Transtibial versus anteromedial transportal femoral tunnel in single-bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized controlled trials.

The purpose of this study was to systematically review and meta-analyze randomized controlled trials (RCTs) reporting the comparative clinical and functional outcomes, postoperative complications, and radiological outcomes of single-bundle anterior cruciate ligament reconstruction (ACLR) performed using the transtibial (TT) approach or anteromedial (AM) technique. A systematic review of the literature was performed according to Cochrane and PRISMA guidelines. RCTs comparing TT and AM techniques were considered only. The quality of the studies was defined using the GRADE system, and the risk of bias was assessed with the RoB 2 tool. The primary endpoint was to systematically review and meta-analyze the clinical outcomes, residual laxity and failure rate of both AM and TT techniques. In the current meta-analysis 13 RCTs involving 989 patients who underwent arthroscopic single-bundle ACLR (486 TT and 503 AM) were included. Patients undergoing AM technique resulted in higher objective-IKDC (p < 0.001) and Lysholm scores (p = 0.002), despite a lower incidence of pathological anterior tibial translation (p < 0.001) and positive pivot-shift test (p < 0.001). No differences were detected in IKDC subjective score (p = 0.26), Tegner activity scale (p = 0.18) and graft failure (p = 0.07). ACL reconstruction through AM portal technique provides better clinical outcomes and lower incidence of residual rotational and anteroposterior laxity in comparison with the TT technique. No statistically significant difference in subjective outcomes and graft failure was reported.

Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome.

PURPOSE: The medial patello-femoral ligament (MPFL) is considered the primary restraint against patellar dislocation and its reconstruction is indicated in recurrent patellar instability. An anatomical positioning of MPFL femoral insertion is recommended to achieve satisfactory clinical outcomes and prevent osteoarthritis (OA) due to an altered kinematics. The purpose of the study was first to assess the relationship between correct femoral tunnel position and better clinical outcomes and lower patellofemoral osteoarthritis rate. Second, correlation of outcomes with factors potentially affecting the results, such as the type of graft, patellar height and trochlear dysplasia. METHODS: Fifty-three patients (58 knees) who underwent MPFL reconstruction between 2009 and 2018 by a senior knee surgeon were retrospectively evaluated. Knee radiographs were performed before surgery, 12 months later and at last follow-up to assess trochlear dysplasia, patellar height and patellofemoral OA. The tibial tuberosity-trochlear groove (TT-TG) value was measured on a CT scan. The accuracy of graft positioning was evaluated on sagittal radiographs according to Schöttle et al. Subjective outcomes were collected before surgery, at 12 months and at last follow-up using several validated scores. RESULTS: Forty-six patients (51 knees) with a mean age of 24.1 ± 7.4 years were included in the study. Mean follow-up was 8.9 ± 2.1 years. A significant improvement in all clinical scores was observed at 12 months and final follow-up. Anatomic Insertion (AI) of reconstructed MPFL was considered optimal in 33 (64.7%) and sub-optimal in 18 (35.3%) patients. Sub-optimal AI resulted in lower Kujala, IKCD and higher VAS score (p < 0.01); moreover, for every 1 mm distance in any direction from the ideal insertion, a decrease of 0.8 [95% CI (-1.4; -0.2)] in Kujala score and 0.8 [95% CI (-1.3; -0.3)] in IKDC was observed. At final follow-up, 8 patients presented patellofemoral OA Iwano grade 3 (15.7%): although that incidence did not correlate to graft positioning, the use the artificial ligament in all these cases appeared to be significant. CONCLUSION: The present study confirms the importance of an optimal anatomic femoral insertion in MPFL reconstruction, reporting a significant positive correlation between graft positioning and clinical outcome. No significant correlations were found between anatomic insertion and patello-femoral OA development. LEVEL OF EVIDENCE: IV.

Closing-wedge high tibial osteotomy, a reliable procedure for osteoarthritic varus knee.

PURPOSE: The purpose of this study was to analyze the long-term clinical and radiological outcomes of patients who underwent closing-wedge High Tibial Osteotomy (HTO) for the treatment of medial compartment osteoarthritis and to evaluate the conversion rate to knee arthroplasty. METHODS: A retrospective, non-randomized, monocentric study was performed in our Institution considering 166 patients between 1989 and 2012. The final population was composed by 82 patients (94 knees), median age at time of operation was 53 (range 45-73) years. All patients were evaluated clinically (HSS Score, Tegner Scale, VAS and Crosby-Insall Grading) and radiographically (osteoarthritis staging, hip-knee-ankle (HKA) angle, tibial slope and metaphyseal varus). RESULTS: Mean follow-up was 11.9 ± 7.2 years. HSS Score increased significantly from 70.8 ± 10 to 93.2 ± 9.1 (p < 0.05) instead Tegner Scale increased from 1.3 ± 0 (range 1-4) to 2.8 ± 0.7 (range 2-6) at the last control (n.s.); VAS score significantly decreased from 7.9 ± 1.4 to 1.6 ± 1.1 (p < 0.05) at last follow-up. According to the Crosby-Insall Grading System, 80 patients (97.4%) reported excellent-good results. HKA angle decreased from 6.9° ± 3.5 to 2.6° ± 2.6 (p < 0.01), tibial slope decreased from 10.1° ± 1.4 to 6.8° ± 2.1 (p < 0.05) and finally the metaphyseal varus decreased from 4.2° ± 0 to 2.1° ± 1.2 (n.s.) at the last follow-up. Adverse events were reported in 4.8%. Osteotomy survivorship rate resulted 92% at 10 years, 82% at 15 years and 80% at 20 years. Sixteen revisions (9.6%) were reported at a mean period of 12.8 years. CONCLUSIONS: CW-HTO is a valid option for medial osteoarthritis treatment, with successful results in both clinical and radiological outcomes. LEVEL OF EVIDENCE: IV.

Long-term follow-up evaluation of autologous chondrocyte implantation for symptomatic cartilage lesions of the knee: A single-centre prospective study.

INTRODUCTION: Autologous Chondrocyte Implantation (ACI) has been the first technique in reconstruction of a valid articular surface. The aim of this study was to evaluate clinical results of this technique at an average follow up of 162±27months (range 88-208) in a group of patients who underwent ACI. MATERIALS AND METHODS: 32 patients were operated between 1997 and 2007 for chondral lesions or osteochondritis dissecans of the knee. Mean size of the defect was 5.48cm2±1.53 (range 2-9). Nine patients were treated with I generation technique and 23 with II generation. All patients were evaluated with Subjective IKDC and Tegner Activity Scales for clinical outcomes and with EQ-VAS for a quantitative measure of health after intervention, starting from pre-operative period and at regular follow up (minimum 88 months-maximum 208 months). RESULTS: A significant increment of all scores was noticed comparing preoperative and postoperative results. In particular medium IKDC score increased from 40.3±9.6 in preoperative evaluation to 74.2±11.6 at one year (p<0.00001) and to 83.9±10.4 at 5 years follow up (p<0.001). Mean IKDC values at the last follow-up were 80.3±14.2, showing no statistical differences with those obtained at five-year follow-up. Tegner Activity Scale values increased from 2.8±1.1 preoperatively to 4.1±1.1 (p<0.0001) after one year and to 6±1.1 at five years (p<0.0001). Mean Tegner Activity Scale values decreased to 4.8±1.4 at the last follow-up. EQ-VAS evaluation showed superposable results comparing the 5 years evaluation with the ones at a medium follow up of 162±27months. DISCUSSION: The most important finding is the reliability at long-term of ACI technique, which in our series gave excellent clinical results. No statistical differences were observed between first- and second-generation. Clinical outcomes were significantly better for defects in the femoral condyles, influenced by age (worse results over 30 years old). CONCLUSIONS: ACI represents a valid technique for chondral and osteochondral lesions of the knee in a population heterogeneous for age, sex and activity level with good results even at a long term follow up.