] = 2.75). Performing an OFR phase during the rehabilitation was associated with better subjective outcomes (OR = 2.71). Length of rehabilitation strongly influenced the RTP rate (OR = 13.16). Conversely, higher ACL-RSI score was inversely related to RTP. Objective IKDC score was inversely related to the ACL-RSI (OR = 0.31), whereas subjective score was correlated with both the total ACL-RSI score (OR = 0.15) and the level of activity (OR = 0.20). Conclusion  This study confirmed the role of rehabilitation on subjective and objective outcomes and on RTP. Particularly, the complete adherence to a rehabilitation program, including an OFR phase, resulted in better subjective outcomes and higher RTP rate. The relationship between psychological factors, measured through the ACL-RSI score, and RTP was confirmed. Level of Evidence  Level III, observational study without a control group.

Objective: To evaluate the medium-term outcomes of a posterior-stabilized mobile-bearing total knee arthroplasty (PS-MB-TKA) and the role of different prognostic factors., Methods: Patients indicated for a primary cemented PS-MB-TKA between 2002 and 2010 were included and prospectively evaluated using the Knee Society Scoring System (KSS) and the Hospital for Special Surgery (HSS) knee scores. The Knee Society Roentgenographic Evaluation form was used for the radiological evaluation. Different variables were collected and divided into patient- and surgery-related. Logistic regression was used to analyze the correlation between these variables and implants outcomes and survivorship., Results: In total, 149 cases were included (67.8% female, average age 70.4 years, SD ±9.4). The patella was resurfaced in 12.1% of the cases. All the implants were cemented. The average follow-up was 87.3 months (SD ±21.2). Postoperatively, there was a statistically significant improvement in all the scores. The cumulative survival was 96.2% (SD ±0.02%). At the regression analysis, female gender was associated to worse satisfaction KSS (OR = 0.26), functional KSS (OR = 0.22), and HSS (OR = 0.37) scores. Patellar resurfacing and subsequent contralateral procedures were associated to better functional KSS score (OR = 4.13, OR = 2.21), as well as varus preoperative alignment (OR = 2.12). On contrary, valgus preoperative alignment was associated to worse objective KSS score (OR = 0.23). No variables were correlated to failure or presence of radiolucent lines., Conclusion: Good medium-term outcomes were obtained using PS-MB-TKA, with a cumulative survivorship of 96.5%. Female gender and valgus preoperative alignment were associated to worse objective and subjective outcomes. Conversely, patellar replacement, subsequent contralateral TKA, and varus preoperative alignment were associated to better functional outcomes.

Knee extensor mechanism rupture is a serious complication of total knee arthroplasty (TKA). Its prevalence ranges from 1 to 10% and it is commonly observed as a chronic multifactorial pathology with the patellar tendon as the most common site of rupture. Knee extensor mechanism reconstruction can be performed using allogenic or synthetic grafts. In the literature it is still not clear whether one of these techniques is superior to the other and the choice is usually tailored to the patient case by case. Allografts allow better restoration of the anatomical landmarks, whereas the mesh technique is more reproducible and the graft does not elongate over time. Allografts carry an increased risk of infection compared with synthetic reconstructions, while the mesh technique is cheaper and more readily available. In this paper, we review the etiology, diagnosis and treatment of this pathology, drawing on the most recent literature.

Meniscal tears are commonly associated with anterior cruciate ligament (ACL) injuries. A deficient medial meniscus results in knee instability and could lead to higher stress forces on the ACL reconstruction. Comparison of results in meniscectomy and meniscal repairs revealed worse clinical outcomes in meniscectomy, but higher re-operation rates in meniscal repairs. Our aim was to review the results of ACL reconstruction associated with meniscectomy or meniscal repair.

Chronic insufficiency of the knee extensor mechanism is a very challenging pathology to treat. An insufficient extensor mechanism negatively affects implant survival and patient outcomes. The causes of insufficiency can be several, and the surgeon has to be prepared to manage them intraoperatively and postoperatively. Various reconstructive techniques have been proposed, but traditional results in patients with a total knee arthroplasty are usually inferior to those patients with native knee joints. It is of primary importance to understand the anatomy, and tailor the correct treatment to the patient.

Primary total knee arthroplasty is the treatment for end-stage arthritis of the knee; in the last years, it is becoming more common and reliable, due to technical and implant improvement. With larger implant rates, the overall complications will increase and pain is the most common sign of implant failure. Pain can be related to a lot of different clinical findings, and the surgeon has to be aware of the various etiologies that can lead to failure. Pain does not always mean revision, and the patient has to be fully evaluated to have a correct diagnosis; if surgery is performed for the wrong reason, this will surely lead to a failure. In this paper, the authors revised the more common causes of failure that can have a painful onset proposing an approach for diagnosis and treatment.

The pathogenesis of tendon degeneration and tendinopathy is still partially unclear. However, an active role of metalloproteinases (MMP), growth factors, such as vascular endothelial growth factor (VEGF) and a crucial role of inflammatory elements and cytokines was demonstrated. Mechanical stimulation may play a role in regulation of inflammation. In vitro studies demonstrated that both pulsed electromagnetic fields (PEMF) and extracorporeal shock wave therapy (ESWT) increased the expression of pro-inflammatory cytokine such as interleukin (IL-6 and IL-10). Moreover, ESWT increases the expression of growth factors, such as transforming growth factor β(TGF-β), (VEGF), and insulin-like growth factor 1 (IGF1), as well as the synthesis of collagen I fibers. These pre-clinical results, in association with several clinical studies, suggest a potential effectiveness of ESWT for tendinopathy treatment. Recently PEMF gained popularity as adjuvant for fracture healing and bone regeneration. Similarly to ESWT, the mechanical stimulation obtained using PEMFs may play a role for treatment of tendinopathy and for tendon regeneration, increasing in vitro TGF-β production, as well as scleraxis and collagen I gene expression. In this manuscript the rational of mechanical stimulations and the clinical studies on the efficacy of extracorporeal shock wave (ESW) and PEMF will be discussed. However, no clear evidence of a clinical value of ESW and PEMF has been found in literature with regards to the treatment of tendinopathy in human, so further clinical trials are needed to confirm the promising hypotheses concerning the effectiveness of ESWT and PEMF mechanical stimulation.

Patellar tendinopathy is very common in patients complaining of anterior knee pain. Its aetiology is still unclear, but neovascularisation seems to play a role. Different treatments have been proposed overtime, from rehabilitation to platelet-rich-plasma injections, but there is no agreement on the best treatment protocol. The final stage of patellar tendinopathy is patellar tendon rupture. In these cases surgical treatment is often required. The aim of this literature review is to focus on the aetiology, diagnosis, and treatment of both patellar tendinopathy and rupture. We report the conservative treatments proposed for patellar tendinopathy and the surgical techniques described for its rupture.

The integrity of the meniscal root insertions is fundamental to preserve correct knee kinematics and avoid degenerative changes of the knee. Injuries to the meniscal attachments can lead to meniscal extrusion, decreased contact surface, increased cartilage stress, and ultimately articular degeneration. Recent and well designed studies have clarified the anatomy and biomechanics of the medial and lateral meniscal roots. Although the treatment of meniscal root tears is still controversial, many different techniques have been described for root repair. The goal of this review is to summarize the existing knowledge regarding meniscal root tears, including anatomy, biomechanics and imaging. In addition, the most common surgical techniques, together with the clinical outcomes, are described.

Purpose: this study was conducted to investigate the influence of the popliteus tendon (PT) on the static stability of total knee arthroplasty (TKA)., Methods: twenty knees were used. In 10 right knees, a cruciate-retaining (CR) TKA trial prosthesis was implanted; in the other ten knees (left knees), the posterior cruciate ligament was cut and a posterior substitution (PS) TKA trial prosthesis was implanted. Lamina spreaders were set at 100 N of tension, one on the medial and one on the lateral articular space. Gaps were then measured with a caliper before and after PT sectioning., Results: the correlation between femoral dimensions and popliteus insertion distance from articular surfaces was measured with the Pearson correlation index and considered significant. In the CR-TKA group, medial and lateral gap measurements showed a significant increase after PT sectioning both in flexion and in extension. In the PS-TKA group, lateral gap measurements showed a significant increase after PT sectioning both in flexion and in extension, while the medial gap measurements increased significantly only in flexion., Conclusions: PT sectioning destabilized both the lateral and the medial aspects of the knee. A greater effect was observed in the lateral compartment. The most statistically reliable effect was observed with the knee in flexion. In addition, we observed that preserving the PCL does not prevent lateral gap opening after PT sectioning., Clinical Relevance: PT should always be preserved when performing a TKA, because its resection can affect gap balancing, in flexion and in extension., Type of Study: controlled laboratory study.

Exercise-induced leg pain is a common condition in athletes and in people involved in recreational sports. The diagnosis is not always straightforward: many conditions may cause exercise-induced leg pain. The aim of the present review is to provide a complete discussion of the most common pathologies related to this condition. Particular attention is dedicated to the history and the physical examination, which are fundamental for requesting the correct diagnostic tests or imaging techniques necessary for a precise diagnosis.

Valgus knee deformity is a challenge in total knee arthroplasty (TKA) and it is observed in nearly 10% of patients undergoing TKA. The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation. Bone tissue variations consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodelling. Soft tissue variations are represented by tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of the gastrocnemius and iliotibial band. Complete pre-operative planning and clinical examination are mandatory to manage bone deformities and soft tissue contractions/elongations and to decide if a higher constrained prosthesis is necessary. Two different approaches have been described to perform TKA in a valgus knee: the anteromedial approach and the anterolateral one. In valgus knee deformity bone cuts can be performed differently in order to correct low-grade deformities and reduce great deformities. There is still debate in the literature on the sequence of lateral soft tissue release to achieve the best alignment without any instability. The aim of this article is to review the anatomical variations underlying a valgus knee, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. We will also review the main approaches and surgical techniques both for bone cuts and soft tissue management. Finally, we will report on our experience and technique.

Presently, tibiotalar fusion remains a valid treatment option in patients affected by end-stage arthritis of the ankle that is unresponsive to other treatments. Over the years, many different surgical techniques have been described to make this kind of surgery less invasive and invalidating. Consequently, the last two decades have seen arthroscopic ankle fusion gain in popularity with many studies aiming to understand its advantages compared with open surgery, indications, and contraindications. The review of literature revealed a lower rate of complication, faster recovery, and shorter time of hospitalization with arthroscopic arthrodesis, in comparison with open surgery. These characteristics, along with a reduction of costs, will probably increase the use of arthroscopic ankle arthrodesis in the near future.

The anterior cruciate ligament reconstruction is a common procedure that improves stability and function of the knee. The surgical technique continues to evolve and many issues are still under debate. These mainly include: (1) graft selection (patellar tendon, hamstring, quadriceps tendon, or allografts), (2) surgical technique (double versus single bundle), and (3) femoral tunnel drilling. Currently, the most controversial one is the femoral tunnel drilling (transtibial vs. anteromedial portal drilling). Common opinion is that drilling the femoral tunnel through the anteromedial (AM) allows a more anatomic placement of the graft and a better rotational stability; therefore, this technique is gaining in popularity compared with the transtibial drilling despite a greater difficulty and the risk of medial condyle damage, tunnel back wall blowout, and inadequate socket length. The aim of this article is to describe the surgical technique of the anterior cruciate ligament reconstruction (single and double bundle), drilling the femoral tunnel through the AM portal.