Search

Background: Patellar dislocation accounts for 2–3% of all knee lesions and is the second most common cause of traumatic hemarthrosis of the knee. Proper treatment is essential to minimize long term sequelae, such as recurrent dislocation, painful subluxation, and osteoarthritis. Aim: The purposes of this perspective randomized study were: 1) to evaluate the mid-term clinical and radiological results of the Elmslie–Trillat procedure for the treatment of traumatic patellar re-dislocation; and 2) to compare the results, especially radiological osteoarthritis development, with those of non-operative management for traumatic patellar re-dislocation. Methods: From June 2013 to February 2015, 65 patients were admitted to our Emergency Department for a first patellar dislocation episode. All patients were treated non-operatively. When a second episode occurred within two years, patients were randomly assigned in two groups: Group A, patients treated surgically with Elmslie-Trillat procedure, and Group B, patients were further treated non-operatively. The Knee Society Score (KSS), Lysholm scale and Kujala questionnaire were administered immediately after the re-dislocation and at the final follow-up. Tangential patella radiographs were evaluated for patellofemoral osteoarthritis and graded according to Sperner’s classification. Results: The mean follow-up was 6.4±1.7 years (range 5-8) in Group A and 6.3±2.1 years (range 5-9) in Group B. In Group A, the KSS and Lysholm scale showed significant differences between pre- and post-operatively values (p

Background: Interest in the role of lateral extra-articular tenodesis (LET) in preventing rotatory instability and the pivot-shift phenomenon after anterior cruciate ligament reconstruction (ACLR) has been recently renewed. Nevertheless, there is still concern about overconstraint of the lateral compartment of the knee and the risk of subsequent osteoarthritis (OA). Purpose: The purpose of this retrospective study was to compare long-term subjective and objective outcomes and the rate of OA development between patients undergoing isolated ACLR (iACLR) with a hamstring tendon autograft and those with a combined Arnold-Coker modification of the McIntosh extra-articular procedure. Risk factors for long-term OA were evaluated. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 165 consecutive patients treated at a single center by ACLR. A total of 86 patients underwent iACLR (iACLR group) and 79 received combined intra- and extra-articular reconstruction (ACLR+LET). The International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores were administered. Knee stability was tested through the Lachman test, the pivot-shift test, and the KT-1000 knee arthrometer test. A positive pivot-shift test (++/+++), laxity on the KT-1000, and referred giving-way episodes or revision ACLR were considered failures. Radiographic results were assessed according to the Fairbank, IKDC, and Kellgren-Lawrence scales. Radiographic evaluation included both the overall tibiofemoral joint and the medial and lateral compartment separately. A univariate and a multivariate logistic regression with penalized maximum likelihood was used to identify risks factors associated with long-term OA. Results: The mean follow-up was 15.7 years. There were no statistically significant differences in subjective scores between the 2 groups. A side-to-side difference >5 mm on the KT-1000 arthrometer evaluation was found in 8 patients in the iACLR group and in 1 patient in the ACLR+LET group ( P = .01). Nine cases of failure were found in the iACLR group and only 1 case was found in the ACLR+LET group ( P = .0093). Patients in the iACLR group had a significantly higher OA grades than those in the ACLR+LET group for the overall tibiofemoral joint and the lateral compartment of the knee. No differences were found in the medial compartment. A higher level of lateral compartment OA was found in patients who received partial lateral meniscectomy in the iACLR group compared with those in the ACLR+LET group. Univariate and multivariate analysis results demonstrated that meniscectomy was the most significant factor for long-term OA development. Conclusion: A significantly higher risk of long-term OA was found with iACLR than with ACLR combined with the Arnold-Coker modification of the McIntosh extra-articular procedure. Knees with combined ACLR also had a significantly lower OA grade after partial lateral meniscectomy. Additionally, those undergoing combined ACLR had better knee stability and lower graft rupture rates at the long-term follow-up. Partial meniscectomy was the main risk factor negatively associated with OA changes.

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.

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

Background: The impact of anterior cruciate ligament reconstruction (ACLR) on the performance and career of professional soccer players has not been extensively investigated. Purpose: To evaluate in professional European soccer players (1) the ACL injury incidence, (2) the return-to-play (RTP) rate and time after ACLR, (3) career survival and athlete performance in the first 3 postoperative seasons after RTP, (4) factors likely related to different outcomes after ACLR, and (5) any related differences between the top 8 European soccer leagues. Study Design: Descriptive epidemiology study. Methods: Included were professional soccer players in the top 8 European Soccer leagues (Serie A [Italy], Premier League [England], Ligue 1 [France], LaLiga [Spain], Bundesliga [Germany], Jupiler Pro League [Belgium], Liga NOS [Portugal], and Premier Liga [Russia]) who sustained an ACL injury during seasons 2014 to 2015, 2015 to 2016, and 2016 to 2017. Data were retrieved from publicly available online sources. Outcomes were evaluated based on player age (30 years), position (goalkeeper, defender, midfielder, and forward), affected side (dominant vs nondominant), and league. Results: Overall, 195 players sustained an ACL injury, for a mean annual ACL injury incidence of 1.42%. The RTP rate was 95%, with a mean RTP time of 248 ± 136 days. Within the third postoperative season, 66 players (36%) competed in a lower level national league, and 25 (13.6%) ended their careers; a significant reduction in the mean minutes played per season was found in all 3 postoperative seasons. Player age correlated significantly with reduction in performance or recovery from an ACL injury. No significant correlation was found between postoperative player performance and affected side, position, league, or time to RTP. Conclusion: A substantial ACL injury incidence was found in top European elite soccer players; however, a high RTP rate in a reasonable time was seen after ACLR. Nevertheless, professional soccer players experienced a short-term decline in their performance.

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

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.

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.

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...

Rationale Detection of α-defensins in synovial fluid is gaining more and more interest in the field of correct diagnosis of periprosthetic joint infections (PJIs). At present, they can be assessed by a quantitative enzyme-linked immunosorbent assay which is expensive and time-consuming and by a qualitative lateral flow immunoassay which is rapid but quite expensive and whose clinical sensitivity is debated. Thus, developing an alternative rapid, accurate, and low-cost assay for α-defensins is important to make α-defensins actionable as novel key clinical markers. Methods Synovial fluid (SF) samples were obtained from 18 patients undergoing revision of primary joint arthroplasty. Of these, eight met the 2013 Musculoskeletal Infection Society (MSIS) criteria for PJIs, the remaining were classified as aseptic failure. Microbiological analysis and Synovasure assays were carried out on all samples. Sample preparation and the matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) settings were adjusted to detect human neutrophil peptide (HNP)-1, -2 and -3 and to obtain optimal results in term of sensitivity and stability. Results MALDI-TOF MS was able to detect HNPs in SF from septic patients. No signals for HNPs were detected in SF from aseptic failure. The limits of detection (LOD) were 2.5 and 1.25 μg/mL for HNP-2 and HNP-1, respectively. The turnaround time of the analysis is 20 min, and SF samples are stable at -20°C for up to 3 days. Assay sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 100% for all parameters. On the same SF samples, the Synovasure assay showed lower sensitivity specificity, and PPV and NPV of 87.5%, 90%, 87.5% and 90%, respectively. Microbiological analysis of SF confirmed the presence of bacteria only in SF MSIS-positive patients. Conclusions The reported MALDI-TOF MS assay was able to detect and differentiate HNPs in SF samples and showed a slightly better diagnostic accuracy than the Synovasure assay.

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.

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.