Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation.

BACKGROUND: Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma. MATERIALS AND METHODS: Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. RESULTS: Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells. CONCLUSIONS: Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

Hallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis.

INTRODUCTION: Treatment of hallux valgus deformity associated with mild or moderate osteoarthritis (OA) is still a topic of debate. In the literature, there are few studies concerning the management of patients affected by this condition. This study aims to report the experience at mid- to long-term results of an original joint-preserving surgical technique. MATERIALS AND METHODS: Patients affected by mild to moderate hallux valgus deformity and associated to grade 1-2 OA and treated with modified Simple-Effective-Rapid-Inexpensive (SERI) technique from 2008 to 2018 were selected. Inclusion criteria were mild or moderate hallux valgus angle (HVA) <40° and an intermetatarsal angle (IMA) <20° and associated grade 1-2 OA of the first metatarso-phalangeal joint (MTPJ). RESULTS: 128 feet in 120 consecutive patients, undergone modified SERI procedure, have been retrospectively reviewed at a mean follow-up of 5.1 ± 3.8 years (range 2-11). American Orthopaedics Foot Ankle Society (AOFAS) score that was significantly improved from 44.2 ± 13.2 to 88.2 ± 9.6. Pre-operative average HVA and IMA values decreased respectively from 31.6° ± 3.9° to 9.1° ± 4.4° and from 16.2° ± 3.8° to 7.2° ± 3.1°. The average distal metatarsal articular angle (DMAA) value improved from 28.2° ± 6.5° to 7.1° ± 6°. OA of the first MTPJ highlighted a grade 1 in 46 feet and a grade 2 in 82 feet pre-operatively and a grade 0 in 30 feet, grade 1 in 82 feet, and grade 2 in 16 feet at the final follow-up. CONCLUSIONS: The modifications to the SERI technique could extend the indications to patients affected by hallux valgus with mild to moderate OA. The wider case series and the longer follow-up of this study make us believe this technique is very useful for improving the quality of life in these patients. LEVEL OF EVIDENCE: IV.

Post-operative complications of tibial plateau fractures treated with screws or hybrid external fixation.

PURPOSE: To assess the complications and second surgeries rates at 1 year follow-up in a group of patients underwent minimally invasive fixation with screws or hybrid external fixation (HEF) for tibial plateau fractures (TPF). The hypothesis was that low Schatzker (I-IV) TPF would have shown a lower complication rate with respect to high Schatzker (V-VI) TPF. METHODS: 148 patients who underwent minimally invasive surgery with screws or HEF for TPF were included and pooled in two groups: mono-condylar (Schatzker I-IV) and bi-condylar (Schatzker V-VI). The rate of second surgeries and complications, such as stiffness, infection, wound dehiscence and malunion occurred within 1 year, were reported. RESULTS: Statistically significant difference between mono-condylar and bi-condylar groups was found in terms of stiffness (18% vs. 37%, p = 0.01), malunion (4% vs 21%, p = 0.004) and second surgeries (32% vs. 48%, p = 0.049). Associated procedures performed during TPF fixation increased risk of second surgeries (OR 2.1, p < 0.001). No differences in terms of second surgeries and complications were found in bi-condylar group treated with screws and HEF. CONCLUSION: Bi-condylar TPF treated with minimally invasive surgery developed a significantly higher rates of stiffness, malunion and second surgeries within 1 year compared to mono-condylar fractures. Moreover, when an associated procedure was performed, the risk of a reoperation was nearly doubled. Trial registration number PG 0012506 CE AVEC 620/2018/Oss/IOR.

Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021?

Total knee arthroplasty in valgus knee deformities continues to be a challenge for a surgeon. Approximately 10% of patients who undergo total knee arthroplasty have a valgus deformity. While performing total knee arthroplasty in a severe valgus knee, one should aware with the technical aspects of surgical exposure, bone cuts of the distal femur and proximal tibia, medial and lateral ligament balancing, flexion and extension gap balancing, creating an appropriate tibiofemoral joint line, balancing the patellofemoral joint, preserving peroneal nerve function, and selection of the implant regarding constraint. Restoration of neutral mechanical axis and correct ligament balance are important factors for stability and longevity of the prosthesis and for good functional outcome. Thus, our review aims to provide step by step comprehensive knowledge about different surgical techniques for the correction of severe valgus deformity in total knee arthroplasty.

Patient-reported outcomes of intra-articular hyaluronic acid for osteoarthritis of the knee: a prospective and multicentric case series.

BACKGROUND: In the present study, patients with symptomatic knee osteoarthritis (OA) were treated with single intra-articular injection of a high molecular weight, non-cross-linked hyaluronic acid (HA), highly concentrated (2%) and associated with sorbitol (4%). The aims of this study were to (1) evaluate clinical outcome after 6 months, (2) evaluate clinical outcomes after 12 months and (3) evaluate clinical outcomes according to OA grade. Hypothesis of the study was that a single intra-articular injection of this HA associated with sorbitol leads to a significant clinical improvement within 6 months in patients with early or moderate knee OA. MATERIALS AND METHODS: A total of 77 patients were enrolled in this prospective multicentric study. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was recorded at baseline and at months 1, 3, 6 and 12 following the intra-articular injection. Moreover, a stratified analysis of all WOMAC items following the OA grade was performed for both groups of patients, one with low (grade I-II according to Kellgren-Lawrence classification) and another with moderate OA grade (grade III according to Kellgren-Lawrence) and the differences between groups were evaluated. RESULTS: Seventy-three patients completed the 12 months follow-up. Pain, stiffness, functional limitation and total scores were significantly reduced at 1, 3 and 6 months (p < 0.05), but not at 12 months. Stratified analysis of all subscores according to OA grade showed that pain, functional limitation and total score decreased at 1, 3, 6 and 12 months (p < 0.05) in both groups. Stiffness was the only item that decreased significantly at 1, 3 and 6 months but not at 12 months in both groups. All subscore values were significantly lower in the group of patients with low OA grade compared to the one with moderate OA grade. No adverse events were reported. CONCLUSION: At 6 months after a single intra-articular injection of a high molecular weight, non-cross-linked HA associated with sorbitol, WOMAC scores decreased significantly. Clinical benefits were observed both in patients with low and in those with moderate OA grade, with better results in the first group.

Küntscher nails with static cement spacer: A simple technique in periprosthetic knee infections with massive bone loss and instability.

BACKGROUND: Two-stage revision for periprosthetic knee infection is challenging in cases of massive bone loss and instability. The present study aims to describe our experience with an alternative technique of reinforced cement spacer, usually necessary in these situations, focusing on its advantages and clinical results. METHODS: We retrospectively identified all patients who underwent a two-stage revision for periprosthetic knee infection using two intramedullary Küntscher nails as reinforcement from January 2010 to September 2018. From each medical record, we extracted the type of explanted prosthesis, isolated micro-organism, number of cement spacers before index procedure (and related episodes of spacer dislocation) and final treatment. RESULTS: Twelve patients were identified, mean age of 64.0 years (range 39-85). In four of them, the reinforced spacer was used twice for persistent infection, with a total of 16 procedures performed and no cases of dislocation. Ten patients were finally treated with reimplantation or arthrodesis with intramedullary nails, whereas an above-knee amputation was necessary for two patients. Infection was eradicated in 10 patients out of 12 (83%) at a mean follow up of 34.3 months (range 10-62). CONCLUSIONS: This technique is an effective alternative to traditional spacers in cases of massive bone loss, producing a mechanically stable joint and preserving adequate tissue tensions. The construct is technically easy to perform and, not less importantly, to remove during stage 2. Further studies, with larger groups, are necessary to determine its validity.

Do we trust scientific evidence? A multicentre retrospective analysis of first IVF/ICSI cycles before and after the OPTIMIST trial.

STUDY QUESTION: Has the practice of individualizing the recombinant-FSH starting dose been superseded after the largest randomized controlled trial (RCT) in assisted reproduction technology (ART), the OPTIMIST trial? SUMMARY ANSWER: The OPTIMIST trial has influenced our ART daily practice to a limited degree, but adherence is still generally poor. WHAT IS KNOWN ALREADY: Although the 'one size fits all' approach has been discouraged for decades by most authors, the OPTIMIST study group demonstrated in a large prospective RCT that, in general, dosage individualization does not improve the prospects for live birth, although it may decrease ovarian hyperstimulation syndrome (OHSS) risk in expected high responders. STUDY DESIGN, SIZE, DURATION: Retrospective analysis of all first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles from 1st January 2017 to 31st December 2018, before and after the OPTIMIST publication on November 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two thousand six hundred and seventy-seven patients, between 18 and 42 years old, undergoing their first IVF-ICSI cycle in seven Italian fertility centres, were included. Patients were allocated to three groups according to their ovarian reserve markers: predicted poor ovarian responders (POR), predicted normo-responders (NR) and expected hyper-responders (HRs). MAIN RESULTS AND THE ROLE OF CHANCE: Between 2017 and 2018, there was an overall increase in prescription of the standard 150 IU dose proposed by the OPTIMIST trial and a reduction in the use of a starting dose >300 IU. After subgroup analysis, the decrease in doses >300 IU remained significant in the POR and NR sub-groups. LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study. Physicians need time to adapt to new scientific evidence and a comparison between 2017 and 2019 may have found a greater impact of the Optimist trial, although other changes over the longer time span might have increased confounding. We cannot be sure that the observed changes can be attributed to knowledge of the OPTIMIST trial. WIDER IMPLICATIONS OF THE FINDINGS: Clinicians may be slow to adopt recommendations based on RCTs; more attention should be given to how these are disseminated and promoted. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used for this study. E.P. reports grants and personal fees from MSD, grants from Ferring, from IBSA, grants and personal fees from Merck, grants from TEVA, grants from Gedeon Richter, outside the submitted work. E.S. reports grants from Ferring, grants and personal fees from Merck-Serono, grants and personal fees from Theramex, outside the submitted work. All other authors do not have conflicts of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Two different posterior-stabilized mobile-bearing TKA designs: navigator evaluation of intraoperative kinematic differences.

PURPOSE: The purpose of this study was to compare two types of posterior-stabilized (PS) mobile-bearing (MB) total knee arthroplasties (TKAs). The hypothesis was that no major differences were going to be found among the two TKA designs. METHODS: Two cohorts of patients who were divided according to implant design (Cohort A, new design gradually reducing radius PS MB TKA; Cohort B, traditional dual-radius PS MB TKA) were analyzed by means of intraoperative navigation. All operations were guided by a non-image-based navigation system that recorded relative femoral and tibial positions in native and implanted knees during the following kinematic tests: passive range of motion (PROM), varus-valgus stress test at 0° and 30° (VV0, VV30) and anterior/posterior drawer test at 90° of flexion (AP90). RESULTS: There were no significative differences in kinematic tests between the two implants. Cohort A, however, showed a different post-implant trend for VV0 and VV30 that were lower than the pre-implant ones, as expected, while for Cohort B, the trend is opposite. However, the gradually reducing radius prosthesis (Cohort A) showed a trend of improving stability (29% compared to the preoperative status) in mid-flexion (VV30) which the traditional dual-radius design (Cohort B) would not. Moreover, we found no differences among postoperative results of the two TKA designs. CONCLUSION: Despite design variations, no difference has been found among the prostheses in terms of PROM, rotations and translations. Both design kinematics did not show paradoxical external rotations, but an increase in femoral translation in mid-flexion without affecting the functioning of the prosthesis. LEVEL OF EVIDENCE: II.

Migration of the femoral component and clinical outcomes after total knee replacement: a narrative review.

Loosening is considered as a main cause of implant failure in total knee replacement (TKR). Among the predictive signs of loosening, migration is the most investigated quantitative parameter. Several studies focused on the migration of the tibial component in TKR, while no reviews have been focused on the migration of the femoral component and its influence on patients' clinical outcomes. The aim of this narrative review was (1) to provide information about of the influence of migration in femoral component of TKR prostheses, (2) to assess how migration may affect patient clinical outcomes and (3) to present alternative solution to the standard cobalt-chrome prostheses. A database search was performed on PubMed Central® according to the PRISMA guidelines for studies about Cobalt-Chrome femoral component migration in people that underwent primary TKR published until May 2020. Overall, 18 articles matched the selection criteria and were included in the study. Few studies investigated the femoral component through the migration, and no clear migration causes emerged. The Roentgen Stereophotogrammetric Analysis has been mostly used to assess the migration for prognostic predictions. An annual migration of 0.10 mm seems compatible with good long-term performance and good clinical and functional outcomes. An alternative solution to cobalt-chrome prostheses is represented by femoral component in PEEK material, although no clinical evaluations have been carried out on humans yet. Further studies are needed to investigate the migration of the femoral component in relation to clinical outcomes and material used.

Management of high-grade hallux rigidus: a narrative review of the literature.

Hallux rigidus is a disease characterized by an osteoarthritic degeneration of the first metatarsophalangeal joint. Aetiology of hallux rigidus is not clear in the literature. History of trauma is considered one of the most common causes of unilateral hallux rigidus. Also, repetitive microtraumas or inflammatory and metabolic causes such as gout, rheumatoid arthritis and seronegative arthropathy can cause degeneration of the joint. The aim of this literature narrative overview is to summarize and expose the great amount of management concepts and information, including the well-codified main operative procedures to treat of hallux rigidus. This may provide current information for med-school students, researchers and physicians. A comprehensive literature search using PubMed database has been performed. The management for hallux rigidus can involve a variety of therapeutic interventions, conservative or operative. High-grade hallux rigidus represents a complex disease characterized by several clinical and pathological findings, and to achieve optimal results, surgical treatment should be chosen between several surgical techniques depending on the degree of arthritis and other different clinical conditions.

Advanced microscopy analysis of the micro-nanoscale architecture of human menisci.

The complex inhomogeneous architecture of the human meniscal tissue at the micro and nano scale in the absence of artefacts introduced by sample treatments has not yet been fully revealed. The knowledge of the internal structure organization is essential to understand the mechanical functionality of the meniscus and its relationship with the tissue's complex structure. In this work, we investigated human meniscal tissue structure using up-to-date non-invasive imaging techniques, based on multiphoton fluorescence and quantitative second harmonic generation microscopy complemented with Environmental Scanning Electron Microscopy measurements. Observations on 50 meniscal samples extracted from 6 human menisci (3 lateral and 3 medial) revealed fundamental features of structural morphology and allowed us to quantitatively describe the 3D organisation of elastin and collagen fibres bundles. 3D regular waves of collagen bundles are arranged in "honeycomb-like" cells that are comprised of pores surrounded by the collagen and elastin network at the micro-scale. This type of arrangement propagates from macro to the nanoscale.

Low rate of return to pre-injury sport level in athletes after cartilage surgery: a 10-year follow-up study.

PURPOSE: Although articular surface is frequently damaged in athletes, results in terms of return to sport and level of activity after cartilage surgery remain rather unpredictable and poorly documented. The aim of this study is to evaluate the clinical outcome in terms of rate and level of return to sport in a group of competitive athletes who underwent matrix-assisted autologous chondrocyte transplantation (MACT), as well as the impact on their athletic career. METHODS: Thirty-one male patients (mean age 22.6 ± 6.3 years) p racticing sport at competitive level, affected by focal chondral/osteochondral lesions of the distal femur, were enrolled and treated with arthroscopic hyaluronan-based MACT. Patients were evaluated prospectively at 1-year intervals with the IKDC subjective, Tegner, and EuroQol VAS scores during their pre-operative visit and subsequent follow-ups for up to 10 years. Return to sport in terms of level, time and maintenance of the activity level was documented, together with surgical or clinical failures. RESULTS: A marked improvement in all scores was found: IKDC increased from 40.3 ± 13.4 to 81.7 ± 14.4 (p < 0.0005) at 12 months; a further improvement was observed at 2 years (89.5 ± 11.3; p = 0.008), then results were stable for up to 10 years (87.3 ± 13.6). The analysis of return to sport documented that 64.5% of patients were able to return at a competitive level, and 58.1% performed at the same pre-injury level, with activity rates decreasing over time. The rate of patients returning to competitive level was 84% in those without previous surgery (vs. 33% who had undergone previous surgery), 87% for those with traumatic lesions (vs. 33% and 50% for degenerative and OCD lesions, respectively), and 92.3% in younger patients (age < 20 years). Among these factors, multivariate analysis demonstrated that previous surgery was the single most influencing factor for returning to the same sport level (p = 0.010). CONCLUSIONS: These long-term results showed that chondrocyte-based regenerative approach has some limitations in terms of sport-related outcomes. The level of high functional knee restoration needed for such high-demanding activity level can be challenging to achieve, especially in patients with a more compromised joint homeostasis. Return to sport rate varies significantly according to specific patient and lesion characteristics and best results are obtained in young patients with traumatic lesions without previous surgery, which should be considered when treating athletes affected by cartilage lesions. LEVEL OF EVIDENCE: IV.

Virtual simulation of an osseointegrated trans-humeral prosthesis: A falling scenario.

INTRODUCTION: Traditional prosthetic solutions expose the amputee to numerous problems that limit his ability to safely perform the normal activities of daily life. In order to eliminate the problems related to the use of the traditional prosthesis with socket, a new technique was developed for fixing the prosthesis to the amputees based on the principle of osseointegration. The aim of this paper is to study and analyze the stress distribution on the interface between a trans-humeral osseointegrated prosthetic implant and the residual bone, identifying the most stressed areas and thus foreseeing possible failure phenomena of the entire prosthetic system and, after, to compare the stress distribution on three different prosthetic designs that differ from each other for some geometric characteristics. MATERIALS AND METHODS: A healthy individual mimics two fall scenarios of which the trans-humeral amputees can most likely be victims: Static fall and Dynamic fall. A force platform (P-6000, BTS Bioengineering) is required for load data acquisition. The CAD model of the trans-humeral osseointegrated implant was created following the guidelines of the OPRA implant. The bone model was created starting from the CAT scan of a left humerus. The FEM simulation was conducted throught a linear analysis. RESULTS: Both during static fall and dynamic fall, similar trends have been observed for the reaction force Fz, the torque moment Tz, the bending moments Mx and My. From the analysis of the von Mises stress distribution it was found that the stress distribution is more homogeneous in the case where the thread of the fixture is made by a triangular profile with height of the thread equal to 0.5 mm. However, it can be seen that, when passing from a thread with height of 0.5 mm to a 1 mm, there is a slight decrease in the stress on the whole contact zone between the fixture and the humerus. The same improvement can also be seen in the case of trapezoidal threading. CONCLUSION: By modifying the height and/or by varying the thread profile, are obtained slightly better results with respect to the case with a 0.5 mm height triangular thread.

A comprehensive and narrative review of historical aspects and management of low-grade hallux rigidus: conservative and surgical possibilities.

Hallux rigidus, Latin for Stiff Toe, is characterized by an osteoarthritic degeneration of the articular surfaces of the first metatarsophalangeal joint. The aim of this literature narrative overview is to summarize and expose the great amount of management concepts and information, including the well-codified operative procedures and the more up to date knowledge about non-operative and surgical treatment of hallux rigidus. This may provide current information for physicians, medschool attendants and researchers. A comprehensive literature search using PubMed database has been performed, up to April 1, 2017. Several different types of treatment are described in the literature for low-grade hallux rigidus. The management for hallux rigidus can involve a variety of therapeutic interventions, conservative or operative. Hallux rigidus is a complex disease characterized by several clinical and pathological findings, and to achieve optimal results, surgical treatment for low-grade forms should be chosen between several surgical techniques depending on the degree of arthritis and other different clinical conditions.

No evidence for combining cartilage treatment and knee osteotomy in osteoarthritic joints: a systematic literature review.

PURPOSE: To assess whether the combination of HTO and cartilage treatment produced an additional clinical benefit compared to HTO alone. The secondary aim was to identify if there was any difference among different cartilage procedures in terms of healing potential and clinical outcome. METHODS: A systematic review of the literature was performed on PubMed database by three independent observers according to the following inclusion criteria: clinical reports of any level of evidence, written in the English language, with no time limitation, about HTO associated with cartilage surgical and injective treatment, including surveys reporting clinical, radiological, or second-look outcomes at any follow-up time. RESULTS: The database search identified 1956 records: 21 studies were included for the final analysis, for a total of 1068 patients; 10 case series and 11 comparative studies. While overall good results were reported in the case series, the analysis of the comparative studies showed less uniform results. Among the eight studies investigating HTO with cartilage surgical procedures, improved tissue regeneration was found in 5/8 studies, whereas a clinical improvement was reported only in two studies. Three studies on HTO combination with injective treatment showed better tissue regeneration and clinical benefit. CONCLUSIONS: Literature presents low-quality studies, with only few heterogeneous comparative papers. While surgical treatments targeting only the cartilage layer did not achieve clinical improvements, injective treatments targeting the overall joint environment showed promising findings. This prompts further research towards the development of treatments able to improve knee osteotomies outcomes. However, until new evidence will prove otherwise, there is no indication for a combined cartilage treatment in routine clinical practice. LEVEL OF EVIDENCE: Level IV.

How cartilage status can be related to joint loads in anterior cruciate ligament reconstruction: a preliminary analysis including MRI t2 mapping and joint biomechanics.

The knee is the largest and most complex joint in the human body. Traumatic events, such as anterior cruciate ligament (ACL) tear, can lead to an alteration of joint tissues homeostasis. Literature reports an evident correlation between abnormal joint biomechanics and the status of articular tissues. These alterations, due to a sub-optimal ACL reconstruction, may result in an increasing risk of developing degenerative pathologies, such as osteoarthritis. Thus, the identification of the optimal surgical technique is a highly demanding issue in ACL reconstruction. The aim of this study was to analyze the correlation between joint cartilage conditions and knee biomechanics in ACL reconstructions, by integrating MRI T2 mapping investigations, radiostereophotogrammetry-based gait analysis and subject-specific musculoskeletal modelling.

Percutaneous treatment of hallux valgus: What's the evidence? A systematic review.

Hallux and first MTP joint have a fundamental role in the transfer of the weight-bearing load during the normal ambulation. The aim of this paper is to review and analyze the available literature about the percutaneous surgical management of the hallux valgus to highlight its strengths and weakness, also comparing with other minimal invasive techniques. A systematic search of PubMed and Google Scholar databases has been performed, covering the period between 1981 and 2016. Various combinations of the keyword terms "PDO," "hallux valgus," "bunion," "percutaneous," "surgery," "non-invasive," "minimal invasive," "burr," "osteotomy," "distal," "linear," "saw" have been used.Four papers, published from 2005 to 2015, fulfilled the inclusion criteria. A total of 464 hallux valgus has been treated with a properly percutaneous distal first metatarsal osteotomy. Mean AOFAS score, retrieved from the 4 studies included in our review, has been recorded. There are different aspects that the foot and ankle non-experienced surgeon has to consider about percutaneous surgery: limitation of the tools, radioexposure, lack of direct visual control of the osteotomy and higher costs and patient risk due to surgical time.

Anterior cruciate ligament revision with Achilles tendon allograft in young athletes.

BACKGROUND: Return to sport after revision ACL reconstruction is a controversial topic, several studies reported the results of different techniques and graft in sportsman, presenting an incredibly wide range of return to the same pre-injury activity level, from 0% to 100%. The purpose of this study was to evaluate the clinical outcomes and return to sport rate in young athletes after non anatomic double-bundle revision ACL reconstruction with Achilles allograft. HYPOTHESIS: The present revision technique was effective in terms of stability, return to sport and functional outcomes. MATERIAL AND METHODS: All the athletes undergone Revision ACL reconstruction with non-irradiated Achilles tendon allograft with a non-anatomical double-bundle technique were included in the study. A split Achilles tendon allograft was used to reproduce the anteromedial (AM) bundle using the over-the-top position, while the posterolateral (PL) bundle was reconstructed through a femoral tunnel located in the anatomical PL footprint. Sport activity, knee function with Lysholm score, knee laxity and re-injury or re-operations were evaluated. RESULTS: Twenty-six athletes (23 males, three females) with a mean age of 23.4±3.6 years were evaluated at a mean follow-up of 6.0±1.6 years. Overall 69% of patients returned to sport both at elite (44%) or county level (56%) after a mean 6.7±1.5 (3-9 range) months. The mean Lysholm score showed a significant improvement from 64.4±8.1 at pre-operative status to 83.8±11.3 at final follow-up (P<.0001). Seven patients (30%) were rated as excellent, nine (39%) as good, five (22%) as fair and 2 (9%) as poor. Three patients (12%) experienced a further graft rupture after a mean 2.6 years, (3.5 months-48 months range) and two had >5mm side-to-side difference at KT-1000. Therefore, the overall survival rate at mean six years follow-up was 81%. CONCLUSION: The ACL revision with a double-bundle technique using Achilles tendon allograft was successful in 81% of athletes at six years mean follow-up. TYPE OF STUDY AND LEVEL OF EVIDENCE: Retrospective case series, level IV.

Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies.

AIMS: Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft. MATERIALS AND METHODS: A search was performed of Medline and Pubmed using the terms "Anterior Cruciate Ligament" and "ACL" combined with "revision", "re-operation" and "failure". Only studies that reported the outcome at a minimum follow-up of two years were included. Two authors reviewed the papers, and outcomes were subdivided into autograft and allograft. Autograft was subdivided into hamstring (HS) and bone-patellar tendon-bone (BPTB). Subjective and objective outcome measures were analysed and odds ratios with confidence intervals were calculated. RESULTS: A total of 32 studies met the inclusion criteria. Five studies used HS autografts, eight reported using BPTB autografts, two used quadriceps tendon autografts and eight used various types. Seven studies reported using allografts, while the two remaining used both BPTB autografts and allografts. Overall, 1192 patients with a mean age of 28.7 years (22.5 to 39) and a mean follow-up of 5.4 years (2.0 to 9.6) were treated with autografts, while 269 patients with a mean age of 28.4 years (25 to 34.6) and a mean follow-up of 4.0 years (2.3 to 6.0) were treated with allografts. Regarding allografts, irradiation with 2.5 mrad was used in two studies while the graft was not irradiated in the seven remaining studies. Reconstructions following the use of autografts had better outcomes than those using allograft with respect to laxity, measured by KT-1000/2000 (MEDmetric Corporation) and the rates of complications and re-operations. Those following the use of allografts had better mean Lysholm and Tegner activity scores compared with autografts. If irradiated allografts were excluded from the analysis, outcomes no longer differed between the use of autografts and allografts. Comparing the types of autograft, all outcomes were similar except for HS grafts which had better International Knee Documentation Committee scores compared with BPTB grafts. CONCLUSION: Autografts had better outcomes than allografts in revision ACL reconstruction, with lower post-operative laxity and rates of complications and re-operations. However, after excluding irradiated allografts, outcomes were similar between autografts and allografts. Overall, the choice of graft at revision ACL reconstruction should be on an individual basis considering, for instance, the preferred technique of the surgeon, whether a combined reconstruction is required, the type of graft that was previously used, whether the tunnels are enlarged and the availability of allograft. Cite this article: Bone Joint J 2017;99-B:714-23.