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Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.

Myositis ossificans traumatica (MOT) is a self-limiting and self-resolving pathology. In most cases, conservative treatment is chosen as the first step. Surgical treatment is reserved for cases of failure of conservative treatment with persistence of pain and mass. The case presented concerns an 18-year-old soccer player suffering from bilateral adductor longus (AL) MOT results following two different sports injuries. The patient reports the appearance of swelling and palpable mass at the proximal and medial region of the thigh, about 2 cm from the pubic symphysis, along the course of the adductor magnus. The radiological investigation showed the presence of a calcification along the course of the right and left AL muscles. Surgical treatment was considered for the right thigh injury, being symptomatic 1 year after the onset and refractory to other treatments. At 3 months of follow-up, the patient was asymptomatic and completed the rehabilitation program for the recovery of muscle strength and range of motion (ROM). In cases where MOT manifests with resistant pain, ROM restriction and daily activity reduction, surgical excision is the preferred option.

Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons’ use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence. A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods: preoperatively, intraoperatively, and postoperatively. Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative: (A) PJI Risk Stratification: 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit: 36% no limit; 15.4% BMI

A renewed interest in anterior cruciate ligament preservation has been noted using arthroscopic primary repair in patients with proximal tears, but the main concern remained the control of the rotational instability. Segond fracture occurs in less than 10% of cases of acute anterolateral instability, but it can result in continued rotation instability. The aim of this study is to describe the surgical technique to acutely repair both the anterior cruciate ligament and Segond fracture in the acute setting., Technique Video Video 1 This video describes the surgical technique used in this particular type of combined anterior cruciate ligaments and Segond fracture repair.

Acute injuries of the anterior cruciate ligament are often associated with concurrent injuries to the structures of the anterolateral complex, specifically the anterolateral ligament. Some injury patterns of the anterior cruciate ligament involve tearing of the majority of the ligament from the femoral origin, leaving a large, viable ligament remnant. In these patients, a repair of the anterior cruciate ligament back to the femoral origin can be undertaken. Subsequently, percutaneous repair of the anterolateral ligament can be performed through anatomical, percutaneous suture tape augmentation. The combined technique of anterior cruciate ligament repair with anterolateral ligament reinforcement is presented., Technique Video Video 1 Acute primary repair of the ACL was performed in patients with proximal ACL tears (type I, II, and III) and with more than 50% of the tibial remnant intact and with good tissue quality. Anterolateral internal brace augmentation was added in patients with grade 2 or 3 of pivot shift as evaluated with physical examination under anesthesia and in patients with a tear of the ALL as evaluated with preoperative magnetic resonance imaging. (ACL, anterior cruciate ligament; ALL, anterolateral ligament.)

Background Excellent Clinical and patient-reported outcome have been reported following Reverse Shoulder Arthroplasty (RTSA). However, outcomes in range of motion (ROM) remain variable. The role and importance of subscapularis repair during RTSA is a topic of intense debate and the long term-integrity of the subscapularis after repair remains poorly studied. Aims of this study were to radiologically evaluate pre- and postoperative condition of the subscapularis muscle in RTSA with concurrent subscapularis tendon repair using transosseous suture, and to investigate the correlation between clinical and radiological results. Methods Patients who had undergone RTSA with subscapularis repair in our Institute between January 2010 and November 2016 were included. Constant, UCLA, Simple Shoulder Test and Visual Analog Scale (VAS) pain questionnaires were administered pre- and postoperatively. Internal rotation ability was recorded on a 6-point scale. Pre - and postoperatively shoulder CT scans were performed by a blinded examiner from which subscapularis muscle cross-sectional area (SMCSA) and supraspinatus fossa cross-sectional area (SFCSA) were measured in square millimeters. The SMCSA/SFCSA ratio was employed to standardize values for individual anatomical differences between patients. Results The study included 32 patients (32 shoulders). Mean follow-up was 74.6 months ± 15.2 months (range 35–117 months). Statistically significant differences were found between pre- and postoperative VAS score, Constant Score, UCLA and Simple Shoulder Test scales (P 35% was found in 38% of patients. Only 21% of patients maintained their preoperative SMCSA/SFCSA ratio. Overall, a statistically significant difference in pre and postoperative SMCSA/SFCSA ratios was found (P Conclusion Postoperative subscapularis size expressed as SMCSA and SMCSA/SFCSA ratio, was significantly reduced in the majority of patients treated with non-lateralized RTSA design and concurrent subscapularis tendon repair at final follow-up. A correlation between radiological findings and clinical outcomes was not found. RTSA with subscapularis tendon repair provides a high degree of patient satisfaction, as well as statistically significant improvements in clinical outcomes and internal rotation ROM. Being associated with several advantages, subscapularis repair may be routinely recommended. Level of evidence Level II; Prospective Cohort Design; Prognosis Study

Introduction Several surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). Hypothesis The hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-peration than metallic cerclage but no differences in other clinical outcomes. Patients and methods A retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months post-operatively to evaluate clinical scores and complications. Results A total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at two months post-operatively due to painful prominence. There was no significant difference in reoperation rates between the STCC and MWCC groups (p = 1). There were no cases of non-union, malunion or loss of reduction throughout the series. At the final clinical follow-up of 18 months, there were no significant differences in KSS, KOOS or Bostman scores between the groups. Conclusion No significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidence III.

Background:Preoperative grade 3 pivot shift has been reported to be associated with higher rates of anterior cruciate ligament (ACL) failure, persistent instability, and inferior patient-reported outcomes. The etiology of a high-grade pivot shift is multifactorial, and numerous factors have been suggested to be responsible. More attention has recently been focused on injury to the anterolateral structures (ALS) as a risk factor for a grade 3 pivot shift.Purpose:To determine risk factors for grade 3 pivot shift, including soft tissue and osseous parameters.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A prospective evaluation was undertaken of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury). An open exploration of the lateral side of the injured knee was performed at the time of the index procedure. Details regarding patient and injury characteristics were recorded, as were details of soft tissue injuries, including meniscal tears, ALS lesions, medial collateral ligament tears, and chondral injuries. Osseous parameters (tibial slope and condylar ratios) were determined per established magnetic resonance imaging protocols. A multivariate logistic regression with penalized maximum likelihood was used to identify risk factors associated with International Knee Documentation Committee (IKDC) grade 3 pivot shift.Results:The mean ± SD age of the population was 28.3 ± 9.8 years; 67.5% of patients were male. Among patients, 35 (17.5%) had a high-grade pivot shift (IKDC grade 3), and 165 (82.5%) had a low-grade pivot shift (IKDC grades 1 and 2). Univariate and multivariate logistic regression analysis demonstrated that injury to the ALS was the only significant risk factor for grade 3 pivot shift (odds ratio, 13.49; 95% CI, 1.80-1725.53).Conclusion:This comprehensive evaluation of soft tissue and osseous factors has identified that injury to the ALS is the most important risk factor for grade 3 pivot shift in acute ACL-injured knees.

Purpose The aim of this study was to determine the inter- and intra-observer reliability of knee laxity assessment using a non-invasive navigation system in a population of healthy young athletes. It was hypothesized that knee laxity parameters recorded using non-invasive computer navigation would demonstrate good inter- and intra-observer reliability. Methods Healthy volunteers aged between 18 to 30 years were recruited to the study. Static and dynamic knee laxity parameters including anterior tibial translation and tibial rotation during the pivot shift test were recorded on awake patients using non-invasive computer navigation by two independent observers: at the first visit each athlete was evaluated by the consultant and resident surgeons independently; 6 weeks after the first visit all the participants were re-tested only by the resident surgeon. Inter- and intra-observer reliability was calculated and then interpreted according to Cicchetti’s criteria. Results One hundred healthy volunteers were recruited to the study, of these 38 were women (38%), and the average age was 25.5 ± 2.4 years. According to Cicchetti’s criteria the intra- and inter-observer reliability for static measurements were fair for anterior tibial translation (0.572 and 0.529, respectively) and excellent for total passive tibial rotation (0.859 and 0.883, respectively). For the dynamic measurements of translation and rotation during the pivot shift maneuver both measurements demonstrated good to excellent reliability with intra and inter observer reliability ranging from 0.684 to 0.936. Conclusion Non-invasive navigation for the assessment of knee laxity is associated with fair to excellent inter- and intra-observer reliability in a population of healthy volunteers.

As the population ages, it is important to determine whether total knee arthroplasties (TKA)s are safe and beneficial in the octogenarian population. The aims of the present study were: (1) to assess the effect of comorbidities and age on the incidence of postoperative complications following TKA and (2) to evaluate the mid-term outcome of octogenarian patients. A retrospective matched-paired analysis by gender, BMI and duration of follow-up was conducted on 206 patients older than 80 years and younger than 75 years between 2009 and 2016, undergoing primary TKA. The mean follow-up was 5 years. Outcome measures including Oxford Knee Score (OKS), Knee Society Score (KSS), Knee Society Function Score (KSFS), postoperative complications, length of stay (LOS) and survivorship were analysed. The association between complications and comorbidities was assessed using multivariable logistic regression after adjusting for age, Deyo-Charlson Comorbidity Index (D-CCI) and the American Society of Anesthesiologist’s (ASA) physical status classification. In the multivariable models, D-CCI class is an independent predictor for postoperative cardiac complications, delirium and transfusion rate (OR ranging from 1.2 to 69.5 in respect to D-CCI reference class 0). Being ≥ 80 years old was associated with an increased risk of transfusion (OR 3.4; 95% CI 1.7–6.8) and 1.7-day increase in LOS (p

Introduction: Up to 30% of patients with spinal cord injury and to 20% of patients with traumatic brain injury develop neurogenic heterotopic ossification (NHO). Patients develop restriction in joint range of motion (ROM) and impairment in activities of daily life. When neurological recovery occurs, joints dysfunction represents the cause for patients’ autonomy loss. Case Report: We present the case of a 39-year-old Caucasian male involved in a car accident and experienced 14 days of post-traumatic coma. After rehabilitation, no residual motor or sensory neurological deficit was present, but bilateral NHOs surrounding hip joints developed. Seventeen months after trauma, the patient was admitted to our institute. He was confined to bed, absolutely unable to walk, stand or sit. Radiological evaluation consisted in Antero-Posterior X-ray view only, due to the inability to open up his hips for lateral views, and 3D computed tomography scan. “Functional resection” of the ossifications was performed and rehabilitation started from day 1 after surgery. At the final follow-up 24 months from the second operation high grade of clinical satisfaction was reported. The patients were able to walk independently, to put on his socks, and to drive a car and bike. Painless right and left hip ROM was, respectively, 100° and 90° for flexion, 10° for extension, 35° and 30° for abduction, and near normal internal and external rotation. The patient referred that further improvement in mobility and fluency was still present day by day. Conclusion: The rarity of the condition frequently bring to a delay in treatment and the absence of specific guidelines made treatment still dependent on surgeon experiences. A multidisciplinary approach is essential for success. Surgeons should be aware that it is important to refer patients to specialized center, because early resection could provide excellent results, preserving hip, and restoring function and patient independency. Keywords: hip, ossifica

The functional positioning of components in a total hip arthroplasty (THA) and its relationship with individual lumbopelvic kinematics and a patient’s anatomy are being extensively studied. Patient-specific kinematic planning could be a game-changer, however, it should be accurately delivered intraoperatively. The main purpose of this study was to verify the reliability and accuracy of a patient-specific instrumentation (PSI) and laser-guided technique to replicate preoperative dynamic planning. Thirty-six patients were prospectively enrolled and received dynamic hip preoperative planning based on three functional lateral spinopelvic X-rays and a low dose CT scan. Three-dimensional (3D) printed PSI guides and laser-guided instrumentation were used intraoperatively. The orientation of the components, osteotomy level and change in hip length and offset were measured on postoperative CT scans and compared with the planned preoperative values. The length of surgery was compared with that of a matched group of thirty-six patients who underwent a conventional THA. The mean absolute deviation from the planned inclination and anteversion was 3.9° and 4.4°, respectively. In 92% of cases, both the inclination and anteversion were within +/− 10° of the planned values. Regarding the osteotomy level, offset change and limb length change, the mean deviation was, respectively, 1.6 mm, 2.6 mm and 2 mm. No statistically significant difference was detected when comparing the planned values with the achieved values. The mean surgical time was 71.4 min in the PSI group and 60.4 min in the conventional THA group (p &lt, 0.05). Patient-specific and laser-guided instrumentation is safe and accurately reproduces dynamic planning in terms of the orientation of the components, osteotomy level, leg length and offset. Moreover, the increase in surgical time is negligible.

Despite growing attention to the ability of patients to provide informed consent to treatment in different medical settings, few studies have dealt with the issue of informed consent to major orthopaedic surgery in those over the age of 60. This population is at risk of impaired decision-making capacity (DMC) because older age is often associated with a decline in cognitive function, and they often present with anxiety and depressive symptoms, which could also affect their capacity to consent to treatment. Consent to major orthopaedic surgery requires the patient to understand, retain and reason about complex procedures. This study was undertaken to extend the literature on decisional capacity to consent to surgery and anaesthesia of patients over the age of 60 undergoing major orthopaedic surgery. Recruited patients ( N=83) were evaluated using the Aid to Capacity Evaluation, the Beck Depression Inventory, the State–Trait Anxiety Inventory Y, the Mini-Mental State Examination and a visual analogue scale for measuring pain symptomatology. Impairment of medical DMC was common in the overall sample, with about 50% of the recruited patients showing a doubtful ability, or overt inability, to provide informed consent. Poor cognitive functioning was associated with reduced medical DMC, although no association was found between decisional capacity and depressive, anxiety and pain symptoms. These findings underline the need of an in-depth assessment of capacity in older patients undergoing major orthopaedic surgery.

Background: Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction is associated with improved clinical outcomes as compared with isolated intra-articular reconstruction, but the indications are not precisely defined. It may be the case that patients with proven anterolateral injury on preoperative imaging are most likely to benefit, but the accuracy of magnetic resonance imaging (MRI) is not known. Purpose/Hypothesis: To evaluate the correlation between MRI and surgical exploration in acute ACL-injured knees. The hypothesis was that a positive correlation would be identified between imaging and surgical findings for ALL/capsule and iliotibial band (ITB) injuries and that MRI would be highly sensitive, specific, and accurate. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Between January and May 2016, patients presenting with acute ACL injuries were considered for study eligibility. Included patients underwent 1.5-T MRI, which was evaluated by 3 investigators who attributed a Ferretti grade of injury to the anterolateral structures. At the time of ACL reconstruction, a lateral exploration was undertaken, and macroscopic injuries were identified. An evaluation of correlation between MRI and surgical exploration findings was performed. Results: Twenty-six patients participated in the study, and 96% had an ALL/capsule injury. The sensitivity, specificity, and accuracy of MRI and the correlation ( K) with surgical exploration findings were as follows, respectively: any ALL/capsule abnormality—88%, 100%, 88.5%, and 0.47; differentiating partial or complete ALL/capsule tears—78.6%, 41.7%, 61.5%, and 0.23; ITB injuries—62.5%, 40%, 50%, and 0.27. The percentage agreement between MRI and surgical findings was 88% for ALL/capsule injury, 65% for ITB injury, and 53% for Ferretti grading. Conclusion: Surgical exploration demonstrates that injuries occur to the anterolateral structures in almost all acute ACL-injured knees. MRI is highly sensitive, specific, and accurate for detection of abnormalities of the ALL/capsule and shows a high percentage of agreement with surgical findings. MRI has low sensitivity, specificity, and accuracy for the diagnosis of ITB injury. The Ferretti grade could not be reliably established from MRI, and there was only fair agreement between MRI and surgical findings with respect to ITB abnormalities and determination of whether ALL/capsular tears were partial or complete.

Background: The Prognostic Nutritional Index (PNI) is a parameter of nutritional and inflammation status related to toxicity in cancer treatment. Since data for head and neck cancer are scanty, this study aims to investigate the association between PNI and acute and late toxicity for this malignancy. Methods: A retrospective cohort of 179 head and neck cancer patients treated with definitive radiotherapy with induction/concurrent chemotherapy was followed-up (median follow-up: 38 months) for toxicity and vital status between 2010 and 2017. PNI was calculated according to Onodera formula and low/high PNI levels were defined according to median value. Odds ratio (OR) for acute toxicity were calculated through logistic regression model, hazard ratios (HR) for late toxicity and survival were calculated through the Cox proportional hazards model. Results: median PNI was 50.0 (interquartile range: 45.5–53.5). Low PNI was associated with higher risk of weight loss &gt, 10% during treatment (OR = 4.84, 95% CI: 1.73–13.53 for PNI &lt, 50 versus PNI ≥ 50), which was in turn significantly associated with worse overall survival, and higher risk of late mucositis (HR = 1.84, 95% CI:1.09–3.12). PNI predicts acute weight loss &gt, 10% and late mucositis. Conclusions: PNI could help clinicians to identify patients undergoing radiotherapy who are at high risk of acute and late toxicity.

Background Two methods for detecting synovial fluids alpha defensins are available: the enzyme-linked immunosorbent assay and the lateral flow test. For both, the proper role and accuracy remain uncertain. The purpose of this study was to assess the accuracy of the matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) for alpha defensin detection in synovial fluids of patients with total knee arthroplasty/total hip arthroplasty failures. The hypothesis was that the alpha defensin measurement through MALDI-TOF MS assay could be a high sensitive and specific test for periprosthetic joint infections (PJI) diagnosis as compared with Musculoskeletal Infection Society (MSIS) criteria. Methods The study included 138 patients. The 2018 MSIS criteria were used to diagnose PJIs. Synovial fluids were assessed for routinely synovial fluid tests and alpha defensin measurement through MALDI-TOF MS. Sensitivity, specificity, overall diagnostic accuracy, positive and negative predictive values, receiver operator curves, and area under the curve were calculated. Results As per the 2018 MSIS criteria, 59 PJIs (43%) and 79 aseptic failures (57%) were diagnosed. The MALDI-TOF MS assay showed an overall accuracy of 94.9%. The sensitivity was 93%, the specificity was 96%, the positive predictive value was 95%, and the negative predictive value was 95%. Receiver operator curves analysis demonstrates an area under the curve of 0.95 (P Conclusion The MALDI-TOF MS assay showed high sensitivity and specificity for alpha defensin detection in case of total knee arthroplasty/total hip arthroplasty failures. The advantages of the technology, such as the few milliliters of sample needed, the rapidity of obtaining results, and the cost-effectiveness of the procedure could make the MALDI-TOF MS alpha defensin assay a useful and widespread test in clinical practice.

The purpose of this study was to determine the most reliable radiographic measurement method to evaluate PTS as a risk factor for ACL reconstruction failure. Patients who underwent ACL reconstruction or ACL revision reconstruction between January 2009 and December 2014 by a single surgeon were included. Fifty-two consecutive patients who underwent ACL revision reconstruction were compared to a random selection of 52 patients who underwent primary ACL reconstruction and a control group of 52 patients without ACL injury. ACL reconstruction was performed using either ipsilateral (primary) or contralateral (revision) quadrupled hamstring autograft. Lateral knee radiographs were evaluated using three methods: (1) longitudinal axis, (2) anterior tibial cortex axis, and (3) posterior tibial cortex. A significant difference was found between subjects who underwent ACL reconstruction and control knees (6.79° vs. 5.31°, p = 0.046) using the posterior tibial cortex method. No other statistical significance was found between groups. A multiple linear regression analysis found that the PTS as measured by any method was not affected by the patient’s age, sex, height, weight, and BMI. All methods of measurement for PTS demonstrated excellent (ICC > 0.90) intra-rater and inter-rater reliability, but only the posterior tibial cortex method maintained excellent intra-rater and inter-rater reliability (ICC > 0.90) when evaluating patients with ACL revision reconstruction. The posterior tibial cortex measurement is the most reliable method for analyzing the PTS on lateral knee radiographs in patients undergoing ACL revision reconstruction.

Gentamicin-impregnated cement beads and spacers are frequently used in case of infective complications after Total Knee Arthroplasty (TKA). A great number of studies in the literature demonstrated that the local administration of gentamicin produces high local antibiotic levels but low serum and urine gentamicin concentrations. Gentamicin-impregnated cement spacer can induce nephrotoxicity in patients presenting major renal impairment susceptibility. We report a case of acute renal failure using a gentamicin-impregnated block spacer. An 83-year-old woman underwent a gentamicinimpregnated bone–cement spacer implant because of an infected TKA removal. Three days later patient clinical status got worse reporting a decreased urine output and increasing C-reactive protein (CRP), Serum Creatinine (SCr) and Blood Urea Nitrogen (BUN). Because the symptoms could be related to the knee spacer lead us to the decision of gentamicin-impregnated cement spacer removal. The day following the removal procedure showed progressive improvement of general condition with evidence of SCr and BUN normalization. Gentamicin-impregnated cement spacer can induce nephrotoxicity in patients presenting major renal impairment susceptibility.

Advantages of minimally invasive approaches for total hip arthroplasty are still matter of debate. Serum markers have been assessed as objective method to quantify muscle damage after surgery but in literature ambiguous results have been reported. The aim of this prospective randomized study was to: 1) compare serum markers elevation between a minimally invasive direct anterior approach (DAA) and a direct lateral approach (DLA); 2) to establish a correlation between serum markers increase and other perioperative variables.A lesser elevation of markers could be found in patients who underwent a minimally invasive DAA.Seventy patients were enrolled and randomly divided in two groups according to the type of the approach. All patients were treated with the same implant by the same surgeon and received the same rehabilitation protocol. Demographic data, preoperative Harris Hip Score (HHS) and operative time were recorded. Myoglobin, creatine kinase MB (CK-MB), troponin I, C-reactive protein (CRP), haemoglobin (HB) and pain levels were measured pre- and postoperatively.Mean postoperative rise were 524.9±134.6 and 667.8±409.5 for myoglobin, 4.8±2.5 and 6.6±3.7 for CK-MB, and 16.9±5.3 and 15.4±6.4 for PCR, in DAA and DLA groups, respectively. In both groups, postoperatively values were significantly higher than preoperatively (p0.05). Comparing the two groups, no significant differences in serum markers elevations were found. A significantly lower postoperative pain was found in DAA group than in DLA group (2.9 vs. 4.2 and 2.7 vs. 3.6 in second and third day, respectively (p0.05)). No significant correlation was present between the serum marker elevations and age, BMI, HHS, operative time, HB or pain levels (p0.05).Serum markers of muscle damage and inflammation increased in the postoperative period without significant differences between DAA and DLA, even though overall trend was higher in DLA group. The DAA group had significantly lower levels of postoperative pain. No significant correlation between pain and serum markers levels was found.I; randomized study.

Background Recently, there has been renewed interest in primary anterior cruciate ligament (ACL) repair. The aim of this study is to report early clinical and radiological results of a consecutive series of acute ACL tears treated with arthroscopic primary ACL repair within 14 days from injury. Patients and methods A consecutive series of patients with acute ACL tears were prospectively included in the study. Based on MRI appearance, ACL tears were classified into five types, and tissue quality was graded as good, fair, and poor. Patients with type I, II, and III tears and at least 50% of ACL tibial remnant intact with good tissue quality were ultimately included. Clinical outcomes were measured using the Tegner Lysholm Knee Scoring Scale (TLKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), subjective and objective International Knee Documentation Committee (IKDC) scores, and KT-1000. Patients were also followed up with MRI evaluations at 1, 3, and 6 months postoperatively. ACL appearance was graded based on morphology (normal or abnormal) and signal intensity (isointense, intermediate, and hyperintense). Results The mean TLKSS was 98.1, the mean subjective IKDC was 97.6, and the mean KOOS was 98.2. The objective IKDC score was A in eight of ten patients and B in two patients. KT-1000 measurements showed a maximum manual side-to-side difference of less than 2 mm in eight of ten patients, whereas two patients showed a difference of 3 mm. The morphology of the repaired ACL was normal (grade 1) at 1 month follow-up in ten of ten cases, and this appearance persisted at 3 and 6 months postoperatively. The signal intensity at 1 month postoperatively was graded as isointense (grade 1) in four of ten patients, intermediate (grade 2) in five of ten patients, and hyperintense (grade 3) in one of ten patients. At both 3 and 6 months postoperatively, the signal intensity was graded as isointense (grade 1) in nine of ten patients and intermediate (grade 2) in one of ten patients. Conclusions Arthroscopic primary ACL repair performed acutely in a carefully selected group of patients with proximal ACL tears and good tissue quality showed good early clinical and radiological results. Level of evidence Level 4.

Purpose To investigate the relationship between the Segond fracture and the anterolateral complex of the knee. Methods Between January 2014 and March 2020, patients who presented with an anterior cruciate ligament (ACL) tear requiring acute surgical reconstruction (within 10 days from trauma) were evaluated for inclusion in this study. Patients were included if they had an acute ACL tear with an associated Segond fracture (or “Segond lesion”) as detected by radiograph or magnetic resonance imaging. The lateral compartment was exposed in all cases using a 5-cm lateral hockey-stick incision, which was carried down to the iliotibial band. The fascia lata was first inspected and then longitudinally divided along its fibers to expose lateral compartment. The posterolateral corner to Gerdy’s tubercle anteriorly was exposed and examined. Once the Segond fracture was identified, it was recorded and photographed. Results Seventeen patients were enrolled in the study. Dissection of the Segond fracture demonstrated attachment to the anterolateral capsule only. No other discernible attachment to the Segond fracture was noted. Surgical exploration of the anterolateral knee did not reveal injury to the iliotibial band. Conclusions Careful dissection of Segond fractures during repair revealed that there is a discernible attachment with the anterolateral capsule to the bone injury in all patients with acute ACL tears undergoing surgical reconstruction and no connections to the iliotibial band. Clinical Relevance The precise pathogenesis of Segond fractures has been the subject of debate, partially due to the complexity of the anatomy of the anterolateral aspect of the knee. Proper understanding of the anatomy of type IV ALL injures with Segond fractures is important to improve treatment of these injuries.

Suprascapular neuropathy is more frequent in volleyball as compared to other overhead sports. This study aims to report the actual prevalence of suprascapular neuropathy among elite volleyball play...

The aim of this prospective study was to perform a clinical and radiologic evaluation of patients undergoing total hip arthroplasty (THA). The hypothesis is that there is a correlation between the pre-operative degeneration state of the gluteal muscle-tendinous unit and the clinical outcome in terms of functional recovery. Fifty-five patients have met inclusion criteria. All patients included in the sample were subjected to clinical evaluation. The ultrasound examination of the patients of the study was conducted and the following parameters were assessed: Thickness in mm of the gluteus medius tendon; Quality of the gluteus medius tendon; and Trophy and muscular composition. The degree of degeneration of the pre-operative tendon shows a negative statistical correlation with all the pre- and post-operative clinical scales, but presents statistical significance (p

Introduction Rupture of the patellar tendon is becoming more and more frequent, even in sports activities overloading the extensor mechanism of the knee. Platelet-rich plasma (PRP) treatment has been recently introduced in treatment for several knee- and sport-related injuries including muscle strain cartilage defect and tendinopathies. The aim of this case report is to present a case of rupture of the patellar tendon occurred after injections of PRP. Case report A case of a 40-year-old male soccer player sustaining a patellar tendon rupture after a series of 4 PRP injections. At surgery, a complete rupture in the middle of the patellar tendon was found, with severe degenerative changes of the tendon tissue. This case questions the actual efficacy and safety of PRP in severe degenerative tendinopathies.

The COVID-19 outbreak strongly affected Italy, putting a strain on the National healthcare system. Hospitals quickly reorganized the activity to cope with the emergency. This retrospective comparative study aimed to analyze the impact of the lockdown imposed in Italy during the COVID-19 outbreak on acute orthopedic trauma, in order to identify critical issues for improvement and future planning. We collected data on all the trauma admissions to a single University hospital DEA (Department of Emergency and Acceptance) in Rome during the COVID- 19 pandemic lockdown in Italy, comparing them with the corresponding period in 2019. We reported demographic data; the characteristics of the injury, including the anatomical location, fracture, sprain, dislocation, contusion, laceration, whether the injury site was exposed or closed, where the injury occurred, and polytrauma. We also recorded the waiting time in the emergency room and mode of transportation. The study sample was composed of 1199 patients, 636 (53.04%) males and 563 (46.96%) females. The overall number of admissions in 2019 (pre-COVID-19 period) was 995; then it was 204 during COVID-19 outbreak in 2020. The average age of the 2020 group was 51.9 ± 24.8 years, significantly higher than that of the 2019 group (41.4 ± 25.7) (p

Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing. Die chronische Osteomyelitis entwickelt sich häufig aus einer offenen Fraktur, bei periprothetischem Infekt oder bei septischer Arthritis und stellt bei infizierter Pseudoarthrose eine bedeutende Herausforderung der Orthopädie dar. Knocheninfekte und infizierte Pseudoarthrosen werden durch radikales, chirurgisches Debridement von Knochen und Weichgewebe verbunden mit lokaler und systemischer Behandlung mit Antibiotika und temporärer Stabilisierung behandelt. Bei größeren Defekten werden freie oder gestielte Knochen-Lappenplastiken oder Kallus-Distraktions-Techniken angewandt. In der vorliegenden Studie werden die Hebedefekte und Ergebnisse bei Patienten mit infizierten Pseudoarthrosen der unteren Extremitäten nach Behandlung mit freier, medialer Femur-Kondylen-Lappenplastik evaluiert. 11 Männer (Durchschnittsalter 45,6 Jahre) mit einer Pseudoarthrose der tibialen Diaphyse (7 Fälle) oder Pseudoarthrose der femoralen Diaphyse (4 Fälle) mit freier, medialer Femur-Kondylen-Lappenplastik werden untersucht. In allen Fällen wurde das chirurgische Debridement vor der Lappenplastik ausgeführt. Die klinischen und radiologischen Ergebnisse an der Empfängerstelle werden mittels prä- und postoperativee Röntgen- und MRT-Untersuchungen mit einem Follow-up von druchschnittlich 3 Jahren nachuntersucht. In 90,9 % der Fälle wird eine vollständige klinische und radiologische Knochenheilung beobachtet. Im Bereich des Hebedefekts gab es keine erkennbaren Unterschiede zwischen Entnahmeseite des medialen Femur-Kondylus und der kontralateralen Seite. Das Knochegewebe hatte sich im Bereich des Hebedefektes an die unverletzte Gegenseite angeglichen. Auch in der MRT wurde eine Ausheilung des Hebedefekts mir vaskularisiertem Knochen in allen Patienten beobachtet. Diese Nachuntersuchung zeigt, dass der Einsatz von freien Knochen-Lappenplastiken ein wirksames Verfahren zur Behandlung von infizierten Pseudoarthrosen der unteren Extremität darstellt. Ein radikales Debridement der Pseudoarthrose ist Voraussetzung. Die Entnahme der freien, medialer Femur-Kondylen-Lappenplastik führt offenbar zu geringer Morbidität am Hebedefekt. Eine erfolgreiche Ausheilung der Pseudarthrose konnte so in einem Prozentsatz erreicht werden.​.

Transverse patellar fractures are a relatively common injury and typically require surgical fixation. An adequate restoration of patella integrity is essential for proper functioning of the extensor mechanism of the knee and for the prevention of patellofemoral osteoarthritis. Currently, the treatment of transverse fractures of the patellar bone involves several surgical techniques, most of which involve the use of metallic implants. Despite good clinical results following surgery, numerous complications exist, including primarily symptomatic hardware following surgical treatment. The purpose of this article is to describe the technique for treatment of a transverse patellar fracture using a high-resistance tape (FiberTape; Arthrex) and a tensioner (Arthrex) instead of traditional metallic implants.

The aim of the present study was to confirm the effectiveness of adding nanohydroxyapatite (NHA) to a heterologous bone graft in open-wedge high tibial osteotomy (OWHTO) by measuring the bone density via multislice computed tomography (CT) of the tibial osteotomy gap in a mid-term follow-up (five years).Twenty-six patients undergoing OWHTO were randomly assigned to two groups: a pure graft group (Group A), in which the osteotomy gap was filled with only heterologous bone graft, and an NHA group (Group B), in which the osteotomy gap was filled with heterologous bone graft and NHA. CT was performed within one week of the operation, after two months, after 12 months and after five years. CT volume acquired in Hounsfield units (HU) was measured on three planes.The normal bone density was 110.2 ± 11.7 HU. The value of mean density at five years in Group A was 296.8 ± 81.8 HU, while in Group B, it was 202.2 ± 45.1 HU, showing a density more similar to normal bone and greater bone uniformity inside the osteotomy. The difference between the two groups was statistically significant (p 0.05). Furthermore, both groups showed excellent mid-term clinical outcomes without significant differences.This study revealed that absorbability and bone formation at the osteotomy site in the NHA group was significantly higher as compared with the pure graft group at five years postoperatively.

Background Advantages of minimally invasive approaches for total hip arthroplasty are still matter of debate. Serum markers have been assessed as objective method to quantify muscle damage after surgery but in literature ambiguous results have been reported. The aim of this prospective randomized study was to: 1) compare serum markers elevation between a minimally invasive direct anterior approach (DAA) and a direct lateral approach (DLA), 2) to establish a correlation between serum markers increase and other peri-operative variables. Hypothesis A lesser elevation of markers could be found in patients who underwent a minimally invasive DAA. Patients and methods Seventy patients were enrolled and randomly divided in two groups according to the type of the approach. All patients were treated with the same implant by the same surgeon and received the same rehabilitation protocol. Demographic data, pre-operative Harris Hip Score (HHS) and operative time were recorded. Myoglobin, creatine kinase MB (CK-MB), troponin I, C-reactive protein (CRP), haemoglobin (HB) and pain levels were measured pre- and post-operatively. Results Mean post-operative rise were 524.9 ± 134.6 and 667.8 ± 409.5 for myoglobin, 4.8 ± 2.5 and 6.6 ± 3.7 for CK-MB, and 16.9 ± 5.3 and 15.4 ± 6.4 for PCR, in DAA and DLA groups respectively. In both groups, post-operatively values were significantly higher than pre-operatively (p 0.05). Conclusion Serum markers of muscle damage and inflammation increased in the post-operative period without significant differences between DAA and DLA, even though overall trend was higher in DLA group. The DAA group had significantly lower levels of post-operative pain. No significant correlation between pain and serum markers levels was found. Level of evidence I; randomized study.

Introduction Unstable intra articular fractures of distal radius are frequently being managed with open reduction and internal fixation. Volar locking plate based on polyetheretherketon (PEEK) polymer has developed lately as an alternative to conventional metallic devices. The advantage of this kind of plates include the lack of metal allergies, radiolucency, low artefacts on MRI or imaging scans and the high resistance associated to loading forces. The aim of this study was to evaluate the clinical and radiological results using a new Carbon-PEEK volar locking plate compared with titanium volar locking plates for the treatment of distal radius fractures. Methods and Material Thirty patients were included in this study. They all underwent traumatic intra-articular distal radius fractures and were surgically treated with volar locking plates. The patients were randomly divided in two groups: In Group A (15 patients) the fracture was stabilized with a CarboFix volar locking plate whereas in group B (15 patients) with an Acu-Lock Volar Distal Radius Plate. Range of motion (ROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score and X-rays were evaluated. The mean follow up was 12 months. Results Analysis of Wrist ROM revealed that there was no statistical significant difference (p > 0.05) in regards to extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm and between Group A and Group B. The mean score on the DASH was 15.3 in Group A and 13.2 in Group B (p > 0.05). Patients were able to return to their normal activities of daily living at an average of 4 weeks post-op in both Groups. Overall, the mean VAS score was 3.6 There were no statistically significant differences (p > 0.05) on X-Rays examination between two Groups in regards to alignment and fracture healing. Conclusions Volar locking plates represent the most common procedure for the treatment of displaced distal radius fractures. In our series Carbon-peek volar locking plates seems to be analogue to titanium volar locking plates in terms of radiographic parameters and functional outcome.

Background To compare in an animal model the biomechanical properties of four coupled fixation devices currently used in ACL reconstruction. Three out of four devices used a full tibial tunnel with an interference screw, while the other one system used a tibial socket and an adjustable loop suspension device. The null hypothesis is that there are no biomechanical differences between all the techniques tested. Methods Thirty two femur–graft–tibia complexes were mounted on a tensile machine using bovine digital extensor tendons, porcine knees and four different fixation device combinations: – Group A: EndoButton CL and BioRCI – Group B: Rigidfix and Intrafix – Group C: Transfix and Deltascrew – Group D: TightRope-RT with the All-inside GraftLink technique. After a preconditioning with a tensile load of 90 N for five minutes, 1000 cycles between 0 and 150 N were applied to the complex before the final pulled to failure. Stiffness and strength were evaluated at the final pullout, as was the displacement (slippage) at one, 100, 500, and 1000 cycles. Results The multiple mean comparison led to a significant difference for the case of stiffness, with worse results in group C compared to group A (p = 0.037). Conversely, no differences were found in UFL and slippage between all groups (p > 0.05). Conclusion All the tested systems demonstrated in an animal model sufficient properties for a safe postoperative rehabilitation both for strength and for stiffness and slippage under cyclic loading.

Background Segond’s fracture is a well-recognised radiological sign of an anterior cruciate ligament (ACL) tear. While previous studies evaluated the role of the anterolateral ligament (ALL) and complex injuries on rotational stability of the knee, there are no studies on the biomechanical effect of Segond’s fracture in an ACL deficient knee. The aim of this study was to evaluate the effect of a Segond’s fracture on knee rotation stability as evaluated by a navigation system in an ACL deficient knee. Materials and methods Three different conditions were tested on seven knee specimens: intact knee, ACL deficient knee and ACL deficient knee with Segond’s fracture. Static and dynamic measurements of anterior tibial translation (ATT) and axial tibial rotation (ATR) were recorded by the navigation system (2.2 OrthoPilot ACL navigation system B. Braun Aesculap, Tuttlingen, Germany). Results Static measurements at 30° showed that the mean ATT at 30° of knee flexion was 5.1 ± 2.7 mm in the ACL intact condition, 14.3 ± 3.1 mm after ACL cut (P = 0.005), and 15.2 ± 3.6 mm after Segond’s fracture (P = 0.08). The mean ATR at 30° of knee flexion was 20.7° ± 4.8° in the ACL intact condition, 26.9° ± 4.1° in the ACL deficient knee (P > 0.05) and 30.9° ± 3.8° after Segond’s fracture (P = 0.005). Dynamic measurements during the pivot-shift showed that the mean ATT was 7.2 ± 2.7 mm in the intact knee, 9.1 ± 3.3 mm in the ACL deficient knee(P = 0.04) and 9.7 ± 4.3 mm in the ACL deficient knee with Segond’s fracture (P = 0.07). The mean ATR was 9.6° ± 1.8° in the intact knee, 12.3° ± 2.3° in the ACL deficient knee (P > 0.05) and 19.1° ± 3.1° in the ACL deficient knee with Segond’s lesion (P = 0.016). Conclusion An isolated lesion of the ACL only affects ATT during static and dynamic measurements, while the addition of Segond’s fracture has a significant effect on ATR in both static and dynamic execution of the pivot-shift test, as evaluated with the aid of navigation.

Background To evaluate the reliability of the Iliotibial band compared to gracilis tendon as a graft to be used in anterolateral ligament reconstruction. Methods Gracilis tendon and a strip of Iliotibial band compared were harvested from 8 fresh human cadaveric knees. The gracilis tendon was prepared to obtain a graft of 10 cm in length (Group 1). Iliotibial band compared was prepared to obtain a graft of 10 cm in length and 0.5 cm in width from the middle portion (Group 2). All the specimens were fixed on a servo hydraulic tensile machine with dedicated cryo-clamp. The loading protocol, used to compare the previously published results of ultimate failure load and Stiffness of the anterolateral ligament (Group 3), included a cyclic preconditioning between 10 and 25 N at 0.1 Hz for 10 cycles and then a load to failure test at 20 mm/min. Findings Gracilis tendon showed higher Ultimante Failure Load and stiffness when compared to a strip of Iliotibial band. Gracilis tendon and a strip of Iliotibial band compared showed higher Ultimante Failure Load and stiffness when compared with native anterolateral ligament as reported by Kennedy. Interpretation Both grafts tested in the present studies are suitable for an anatomical anterolateral ligament reconstruction.

The present study reports the clinical results of excision of a symptomatic os trigonum using an endoscopic procedure in professional ballet dancers. The hypothesis was that posterior endoscopic excision of the os trigonum would be safe and effective in treating posterior ankle impingement syndrome related to the os trigonum. Twelve professional dancers underwent excision of a symptomatic os trigonum for PAIS using a posterior endoscopic technique after failure of conservative treatment. The patients were evaluated pre- and postoperatively according to the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner activity scale score, and the visual analog scale score. The surgical time, timing of a return to sports, patient satisfaction, and any complications related to the procedure were recorded. The average postoperative follow-up duration was 38.9 ± 20.6 (range 12 to 72) months. The mean Tegner activity scale score increased from 4.3 ± 0.8 (range 3 to 5) preoperatively to 9 ± 0.2 postoperatively (p

Background Pre-operative high-grade pivot shift is associated with higher rates of ACL graft failure; persistent instability and inferior patient reported outcomes. The pathophysiology of high-grade pivot shift is multifactorial and numerous factors have been implicated. Purpose The aim of this study was to determine risk factors for high-grade pivot shift, with a particular emphasis on addressing the limitations of previous studies, by including a comprehensive evaluation of both soft-tissue and osseous parameters. Study design Case series. Methods A prospective evaluation of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury) was undertaken. An open lateral exploration was undertaken at the time of the index procedure. Details regarding patient and injury characteristics were recorded. Osseous parameters (tibial slope and condylar ratios) were determined using established MRI protocols. A multivariate logistic regression with Penalized Maximum Likelihood was used to identify risk factors associated with grade 3 pivot shift. A stepwise descending strategy was applied from the initial full model to determine the most parsimonious one, removing step-by-step all the non-statistically significant parameters and keeping only the clinically relevant parameters and confounding factors (if any). Results The mean age of the population was 28.3 ± 9.8 years. 67.5% of patients were male. Thirty-five (17.5%) of patients had a high grade (grade 3) pivot shift and 165 (82.5%) had a low-grade pivot shift (grades 1 and 2). Both uni- and multivariate analyses demonstrated that injury to the Anterolateral structures of the knee was the only significant risk factor for high-grade pivot shift. When this was subcategorized further, it was identified that both complete and incomplete tears of the ALL, and Segond fractures were all significant risk factors for high-grade pivot shift. Conclusions A comprehensive evaluation of soft-tissue and osseous factors has identified that injury to the Anterolateral Structures of the knee is the most important risk factor for explosive pivot shift in acute ACL-injured knees.

The aim of this study was to describe clinical and radiological long-term results of an arthroscopic partial meniscectomy associated with an outside-in decompressive needling of the cyst for lateral parameniscal cyst. Eighteen patients with symptomatic parameniscal cysts treated between April 2002 and September 2009 were retrospectively included in the study. All patients underwent arthroscopic partial meniscectomy (preserving peripheral rim) and needling of the cyst using a 20-gauge needle. Pre- and post-operative IKDC, Tegner, and Lysholm scores were used to evaluate clinical results. Radiological results were obtained from pre- and post-operative radiographies and post-operative MRI scans. Both supine and weight bearing MRI examinations were performed. Kellgren-Lawrence and WORMS scales were used to evaluate osteoarthritis development of the knee. The mean follow-up period was 11.6 ± 2.6 years (range 7–15). Horizontal lesions were found in 56% of patients. All patients fully recovered. Mean Lysholm scores passed from mean pre-operative value 52 ± 16.9 to post-operative 85 ± 11.9 (P < 0.01) and mean IKDC scale score changed from 49.5 ± 14.7 to 67 ± 23.5 (P < 0.01). Mean Tegner scores did not change significantly. Post-operative radiographies showed a Kellgren-Lawrence scale grade 0 in six patients (33%), a grade I in eight (44%), a grade II in three (17%), and a grade III in one patient (6%). No patients were found with a Kellgren-Lawrence scale grade IV. No significant differences with pre-operative radiographies were found (chi-square = 1.867; df = 3; P = 0.60) in osteoarthritis development of the knee. Reported WORMS scores had an average of 12.4 ± 5.1. No recurrence of any cysts was observed. Different treatments for lateral meniscal cysts have been proposed, but proper management of the cyst is still controversial. The results of this study suggest that the outside-in needling of the cyst associated with partial meniscectomy is a highly effective, simple, and repeatable technique. Excellent clinical outcomes were reported at a mean follow-up of 11.6 ± 2.6 years (range 7–15). Imaging evaluation showed no significant evolution to osteoarthritis of the knee. Partial arthroscopic meniscectomy associated with percutaneous decompressive needling of the cyst wall under arthroscopic visualization showed positive clinical and radiological long-term results. Neither traditional radiographies nor innovative standing MRIs showed findings of osteoarthritis.

To compare the long-term effectiveness of non-operative treatment with immediate arthroscopic surgical stabilization in young, active patients after first-time anterior glenohumeral dislocation. Consecutive patients aged 15–25 years who suffered primary traumatic anterior glenohumeral dislocation were enrolled in this prospective, non-randomized investigation. In total, 160 patients were enrolled—64 opted for surgical stabilization (group A), while 96 opted for conservative treatment (group B). At final follow-up of over 6.5 years, 60 patients in group A (96.7% males, age 22.8 ± 3.2) and 70 patients in group B (90.0% males, age 20.8 ± 2.9) were evaluated with physical examination, patient-reported outcome measures (PROMs), and radiological studies. Recurrence and return to sport (RTS) data were collected, and variables were compared between groups. Recurrence rate in group A was 13.3% at mean latency of 3.3 ± 1.9 years, compared to 71.4% at mean latency of 2.1 ± 1.5 years in group B (P

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To describe the surgical findings of the anterolateral complex in patients with the “unhappy triad” lesion of the knee. One hundred and twenty-five consecutive patients presenting with acute anterior cruciate ligament (ACL) tears were selected for this study. Only cases, evaluated with a valgus stress test under fluoroscopy, with a medial opening more than 5 mm of the medial collateral ligament (MCL) were included in the study (11 patients). For the included cases, open MCL surgical repair was performed only in cases with a valgus stress test more than 10 mm as revealed by fluoroscopy (3 patients). All included cases (11 patients) underwent ACL reconstruction and exploration of the anterolateral complex that was then assessed, photographed, classified, and eventually repaired. At clinical evaluation under anaesthesia, all patients presented a positive Lachman test and a pivot shift test graded as ++ in four cases and +++ in five cases, not valuable in two cases. At surgical exploration, the anterolateral complex was involved in all cases (11 patients): one case demonstrated a type I injury, eight cases a type II injury, two cases a type III injury, and no patient with a type IV injury (Segond’s fracture). All anterolateral complex lesions were repaired by direct suture and re-tensioning. On the basis of a recent analysis performed by other authors, we could speculate that injuries of ACL and anterolateral compartment occur in the very early phase of the injury when the knee is forced into internal rotation. The MRI evidence of bone bruising in the lateral compartment in most cases of the present series support the hypothesis of an internal rotation torque. The unhappy triad of injuries to the knee is actually a tetrad involving not just the ACL, MCL, and medial/lateral meniscus but also involved the anterolateral complex.

Introduction. Intra-articular ganglion cysts of the knee joint are rare and mostly incidental findings in magnetic resonance imaging (MRI) or arthroscopy. Posterior cruciate ligament (PCL) ganglion cyst in a child is an extremely rare finding, and to the best of our knowledge, only one case has been described in the literature. We report a case of a large intra-articular ganglion cyst of the knee arising from the PCL in an autistic child. Case Presentation. An 8-year-old Caucasian boy affected by autism presented with nontraumatic knee pain. His parents, observing child’s gait, reported recurrent limp while walking, sometimes accompanied by knee locking. Clinical examination was hindered by the noncompliance of the patient and revealed painful limitation of terminal flexion and extension. MRI scans showed a large ganglion cyst located in the intercondylar notch. Arthroscopy confirmed an intrasubstance PCL ganglion cyst, extending both anteriorly and posteriorly. Complete excision of the cyst was performed, with full recovery of the child and no recurrence. Conclusion. In pediatric patients with pain or limited knee range of motion, physicians should consider the possibility of a ganglion cyst arising from the PCL, despite its rarity. Arthroscopic excision is a safe and effective procedure that guarantees a complete recovery of the patient with the lowest rate of recurrence.

Several extra-articular surgical techniques in addition to anterior cruciate ligament reconstruction have been proposed to better restore rotational instability of the knee. One option is surgical repair of the anterolateral ligament in acute cases to achieve an anatomic reconstruction. An additional augmentation to the repair could allow a load-sharing—and thus protective—effect for the repair during the healing process. The purpose of this Technical Note is to describe a primary repair of the anterolateral ligament with suture tape augmentation (Internal Brace; Arthrex, Naples, FL) in a patient with an acute anterior cruciate ligament tear.

Purpose: Treatment of patients with dementia and hip fracture is challenging. Total hip arthroplasty (THA) with dual mobility cup (DMC) has been designed to reduce the rate of dislocation by increasing the stability of the implant. This study aimed to compare the dislocation rates of DMC THA with hemiarthroplasty (HA) in elderly patients with displaced femoral neck fracture (FNF) and a diagnosis of dementia. Methods: All patients with a displaced FNF and dementia diagnosis were prospectively randomized to hemiarthroplasty or THA with DMC treatment during a 2-year period. Finally, the outcomes of 30 patients in the HA group were compared with those of 30 patients in the DMC THA group. Dislocation rate at a minimum follow-up of 1 year was evaluated as the primary outcome. Reoperation rate, time to surgery, surgical time, length of hospital stay, and 30-day and 1-year mortality were also evaluated. Results: There was a significant difference regarding rates of dislocation in favor of THA with DMC and with regard to length of surgery (p = 0.04) in favor of bipolar HA. Dislocation occurred in five patients (16.6%) treated with bipolar HA and no one (0%) in patients treated with THA with DMC (p = 0.019). There was no difference with regard to the 30-day mortality, 1-year mortality, reoperations, and length of hospital stay between the two groups of patients. Discussion: THA with DMC seems to be a safe and reliable choice to reduce the rate of dislocation at 1 year in patients with dementia and FNF without a higher risk of mortality.

Biological arthroplasties are the most used surgical techniques, for the treatment of trapeziometacarpal osteoarthritis; all of them provide the reconstruction of trapeziometacarpal joint by a tendon graft. The aim of the study is to compare two surgical techniques: interposition arthroplasty and suspension arthroplasty at 12-month follow-up in order to evaluate the clinical and radiographic results. Sixty-seven patients surgically treated for basal thumb osteoarthritis were divided into two groups: 36 patients, (8 M; 27 F) (39 hands), treated with interposition arthroplasty are included in group A and 31 patients, (6 M; 25 F) (34 hands), treated with suspension are included in group B. Both groups were radiographically evaluated with X-ray and MRI at 12 months and clinically evaluated with DASH score, VAS, Grind test, hand grip tests, Kapandji test and ROM before surgery and at final follow-up. At final follow-up about Kapandji test, in group A, 31 hands (79.4%) presented Kapandji score of 10 and eight hands (20.6%), a Kapandji score of 8. In group B, six hands (17.6%) reported a Kapandji score of 8 and 28 patients (82.4%), a Kapandji score of 10 (p