Higher activity level after opening wedge high tibial osteotomy compared to medial unicompartimental knee arthroplasty in a selected cohort of advanced age: A propensity score-matched analysis.

BACKGROUND: High tibial osteotomy (HTO) and medial unicompartmental knee arthroplasty (mUKA) are accepted treatment for medial knee osteoarthritis (OA). Patients often present meeting indications for both procedures. The purpose of this study was to compare results after MOWHTO and UKA in a matched population of patients older than 50 years. METHOD: A retrospective analysis searching for patients older than 50 years meeting indication both for UKA and MOWHTO was performed. A propensity score matching (PSM) based on demographics and clinical data was performed. Tegner activity scale (TAS), Lysholm knee score (LKS) and numeric rating scale for pain (NRS) were recorded prospectively prior to surgery, at 6 months and after a minimum of 4 years. RESULTS: 64 UKA and 71 MOWHTO were found. Mean follow up was similar (54,05 ± 4,80 and 52,62 ± 3,91). A significant improvement was found in both groups for all outcomes at 6 months and at final follow up. PSM yielded 29 pairs. Patients treated with MOWHTO showed superior TAS scores at 6 months (3,41 ± 0,50 vs 3,10 ± 0,56; p < 0,05) and at final follow up (3,83 ± 0,80 vs 3,27 ± 0,59; p < 0,005). NRS and LKS were comparable between groups. CONCLUSIONS: MOWHTO performed using an open wedge technique, with locking plate and a fast rehabilitation protocol guaranteed higher level of activity than UKA in patients older than 50 years. Difference is significant already at 6 months and last longer than 4 years. LEVEL OF EVIDENCE: III.

Simultaneous Bilateral Total Knee Arthroplasty in Elderly: Are There Factors that Can Influence Safety and Clinical Outcome?

Objective: The aim of this study was to look for preoperative patients' related factors correlating with worse clinical outcomes in a cohort of elderly patients undergoing simultaneous bilateral total knee arthroplasty (SiBTKA) to search for risk factors, which may influence clinical outcomes and safety. Subjects and Methods. The hospital database was mined searching for patients older than 70 years that underwent SiBTKA for severe bilateral knee osteoarthritis (OA) between 2012 and 2016. Preoperative clinical information, Oxford Knee Score (OKS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) prior to surgery were recorded. The OKS and the KOOS were submitted again after a minimum of 5 years of follow-up (FU). Results: An improvement was observed in all clinical scores at last FU. The major complication rate was 5.4%. No patients' clinical data showed correlation with perioperative complications or need for transfusions. Functional scores at the last FU were negatively affected by age at surgery and positively affected by preoperative clinical scores. Discussion. In the setting of severe symptomatic bilateral knee OA, SiBTKA seems to be effective in improving symptoms at midterm follow-up, with acceptable rates of perioperative complications in patients older than 70. Higher age at surgery and lower preoperative functional scores are associated with worse clinical outcomes at FU. This could assist surgeons in advising patients that delay of surgical treatment could worsen outcomes.

The use of augmented reality for limb and component alignment in total knee arthroplasty: systematic review of the literature and clinical pilot study.

PURPOSE: A systematic review of the literature has been carried out to assess the actual evidence of the use of augmented reality in total knee arthroplasty (TKA). We then conducted a pilot clinical study to examine the accuracy of the Knee + augmented reality navigation in performing TKA. The present augmented reality (AR) system allows the surgeon to view the tibial and femur axis superimposed on the surgical field through the smart glasses. It provides real-time information during surgery and intraoperative feedback. METHODS: A systematic review of the PubMed, MEDLINE, and Embase databases up to May 2021 using the keywords "augmented reality", "knee arthroplasty", "computer assisted surgery", "navigation knee arthroplasty" was performed by two independent reviewers. We performed five TKAs using the Knee + system. Patients were 4 females, with mean age of 76.4 years old (range 73-79) and mean Body Max Index (BMI) of 31.9 kg/m2 (range 27-35). The axial alignment of the limb and the orientation of the components were evaluated on standardized pre and postoperative full leg length weight-bearing radiographs, anteroposterior radiographs, and lateral radiographs of the knee. The time of tourniquet was recorded. The perception of motion sickness was assessed by Virtual Reality Sickness Questionnaire (VRSQ) subjected to surgeon immediately after surgery. RESULTS: After duplicate removal, a total of 31 abstracts were found. However, only two studies concerned knee arthroplasty. Unfortunately, both were preclinical studies. Knee + system is able to perform a cutting error of less than 1° of difference about coronal alignment of femur and tibia and less than 2° about flexion/extension of femur and posterior tibial slope. The absolute differences between the values obtained during surgery and the measurement of varus femur, varus tibia, posterior slope, and femur flexion angle on post-operative radiographs were 0.6° ± 1.34°, 0.8° ± 0.84°, 0.8° ± 1.79°, and 0.4 mm ± 0.55 mm, respectively. CONCLUSIONS: On light of our preliminary results, the Knee + system is accurate and effective to perform TKA. The translation from pilot study to high-level prospective studies is warranted to assess accuracy and cost-effective analysis compared to conventional techniques. LEVEL OF EVIDENCE: IV.

All-inside repair of meniscal bucket handle tears: a retrospective study at mean 4-years follow-up evaluation.

Bucket-handle tears represent approximately 10% of all meniscal tears. Despite the common treatment is subtotal meniscectomy, repair is technically feasible although complex, and represents a key strategy to avoid severe meniscal tissue loss that could accelerate joint degeneration over time. The aim of this retrospective study was to determine the outcomes of arthroscopically-assisted bucket-handle tear repair, and to identify factors correlating with clinical results. Fifty-four patients affected by meniscal bucket handle tear were included in the present retrospective analysis and evaluated up to mean 4-years follow-up. All patients were treated by arthroscopic-assisted all-inside repair. The primary outcome was considered the need for a re-operation due to failure of meniscal repair. Patients were also evaluated by the following items: KOOS, Lysholm, Tegner, IKDC-subjective and Quadruple-VAS score. Subgroup analysis was performed to identify whether concurrent ACL reconstruction, side of the lesion, age at surgery and time from injury to repair could influence clinical outcome. Ten out 54 patients (18.5%) were considered failed and needed reoperation, mainly within one year from surgery. Overall, there was a significant increase in all clinical scores considered and patients were able to get back to previous sport activity level. Patients with concurrent ACL reconstruction presented a lower risk of failure (p=0.025). Patients with lateral meniscus repair showed better clinical outcome compared to medial meniscus. Timing from injury and age at surgery did not correlated with clinical outcome. Our series showed fair results in bucket handle repair up to middle term evaluation. Concomitant ACL reconstruction was associated with lower failure rate whereas lateral meniscus involvement was associated with higher functional scores at final follow-up evaluation.

New plates with polyaxial locking system and PSI technique in medial open wedge high tibial osteotomy: preliminary results.

Medial open-wedge (MOW) high tibial osteotomy (HTO) is proven treatment option, indicated in medial unicompartimental knee osteoarthritis (OA) and in varus OA. New devices and techniques were developed in last years, such as Activemotion plates with polyaxial locking system (Dualtec System®, NewClip-Technics) and PSI technique. We describe outcomes and rate of complications in patients treated with Activemotion plates and PSI technique. From January 2019 to August 2019 a sample of 77 cases (72 NCT plates, 5 PSI technique) was observed, evaluating the rate of complications and the return to activity. The rate of complications is 2.6% and the mean time to return to activity is 10 weeks. MOW HTO with Activemotion plate has showed good results with a low rate of complications. About PSI technique, the preliminary results are excellent, but we need to increase the sample.

Autologous micro-fragmented adipose tissue for the treatment of diffuse degenerative knee osteoarthritis: an update at 3 year follow-up.

BACKGROUND: Conservative therapies for the treatment of knee degenerative processes are used before resorting to surgery; nonetheless, they may offer only short-term benefits. Encouraging preliminary results have been reported using mesenchymal stem cells (MSCs), either alone or in association with surgery. Among the many sources, adipose tissue has created a huge interest, because of its anti-inflammatory and regenerative properties ascribed to the cells of its stromal vascular fraction. We previously reported the safety and feasibility of autologous micro-fragmented adipose tissue as adjuvant for the surgical treatment of diffuse degenerative chondral lesions at 1 year. Here we present the outcomes of the same cohort of patients evaluated at 3 year follow-up. Micro-fragmented adipose tissue was obtained using a minimal manipulation technique in a closed system. The safety of the procedure was evaluated by recording type and incidence of any adverse event. The clinical outcomes were determined using the KOOS, IKDC-subjective, Tegner Lysholm Knee, and VAS pain scales taken pre-operatively and at 12 and 36 months follow-up. FINDINGS: No adverse events, lipodystrophy cases at the harvesting site nor atypical inflammatory reactions at the joint level were reported. Of the 30 patients previously treated, one was lost, and seven received additional treatments in the period of observation. On average, the 22 patients that had no other treatments in the 3-year period showed that the results observed at 1 year were maintained. Moreover, 41, 55, 55 and 64% of the patients improved with respect to the 1-year follow-up in the Tegner Lysholm Knee, VAS, IKDC-subjective and total KOOS, respectively. CONCLUSION: Our results point to autologous and micro-fragmented adipose tissue injection as an innovative and safe approach for the management of diffuse degenerative knee chondropathy in the mid-term. The procedure is simple, affordable, minimally invasive, and compliant with the regulatory panorama.

Autologous and micro-fragmented adipose tissue for the treatment of diffuse degenerative knee osteoarthritis.

BACKGROUND: Chondral lesions of the knee represent a challenge for the orthopaedic surgeon. Several treatments have been proposed with variable success rate. Recently, new therapeutic approaches, such as the use of mesenchymal stem cells, have shown promising results. The adipose tissue is a good source of these naturally occurring regenerative cells, due to its abundance and easy access. In addition, it can be used to provide cushioning and filling of structural defects. The 1-year safety and outcome of a single intra-articular injection of autologous and micro-fragmented adipose tissue in 30 patients affected by diffuse degenerative chondral lesions was evaluated. METHODS: Micro-fragmented adipose tissue was obtained using a minimal manipulation technique in a closed system. The safety of the procedure was evaluated by recording type and incidence of any adverse event. The clinical outcomes were determined using the KOOS, IKDC-subjective, Tegner Lysholm Knee, and VAS pain scales taken pre-operatively and at 12 months follow-up. A level of at least 10 points of improvement in the scores has been selected as cut-off representing a clinically significant difference. RESULTS: No relevant complications nor clinical worsening were recorded. A total median improvement of 20 points has been observed in IKDC-subjective and total KOOS, and a higher percentage of success was found in VAS pain and Tegner Lysholm Knee, where the total median improvement was 24 and 31 points, respectively. CONCLUSION: The results of this study show the safety and feasibility of using autologous and micro-fragmented adipose tissue in patients affected by diffuse degenerative chondral lesions. The technique is safe, minimally invasive, simple, one-step, with low percentage of complications, and compliant with the regulatory panorama.

A novel technique for combined medial collateral ligament and posterior oblique ligament reconstruction: technical note.

PURPOSE: In the last year, we have performed a new technique for combined medial collateral ligament (MCL) and posterior oblique ligament (POL) reconstruction in chronic setting of anterior cruciate ligament and MCL complex deficiency. Autogenous semitendinosus tendon with the tibial attachment preserved has been used for the medial/posteromedial compartment reconstruction. We describe the operative technique. METHODS: Between January and December 2014, 12 consecutive patients with multiligamentous injuries underwent concomitant MCL/POL using a novel technique. The usefulness of the novel technique is the semitendinosus sling on the semimembranosus tendon and the POL fixation with the knee in full extension. RESULTS: An ideal anteroposterior and rotational stability avoiding the medial compartment over constraint was achieved, in the immediate after surgery, due to the sequence of the bundle fixations and to the semitendinosus sling below the semimembranosus tendon. CONCLUSIONS: This technique is easily reproducible and useful and restores the medial stability immediately after surgery.

Minimally invasive posterior stabilization for treating spinal tuberculosis.

We describe a case of dorsal-lumbar vertebral tuberculosis (Pott's disease) first treated with antibiotic therapy, bed rest, and cast. After 2 months of treatment patient's symptoms worsened. Minimally invasive posterior vertebral stabilization was carried out, with excellent clinic and radiographic results.

Effects of pulsed electromagnetic fields on patients' recovery after arthroscopic surgery: prospective, randomized and double-blind study.

Severe joint inflammation following trauma, arthroscopic surgery or infection can damage articular cartilage, thus every effort should be made to protect cartilage from the catabolic effects of pro-inflammatory cytokines and stimulate cartilage anabolic activities. Previous pre-clinical studies have shown that pulsed electromagnetic fields (PEMFs) can protect articular cartilage from the catabolic effects of pro-inflammatory cytokines, and prevent its degeneration, finally resulting in chondroprotection. These findings provide the rational to support the study of the effect of PEMFs in humans after arthroscopic surgery. The purpose of this pilot, randomized, prospective and double-blind study was to evaluate the effects of PEMFs in patients undergoing arthroscopic treatment of knee cartilage. Patients with knee pain were recruited and treated by arthroscopy with chondroabrasion and/or perforations and/or radiofrequencies. They were randomized into two groups: a control group (magnetic field at 0.05 mT) and an active group (magnetic field of 1.5 mT). All patients were instructed to use PEMFs for 90 days, 6 h per day. The patients were evaluated by the Knee injury and Osteoarthritis Outcome Score (KOOS) test before arthroscopy, and after 45 and 90 days. The use of non-steroidal anti-inflammatory drugs (NSAIDs) to control pain was also recorded. Patients were interviewed for the long-term outcome 3 years after arthroscopic surgery. Thirty-one patients completed the treatment. KOOS values at 45 and 90 days were higher in the active group and the difference was significant at 90 days (P < 0.05). The percentage of patients who used NSAIDs was 26% in the active group and 75% in the control group (P = 0.015). At 3 years follow-up, the number of patients who completely recovered was higher in the active group compared to the control group (P < 0.05). Treatment with I-ONE aided patient recovery after arthroscopic surgery, reduced the use of NSAIDs, and also had a positive long-term effect.

Interatrial septal aneurysm and genetic prothrombotic disorders: possible interaction in the pathogenesis of pediatric stroke.

Stroke in children is a rare condition and has a multifactorial etiology. The association between ischemic stroke in young adults and some minor cardiac abnormalities such as atrial septal aneurysm with or without interatrial shunting has recently been reported: however, the pathogenetic mechanism still remains unclear. Genetic and acquired prothrombotic disorders are also risk factors for cerebral ischemic events in children. We report a case of ischemic stroke in a 10-year-old female child who was heterozygous for the prothrombin G20210A variant and who presented with an atrial septal aneurysm associated with an interatrial shunt. We hypothesize that these risk factors play a synergic role but their relative importance and whether alone they can determine cerebral embolism remain to be determined.

Clinical approach to the analysis of causes of death in the first two years of life of very-low-birthweight infants in a multicentre setting.

Mortality in the first 2 years of 634 very-low-birthweight infants admitted to eight neonatal intensive care units in Italy, and the factors associated with the net probability of death from each cause, were studied by means of the Cox proportional hazard model. A clinical classification of the causes of death was used. Overall mortality was 33.7% (intercentre range 12.6-52.9%). The highest cause-specific mortality rates were observed for respiratory problems, intra-ventricular haemorrhage (IVH) and infections (14.5%, 6.3% and 5.7% respectively). The leading causes of death were respiratory problems and IVH in the first week of life, infections from the second week up to the end of the first month, and bronchopulmonary dysplasia (BPD) afterwards. Birthweight < 1000 g, gestational age < 30 weeks, absence of spontaneous respiratory activity, unknown body temperature and pH < 7.20 at admission were associated with death from respiratory problems and IVH. Male sex, birthweight < 1000 g and unknown body temperature at admission were associated with death from BPD. Mortality from infections was higher in one centre; no other differences emerged among the eight NICUs. The classification of the causes of death employed and the use of the net probabilities of death appear as practical and useful instruments to study the relationship between specific aspects of medical care and mortality, and to investigate the reasons for differences in performance between neonatal units.

Intelligence outcome in children with shunted hydrocephalus of different etiology.

Children with shunted hydrocephalus of differing etiologies were assessed. There was a more selective loss of non-verbal than of verbal intelligence. The verbal and visuo-perceptual abilities were affected by different sets of variables. Variables related to the hydrocephalus had no effects, while associated supratentorial malformations significantly affected non-verbal functions.

Hallervorden-Spatz disease: clinical and MRI study of 11 cases diagnosed in life.

The diagnosis of Hallervorden-Spatz disease (HSD) has usually been made post mortem, although the recent description of characteristic abnormalities in the globus pallidus has suggested the possibility of an in vivo diagnosis. We present the clinical histories, neurological features and MRI findings of 11 patients, diagnosed as having HSD. Generalized dystonia with predominance of oromandibular involvement, behavioural changes followed by dementia and retinal degeneration were present in all the patients. MRI pallidal abnormalities consisted of decreased signal intensity in T2-weighted images, compatible with iron deposits, and of a small area of hyperintensity in its internal segment ("eye of the tiger" sign). We propose that the combination of these neurological signs with these MRI findings could be considered as highly suggestive of a diagnosis of HSD in living patients.

Exercise performance in very low birth weight children at the age of 7-12 years.

Fifteen very low birth weight children, 9 appropriate for gestational age (AGA, mean birth weight 1302 +/- 164 g) and 6 small for gestational age children (SGA, mean birth weight 1263 +/- 117 g), were studied at the age of 7-12 years, and compared to a group of 26 healthy, age-, sex-, and height-matched children born at term. None of the VLBW children had developed chronic bronchopulmonary disease. Pulmonary function tests and progressive exercise tests on a treadmill were performed. Forced vital capacity, forced expiratory volume at 1 s and forced expiratory flow between 25% and 75% of vital capacity were normal for all subjects. No differences were found in maximum oxygen consumption, anaerobic threshold and maximal heart rate between the AGA and SGA children and the respective controls. Both in the AGA and SGA subgroups, the pre-exercise oxygen uptake results were comparable to those of the controls. In the SGA subgroup the energy cost of running was significantly higher with respect to the controls, while no difference was found between the AGA and the control children. In conclusion, children with birth weight less than 1501 g have normal values of aerobic fitness. In SGA children the efficiency of running is slightly reduced.

The prognostic significance of acute neonatal renal failure.

We evaluated 38 newborns with acute renal failure (plasma creatinine (Pcr) concentration greater than = 1.5 mg/dl), measured between the 2nd and 5th days. We used renal ultrasound to exclude the possibility of congenital renal anomalies, obstructive pathology or vascular disorders. We calculated the glomerular filtration rate (GFR) using Schwartz' formula and the maximal concentrating capacity using intranasal administration of desamino-cis-1-D-arginine-8-vasopressin (DDAVP test). Two newborns were treated with peritoneal dialysis and died during the first month of life. Thirty-six had a follow-up blood sample drawn: 24 preterm babies between 1 and 12 months, and 12 full-term babies between 1 and 36 months of life. From this sampling 4 babies (11.1%) showed defective maximal concentrating ability. Our data reveal the persistence of altered concentrating ability in newborns affected by renal failure and shows that this problem needs a longitudinal study and further diagnostic investigations.

Subependymal pseudocysts in the neonate.

Serial ultrasound examinations were performed through the anterior fontanelle to detect and follow subependymal pseudocysts (SP) in 19 neonates without severe malformations. A high-resolution real-time sector scanner was employed. In 8 cases the SP involved both lateral ventricles, in 11 cases they were unilateral and in 7 neonates they were associated with other cerebral abnormalities. Follow up showed that in 13 cases the SP had disappeared by 9 months. No neuro-developmental abnormalities have so far been observed in the 11 children with isolated SP at birth, while in 5 of the 7 cases with associated cerebral abnormalities neurodevelopmental sequelae developed.