Metal-backed or all-poly tibial components: which are better for medial unicompartmental knee arthroplasty? A propensity-score-matching retrospective study at the 5-year follow-up.

BACKGROUND: This retrospective medium-term follow-up study compares the outcomes of medial fixed-bearing unicompartmental knee arthroplasty (mUKA) using a cemented metal-backed (MB) or an all-polyethylene (AP) tibial component. MATERIALS AND METHODS: The database of our institution was mined for primary mUKA patients implanted with an MB or an AP tibial component (the MB-UKA and AP-UKA groups, respectively) from 2015 to 2018. We compared patient demographics, patient-reported outcome measures (PROMs), and motion analysis data obtained with the Riablo™ system (CoRehab, Trento, Italy). We conducted propensity-score-matching (PSM) analysis (1:1) using multiple variables. RESULTS: PSM analysis yielded 77 pairs of MB-UKA and AP-UKA patients. At 5 years, the physical component summary (PCS) score was 52.4 ± 8.3 in MB-UKA and 48.2 ± 8.3 in AP-UKA patients (p < 0.001). The Forgotten Joint Score (FJS-12) was 82.9 ± 18.8 in MB-UKAs and 73.4 ± 22.5 in AP-UKAs (p = 0.015). Tibial pain was reported by 7.8% of the MB-UKA and 35.1% of the AP-UKA patients (p < 0.001). Static postural sway was, respectively, 3.9 ± 2.1 cm and 5.4 ± 2.3 (p = 0.0002), and gait symmetry was, respectively, 92.7% ± 3.7 cm and 90.4% ± 5.4 cm (p = 0.006). Patient satisfaction was 9.2 ± 0.8 in the MB-UKA and 8.3 ± 2.0 in the AP-UKA group (p < 0.003). CONCLUSIONS: MB-UKA patients experienced significantly better 5-year static sway and gait symmetry outcomes than AP-UKA patients. Although the PROMs of the two groups overlapped, MB-UKA patients had a lower incidence of tibial pain, better FJS-12 and PCS scores, and were more satisfied.

Efficacy and Long-Term Outcomes of Intra-Articular Autologous Micro-Fragmented Adipose Tissue in Individuals with Glenohumeral Osteoarthritis: A 36-Month Follow-Up Study.

BACKGROUND: Glenohumeral osteoarthritis (GOA) is associated with disabling shoulder pain that affects everyday life. Its management comprises various treatment approaches, both conservative and surgical. Regenerative medicine has gained a major role in the conservative treatment of osteoarthritis. Intra-articular injection of adipose-derived mesenchymal stem cells (ADMSCs) is a widely used regenerative medicine approach. The aim of this retrospective study was to report the safety and clinical outcomes of intra-articular injection of ADMSCs in patients with GOA over 36-months. METHODS: This retrospective observational study involved patients with chronic shoulder pain resistant to standard conservative treatment and a diagnosis of concentric GOA, who received an intra-articular injection of autologous micro-fragmented adipose tissue (µFAT). The values of the Constant-Murley score (CMS), the visual analog scale (VAS), and the simple shoulder test (SST), collected at baseline and at 12, 24, and 36 months, were analyzed to assess treatment efficacy. The single assessment numeric evaluation (SANE) was used to rate patient satisfaction. The Friedman test was used to compare observations of CMS, VAS, and SST values repeated on the same subjects. The significance threshold was set at 0.05. RESULTS: The participants were 65 patients with a mean age of 54.19 years and a nearly equal gender distribution. Most had mild concentric GOA classified as Samilson-Prieto grade 1. The mean follow-up duration was 44.25 months. The postoperative clinical scores showed significant improvement. At 36 months, the CMS was 84.60, the VAS score was 3.34, and the SST score was 10.15 (all p < 0.0001). The SANE score at 36 months indicated that 54 patients (83.08%) were completely satisfied with the treatment. CONCLUSION: ADMSC treatment exerted favorable effects on the clinical outcomes of patients with GOA, providing pain relief and improving shoulder function. Our data support its use as a conservative treatment option for osteoarthritis.

Anatomic Combined Anterior Cruciate Ligament and Antero-Lateral Ligament Reconstruction Using Autologous Gracilis and Semitendinosus Graft With Single Tibial and Femoral Tunnel.

Anterior cruciate ligament (ACL) injuries are among the most common lesions in orthopaedics practice, but still today, rates up to 24% of unsatisfactory results are reported. Unaddressed anterolateral complex (ALC) injuries have been claimed to be responsible for residual anterolateral rotatory instability (ALRI) after isolate ACL reconstruction and have demonstrated to increase graft failure. In this article, we present our technique for reconstruction of the ACL and anterolateral (ALL) ligament combining the advantages of the anatomical position and the intraosseous femoral fixation to ensure anteroposterior and anterolateral rotational stability.

Dual-Energy CT for Detecting Painful Knee Prosthesis Loosening.

Background Dual-energy CT (DECT) is an alternative to radiography and single-energy CT (SECT) for detecting prosthesis-related complications. Purpose To compare the diagnostic performance of DECT, SECT, and radiography for knee prosthesis loosening, with use of surgery or imaging follow-up reference standards. Materials and Methods In this prospective single-center study from December 2018 to June 2021, participants with unilateral painful knee prostheses underwent radiographic, SECT, and DECT imaging. Five blinded readers, four radiologists, and one orthopedic surgeon evaluated the images. Prosthesis loosening was diagnosed by a periprosthetic lucent zone greater than 2 mm. The sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of each method were determined and compared with use of a multireader multicase analysis. Results There were 92 study participants (mean age ± SD, 70 years ± 9.4; 67 women) evaluated. Tibial and femoral loosening were diagnosed in 47 and 24 participants, respectively. For the tibia, mean sensitivity and specificity for arthroplasty loosening were 88% and 91%, respectively, for DECT, 73% and 78% for SECT, and 68% and 81% for radiography. For the tibia, DECT demonstrated similar diagnostic performance (AUC, 0.90) to SECT (AUC: 0.90 vs AUC: 0.87, respectively; P = .13) but was superior to radiography (AUC: 0.90 vs AUC: 0.82; P = .002). Overall diagnostic performance of DECT (AUC, 0.87) for the femur was superior to both SECT and radiography (P < .001). Conclusion Dual-energy CT had generally better diagnostic performance in detecting loosening of tibial and femoral components after total knee arthroplasty compared with single-energy CT or radiography. Clinical trial registration no. 2942 © RSNA, 2022.

The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study.

BACKGROUND: The study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA). METHOD: Between 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed. RESULTS: The mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05). CONCLUSION: Both DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.

Lateral extra-articular tenodesis and anterior cruciate ligament reconstruction in young patients: clinical results and return to sport.

Lateral extra-articular tenodesis (L.E.T.) have been proposed to reduce the tibia's anterior translation and internal rotation in concomitant to Anterior cruciate ligament (A.C.L.) reconstruction. Recent studies show that the addition of L.E.T. to A.C.L. reconstruction results in a statistically significant reduction in graft failure. The purpose of the present study was to evaluate the clinical outcomes, complications, and rate of return to preinjury sports level in pediatric patients who underwent combined A.C.L. reconstruction with L.E.T. at a minimum 2-year follow-up. The authors retrospectively evaluated 42 pediatric patients at high risk of graft failure who experienced ACLR connected to L.E.T. IKDC and Tegner-Lysholm Knee Scores Scale were used to assess clinical outcomes, and the Tegner Activity Scale to evaluate the return to sport. No graft failure or subsequent surgery related to A.C.L. reconstruction occurred. Furthermore, 88% of patients returned to the sport. Satisfactory clinical results were obtained on a short and medium-term follow-up. These findings help to consider this procedure for active adolescents at a high risk of graft failure to enhance A.C.L. reconstruction.

Distal femoral osteotomy versus lateral unicompartmental arthroplasty for isolated lateral tibiofemoral osteoarthritis with intra-articular and extra-articular deformity: a propensity score-matched analysis.

PURPOSE: Lateral unicompartmental arthroplasty (UKA) and distal femoral osteotomy (DFO) represent surgical solutions in cases of valgus malalignment and isolated lateral osteoarthritis (OA) of the knee. The aim of the present study was to assess the clinical results, complications, and the overall postoperative alignment of a series of DFO and lateral UKA with a minimum 2-year follow-up in active middle-aged patients. METHODS: Patients with valgus knee and isolated lateral OA who underwent opening-wedge DFO or UKA from 2017 to 2019 were reviewed. Each patient was characterized by a joint line convergence angle (JLCA) > 3° and mechanical lateral distal femoral angle (mLDFA) < 87°. We excluded patients who underwent meniscus or osteochondral allograft during DFO. The Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), complications, and postoperative alignment were assessed. Propensity score matching was used to identify comparable patients. RESULTS: The DFO and lateral UKA groups consisted of 29 patients each. No statistically significant differences in gender, age, body mass index (BMI), length of follow-up, or limb deformity were reported between the two groups. In the DFO group, OKS was reported to improve from 27.51 to 38.59 (p < 0.05) and KOOS from 51.14 to 67.2 (p < 0.05). Similarly, in the UKA group, OKS improved from 26.23 to 35.43 (p < 0.05) and KOOS from 50.12 to 65.91 (p < 0.05). However, the improvement in OKS and KOOS (delta) did not differ between groups (p = 0.35 and p = 0.95). The DFO and UKA groups were characterized by similar postoperative hip-knee-ankle (HKA) angle measurements of -3.26 and -3.00, respectively (p = 0.65). No patients in the UKA group underwent revision or other knee surgeries during follow-up. No infections were detected in either group. In the DFO group, no cases of nonunion or delayed union were reported. However, 40% of DFO patients underwent plate removal. One patient in each group was characterized by progression of medial OA with Kellgren-Lawrence (KL) grade > 3. CONCLUSION: UKA and DFO represent an effective treatment in lateral knee OA with intra-articular and extra-articular deformity. Both surgeries were able to provide a significant and comparable clinical improvement. LEVEL OF EVIDENCE: III, comparative retrospective cohort study.

Tibial Tubercle Screw Fixation on Custom Metaphyseal Cone: Surgical Tip in Severe Metaphyseal Tibia Bone Loss.

Tibial tubercle osteotomy (TTO) facilitates exposure in knee arthroplasty revision. However, it comes with complications, especially if it invades the intramedullary canal. Most revisions are characterized by compromised femur and/or tibia bone stock, and the use of metaphyseal cones or sleeves for implant fixation has become increasingly frequent. Several methods of fixation of the tibial tubercle have been proposed, such as screw fixation, cerclage wiring, and suture repair. Despite screws providing the strongest fixation for TTO, their placement around a tibial intramedullary stem or a metaphyseal tibial cone may be difficult. We described the use of a custom-made metaphyseal tibial cone with holes in its anterior surface that allow the surgeon to achieve accurate TTO fixation by screws.

Autologous Microfragmented Adipose Tissue for the Treatment of Knee Osteoarthritis: Real-World Data at Two Years Follow-Up.

The purpose of the present study was to assess, prospectively, the safety, clinical effectiveness, and feasibility of a single intra-articular injection of microfragmented adipose tissue in different stages of knee osteoarthritis (OA). The study included patients (aged 18−70 years), affected by OA (Kellgren−Lawrence I-IV). Unselected patients were evaluated before and prospectively after 6, 12, and 24 months from the injection. Visual analog scale (VAS) and knee injury and osteoarthritis outcome score (KOOS) were used for clinical evaluations. A total of 202 patients were eligible. The mean follow-up time in the cohort of patients was 24.5 ± 9.6 months. Total KOOS significantly improved from pre-operative baseline levels to 6-month follow-up (p < 0.001), and again between 6- and 12-month follow-ups (p < 0.001). The VAS showed a prompt reduction at 6 months (p < 0.001 vs. baseline), but then it increased again at 12 months compared to the 6-month assessment (p < 0.001), even though it remained lower than baseline (p < 0.001). At 24 months, patients with KL-IV demonstrated a lower improvement compared to baseline; patients that had undergone previous corticosteroid injections had a greater risk to further injection treatment. The collected clinical results suggest that MFAT may represent a safe and effective treatment for OA symptoms, offering a low-demanding and minimally invasive treatment.

The use of autologous platelet-rich fibrin matrix combined with meniscal repair in the treatment of parameniscal cyst: clinical results and cyst recurrence after 2-year of follow up.

PURPOSE: Parameniscal cysts are associate with horizontal meniscal tears. Arthroscopic meniscal repair and the excision of the cyst by mini-open approach represent a valid treatment. However, the recurrence of cyst is still a current issue. Therefore, biological factors may be considered to promote the biological repair and avoid recurrence. The aim of the present study was to report the clinical results and the rate of recurrence of the cyst after minimum 2-year of follow up in a cohort of patients treated by meniscal repair and autologous platelet-rich fibrin matrix augment. METHODS: Patients with lateral parameniscal cyst undergoing arthroscopic meniscal repair and autologous platelet-rich fibrin matrix augment between 2016 and 2019 were retrospectively reviewed in March 2021. Inclusion criteria were absence of prior surgery on the affected knee with minimum 2-year of follow-up. Exclusion criteria were concomitant ligament lesions, rheumatic diseases and knee osteoarthritis. After reviewing the database, each selected patient was contacted and asked to participate in the study; at the follow-up evaluation all patient signed an informed consent. Tegner-Lysholm knee score, IKDC and NRS were collected before surgery and at follow-up. RESULTS: This study included 15 patients (8 male) with mean age of 32.8 years old. No recurrence of the cysts was observed. The Tegner-Lysholm knee score and IKDC subjective scores increased respectively from 41.3 ± 5.4 and 37.6 ± 5.1 at baseline to 92.3 ± 4.6 and 89.4 ± 2.6 at the final follow up. Concerning pain relief, the Numeric Pain Rating Scale (NRS) displayed a significant improvement reaching at the follow up a score of 1,3 ± 1.1 in comparison to 6.8 ± 0.9 at the baseline. CONCLUSION: Surgical management of symptomatic lateral parameniscal cyst with cyst excision, autologous PRP membrane application and meniscus repair demonstrated excellent subjective clinical outcome with any cyst reoccurrence. LEVEL OF EVIDENCE: III, retrospective cohort study.

Autologous Platelet-Rich Fibrin Matrix-Augmented Repair for Parameniscal Cysts: Surgical Technique.

Parameniscal cysts are defined as an internal disorder of the knee joint. It is known that parameniscal cysts are associated with horizontal meniscal tears that could lead to the collection of synovial fluid within the cyst. Despite the treatment of meniscal tears, cyst recurrence is still an issue that needs to be addressed. In this regard, there has been an increasing interest in the use of biologic agents to enhance the vascularity and healing of the meniscus. Preliminary results for biologic therapeutic agents, such as growth factors, bone marrow, and aspirate concentrate, have been encouraging. However, these options are more demanding in regards to time, financial burden, resources, and so on. Autologous platelet-rich plasma is readily available, easy to use, affordable, and minimally invasive. This Technical Note will describe a step-by-step and reproducible technique for the harvesting, preparation, and use of an autologous platelet-rich fibrin matrix used to augment the healing of meniscal repairs.

Elective Orthopaedic Surgery During COVID-19: A Safe Way to Get Back on Track.

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has greatly changed our way of living and working. We have developed a method to treat urgent patients in a safe way, and we applied the same protocol to resume elective surgical procedures. METHODS: We reorganized the system and the management of our orthopaedic department to perform elective surgical procedures in a safe way. During the COVID-19 lockdown, 614 patients underwent elective orthopaedic procedures. RESULTS: No major postoperative complications were recorded. None of the orthopaedic surgeons, health-care personnel, or hospitalized patients was infected in this period of activity. CONCLUSIONS: During COVID-19, it is possible to perform elective surgical procedures in a safe way.

Use of the KineSpring system in the treatment of medial knee osteoarthritis: preliminary results.

PURPOSE: the purpose of this study was to analyze our preliminary results obtained with the KineSpring system in patients suffering from medial compartment knee osteoarthritis (OA). METHODS: between September 2012 and May 2014, 53 patients underwent treatment with the KineSpring system. Patient self-assessment was performed pre-operatively and at 3, 6 and 12 months postoperatively, and included the KOOS, Tegner activity score, Lysholm functional knee score, VAS knee pain score, and IKDC score. Device- and procedure-related adverse events were recorded. RESULTS: mean KOOS subscales, except for the Sport/Recreation subscale at six months, improved over time. Mean WOMAC Pain and Function domains, Lysholm score, IKDC score and VAS knee pain score improved over the follow-up period and were significantly improved at 3, 6 and 12 months postoperatively compared to baseline. Mean Tegner score improved slightly over time. In 5 of the 53 (9.4%) patients re-operation was necessary. In 3 patients the device was removed due to infection (one case) or persistent knee pain (two cases). Surgical arthrolysis was performed in two patients. CONCLUSIONS: in our preliminary experience, the KineSpring system gave good short-term clinical results. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A new hydrogel for the conservative treatment of meniscal lesions: a randomized controlled study.

PURPOSE: this study aimed to investigate the efficacy of intra-articular (IA) administration of a hydrogel formulation obtained from a hyaluronic acid (HA) derivative (HYADD4(®)) in the management of meniscal tears and in meniscal tear repair. METHODS: fifty subjects with degenerative meniscal tears were enrolled into this single-site, observer-blind, parallel-group study. Clinical evaluations were performed at baseline and after 14, 30 and 60 days. Clinical outcomes included: pain reduction (Visual Analog Scale), improvement of knee functionality (WOMAC questionnaire), reduction in length and depth of the meniscal lesion (MRI-confirmed) and SF-36 questionnaire scores. Local tolerability and safety were also investigated. RESULTS: a significant reduction in VAS pain (p< 0.001) in favor of HYADD4(®) was recorded at day 14 and maintained at all the follow-up assessments. Data on knee functionality were in line with the VAS pain assessment results. A significant reduction in length and depth of the meniscal lesion, assessed using MRI, was found in the HYADD4(®) group compared to the control group (p<0.001). CONCLUSIONS: the results of this study may indicate a new treatment option in the conservative management of patients complaining of pain due to meniscal tears. The MRI data suggest that the hydrogel formulation of HA used in this study may also play a role in the healing process of the lesion. LEVEL OF EVIDENCE: Level I, prospective randomized clinical trial.

Distal radius fractures: surgical treatment with internal fixation.

AIM OF THE STUDY: To evaluate the efficacy of plates and screws with angular stability in osteosynthesis of fractures of the distal radius. MATERIALS AND METHODS: We analyzed 52 patients undergone surgery for fracture of the distal radius at the Clinica Ortopedica dell'Università di Trieste; in half of the patients osteosynthesis was provided using Synthes' LCP plates, in the other half we utilized a multidirectional and angular stable plate ("Aptus Radius" by Medartis). Mean follow-up was 28 ± 10 months, patients were evaluated with DASH score (disability of arm shoulder and hand) and the modified Gartland Werley score. RESULTS: There were no significant differences between the two groups in terms of joint function, motility, volar and radial mean inclination. CONCLUSIONS: Based on clinical and radiological results using angular stability plates must be considered as the method of election in the treatment of fractures of the distal epiphysis of the radius; in particular, thanks to the broader technical capabilities that they allow, are particularly indicated in unstable fractures.

Unicondylar knee prosthesis: our experience.

AIM OF THE STUDY: To compare unicompartmental knee arthroplasty with "all poly" tibial component and "metal back" from a clinical and functional point of view. MATERIALS AND METHODS: We evaluated prospectively 50 patients who underwent unicompartmental knee replacement at the Orthopedic Clinic of the University of Trieste. Patients were split into two groups (A and B); in patients from group A has been implanted a Mitus prosthesis (Link) with "all poly" tibial component, in patients from Group B has been implanted an Allegretto prosthesis (Zimmer) with a "metal back" tibial component. The mean follow-up was 36 months. All patients were evaluated using the Knee Society Score. RESULTS: The mean preoperative Knee Society Score (objective and functional) was found to be respectively 48 and 49 or the group A and group B; post-operative score was found to be of 95 and 94 respectively for Group A and group B. The average post-operative ROM was 125 degrees (range, 85-140 degrees) for group A and 130° (range 90°-145°) for group B. CONCLUSIONS: No differences were found between implants with "all poly" tibial component (thickness to be used must be greater than 6 mm) and those with the "metal back". We believe that to achieve positive results over time is important the carefully selection of the patients and the accurate positioning of components.

First metatarsophalangeal joint replacement with total arthroplasty in the surgical treatment of the hallux rigidus.

The hallux rigidus, especially in advanced stage, has always been a challenge as regards the surgical treatment. Over the years there have been various surgical techniques proposed with the aim of relieving pain, correcting deformity and maintain a certain degree of movement. For some years we have addressed the problem with the replacement metatarsophalangeal joint arthroplasty with Reflexion system. As far as our experience we have operated and monitored 25 patients (18 females and 7 males) of mean age 58.1 years, operated with this technique from June 2008 to June 2011. It reached an average ROM of 72° (extension and flexion 45° and 27°) with a good functional recovery in 8 patients, and this articulation was good (50° - 40°) in 12 patients and moderate in 5 with a articular range from 40°- 30°. The clinical results, according to our experience, appear to be favorable, as even patient satisfaction is complete.

Proximal cut-out in pertrochanteric femural fracture.

The average age of population is increasing in parallel with the worldwide incidence of fractures of the proximal femur; among all of them, 45% is represented by pertrochanteric fractures. Many other significant co-morbidity and even mortality are associated to this fractures (osteoporosis, malnutrition, decreased physical activity, reduced visual acuity, neurological deficits, asthenia, balance disorders and altered reflexes). Due to osteoporosis, the greater frequency of these fractures  occurs to elderly women. Among a total of 630 patients with pertrochanteric fracture treated in the Orthopedic Clinic of Trieste from January 2003 to December 2011, 16 cases were about Cut-out (5 males and 11 females). The mean follow-up after the revision surgery was 18 months. The aim of the study was to understand if in pertrochanteric fractures the best osteosynthesis can be guaranteed by the placement of an intramedullary nail or by positioning of plate and screws. It was established that, using intramedullary nail, the best target is to have a good positioning of the method of synthesis with a "Tip-Apex Distance" (TAD) of less than 25 millimeters.