Custom-made implants for massive acetabular bone loss: accuracy with CT assessment.

BACKGROUND: Custom-made implants are a valid option in revision total hip arthroplasty to address massive acetabular bone loss. The aim of this study was to assess the accuracy of custom-made acetabular implants between preoperative planning and postoperative positioning using CT scans. METHODS: In a retrospective analysis, three patients who underwent an acetabular custom-made prosthesis were identified. The custom-made designs were planned through 3D CT analysis considering surgical points of attention. The accuracy of intended implants positioning was assessed by comparing pre- and postoperative CT analyzing the center of rotation (CoR), anteversion, inclination, screws, and implant surface in contact with the bone. RESULTS: The three cases presented satisfactory accuracy in positioning. A malpositioning in the third case was observed due to the posterization of the CoR of the implant of more than 10 mm. The other CoR vectors considered in the third patient and all vectors in the other two cases fall within 10 mm. All the cases were positioned with a difference of less than 10° of anteversion and inclination with respect to the planning. CONCLUSIONS: The current case series revealed promising accuracy in the positioning of custom-made acetabular prosthesis comparing the planned implant in preoperative CT with postoperative CT.

Tricalcium Phosphate as a Bone Substitute to Treat Massive Acetabular Bone Defects in Hip Revision Surgery: A Systematic Review and Initial Clinical Experience with 11 Cases.

The use of tricalcium phosphate (TCP) as a bone substitute is gaining increasing interest to treat severe acetabular bone defects in revision total hip arthroplasty (rTHA). The aim of this study was to investigate the evidence regarding the efficacy of this material. A systematic review of the literature was performed according to the PRISMA and Cochrane guidelines. The study quality was assessed using the modified Coleman Methodology Score (mCMS) for all studies. A total of eight clinical studies (230 patients) were identified: six on TCP used as biphasic ceramics composed of TCP and hydroxyapatite (HA), and two as pure-phase ceramics consisting of TCP. The literature analysis showed eight retrospective case series, of which only two were comparative studies. The mCMS showed an overall poor methodology (mean score 39.5). While the number of studies and their methodology are still limited, the available evidence suggests safety and overall promising results. A total of 11 cases that underwent rTHA with a pure-phase ceramic presented satisfactory clinical and radiological outcomes at initial short-term follow-up. Further studies at long-term follow-up, involving a larger number of patients, are needed before drawing more definitive conclusions on the potential of TCP for the treatment of patients who undergo rTHA.

Orthobiologic Injections for the Treatment of Hip Osteoarthritis: A Systematic Review.

The use of orthobiologics is gaining increasing interest as a minimally invasive treatment for hip osteoarthritis (OA). The aim of this study was to investigate the evidence about the safety and efficacy of these products. A systematic review of the literature was performed according to the PRISMA and Cochrane guidelines. The study quality was assessed using the RoB 2.0 for randomized controlled trials (RCTs) and the modified Coleman Methodology Score (mCMS) for all studies. A total of 20 clinical studies (735 patients) was identified, 12 on PRP injections and eight on cell-based therapies (five from bone marrow, two from adipose tissue, and one from amniotic fluid). The publication trend increased over time, with over 50% of articles published from 2019. The literature analysis showed only six RCTs, all on PRP injections. The mCMS showed an overall fair methodology (mean score 59.4). While the number of studies and their methodology are still limited, the available evidence suggests safety and overall promising results, with the treatment success being inversely proportional to the severity of OA. Further high-level controlled trials are needed before drawing more definitive conclusions on the real potential of orthobiologics for the injective treatment of patients affected by hip OA.

Comparison of a Minimally Invasive Tissue-Sparing Posterior Superior (TSPS) Approach and the Standard Posterior Approach for Hip Replacement.

Purpose: The purpose of this study is to compare the functional and clinical outcomes, blood loss, complication rate, and hospital length of stay (LOS) of total hip replacement (THR) using a minimally invasive tissue-sparing posterior superior (TSPS) approach and the standard posterior approach. Materials and Methods: This retrospective, observational, double-centered study included 38 patients undergoing hip replacement. The patents were divided into two groups: control group (19 patients), who underwent surgery with the standard posterior approach, and treatment group (19 patients), who received the same type of implant with ceramic-on-ceramic bearing via the TSPS approach. Hemoglobin level was assessed preoperatively, on first and second postoperative days, and on discharge day. Harris hip score and Western Ontario and McMaster Universities Arthritis Index were used to measure the clinical and functional outcomes. Hospital LOS and incidence of early and late complications were assessed in both groups. Postoperative anteroposterior pelvis X-ray was performed to assess the correct positioning of implants. Results: Better early clinical outcomes (p = 0.0155), lesser blood loss (p < 0.0001), and reduced hospital LOS (p < 0.0001) were observed in the TSPS group than in the control group. No major adverse effects occurred in both groups, and a satisfactory implant orientation was achieved in all patients. Conclusions: The TSPS approach is a reliable minimally invasive procedure for THR as it allows an accurate orientation of the components and provides better early postoperative functional outcomes, faster recovery, significantly lower blood loss, and shorter hospital LOS than the standard posterior approach. However, further research is needed to confirm the promising results and cost-effectiveness of the TSPS approach in larger cohorts with a longer follow-up period.

Increased Rotatory Laxity after Anterolateral Ligament Lesion in Anterior Cruciate Ligament- (ACL-) Deficient Knees: A Cadaveric Study with Noninvasive Inertial Sensors.

The anterolateral ligament (ALL) has been suggested as an important secondary knee restrain on the dynamic laxity in anterior cruciate ligament- (ACL-) deficient knees. Nevertheless, its kinematical contribution to the pivot-shift (PS) phenomenon has not been clearly and objectively defined, and noninvasive sensor technology could give a crucial contribution in this direction. The aim of the present study was to quantify in vitro the PS phenomenon in order to investigate the differences between an ACL-deficient knee and an ACL+ALL-deficient knee. Ten fresh-frozen paired human cadaveric knees (n = 20) were included in this controlled laboratory study. Intact, ACL-deficient, and ACL+ALL-deficient knees were subjected to a manual PS test quantified by a noninvasive triaxial accelerometer (KiRA, OrthoKey). Kinematic data (i.e., posterior acceleration of the tibial lateral compartment) were recorded and compared among the three statuses. Pairwise Student's t-test was used to compare the single groups (p < 0.05). Intact knees, ACL-deficient knees, and ACL+ALL-deficient knees showed an acceleration of 5.3 ± 2.1 m/s2, 6.3 ± 2.3 m/s2, and 7.8 ± 2.1 m/s2, respectively. Combined sectioning of ACL and ALL resulted in a statistically significant acceleration increase compared to both the intact state (p < 0.01) and the ACL-deficient state (p < 0.01). The acceleration increase determined by isolated ACL resection compared to the intact state was not statistically significant (p > 0.05). The ALL sectioning increased the rotatory laxity during the PS after ACL sectioning as measured through a user-friendly, noninvasive triaxial accelerometer.

Patient-Reported and Quantitative Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autografts.

BACKGROUND: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS). RESULTS: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s2; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, -0.5 ± 1.3 m/s2; side-to-side difference in anterior tibial translation, -0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC (P = .0001), from 28.8 to 32.4 points for the CKRS (P = .04), from 11.2 to 7.9 points for the Marx (P < .0001), and from 75.7 to 91.6 points for the ADLS (P < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up. CONCLUSION: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.

The Contribution of Partial Meniscectomy to Preoperative Laxity and Laxity After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: In Vivo Kinematics With Navigation.

BACKGROUND: Limited in vivo kinematic information exists on the effect of clinical-based partial medial and lateral meniscectomy in the context of anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: In patients with ACL deficiency, partial medial meniscus removal increases the anteroposterior (AP) laxity with compared with those with intact menisci, while partial lateral meniscus removal increases dynamic laxity. In addition, greater postoperative laxity would be identified in patients with partial medial meniscectomy. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 164 patients with ACL tears were included in the present study and divided into 4 groups according to the meniscus treatment they underwent: patients with partial lateral meniscectomy (LM group), patients with partial medial meniscectomy (MM group), patients with partial medial and lateral meniscectomy (MLM group), and patients with intact menisci who did not undergo any meniscus treatment (IM group). A further division in 2 new homogeneous groups was made based on the surgical technique: 46 had an isolated single-bundle anatomic ACL reconstruction (ACL group), while 13 underwent a combined single-bundle anatomic ACL reconstruction and partial medial meniscectomy (MM-ACL group). Standard clinical laxities (AP translation at 30° of knee flexion, AP translation at 90° of knee flexion) and pivot-shift (PS) tests were quantified before and after surgery by means of a surgical navigation system dedicated to kinematic assessment. The PS test was quantified through 3 different parameters: the anterior displacement of the lateral tibial compartment (lateral AP); the posterior acceleration of the lateral AP during tibial reduction (posterior acceleration); and finally, the area included by the lateral AP translation with respect to the flexion/extension angle (area). RESULTS: In the ACL-deficient status, the MM group showed a significantly greater tibial translation compared with the IM group (P < .0001 for AP displacement at 30° [AP30] and 90° [AP90] of flexion) and the LM group (P = .002 for AP30 and P < .0001 for AP90). In the PS test, the area of LM group was significantly larger (57%; P = .0175) than the one of the IM group. After ACL reconstruction, AP translation at 30° was restored, while the AP90 remained significantly greater at 1.3 mm (P = .0262) in the MM-ACL group compared with those with intact menisci. CONCLUSION: Before ACL reconstruction, partial medial meniscectomy increased AP laxity at 30° and 90° and lateral meniscectomy increased dynamic PS laxity with respect to intact menisci. Anatomic single-bundle ACL reconstruction decreased laxities, but a residual anterior translation of 1.3 mm at 90° remained in patients with partial medial meniscectomy, with respect to those with intact menisci.

ACL reconstruction with lateral plasty reduces translational and rotatory laxity compared to anatomical single bundle and non-anatomical double bundle surgery: An in vivo kinematic evaluation with navigation system.

BACKGROUND: Significantly better stability may be achieved with a Single Bundle Lateral Plasty (SBLP) reconstruction compared with the Single Bundle (SB) and Double Bundle (DB) procedures. METHODS: The study included 42 patients who underwent ACL reconstruction. Patients were randomly selected for one of the following surgical procedure defining three study groups: Single-Bundle-Lateral-Plasty, Single-Bundle and Double-Bundle procedures. Laxity evaluation was performed with an intraoperative navigation system. Lachman test (AP30), Drawer test (AP90), Varus-Valgus stress test at 0° and 30° knee flexion (VV0, VV30), Internal-External rotation (IE30, IE90), and pivot shift (PS) test are the clinical test executed for the laxity evaluation. Laxity reduction was defined as the difference between laxity before the fixation of the graft used for the reconstruction and the laxity just after its fixation. FINDINGS: For all the analyzed surgical techniques, the pre-reconstruction laxity values were statistically higher (P < 0.05) than the post-reconstruction values for all the analyzed tests. The analysis of the Drawer test and Internal-External rotation at 30° and 90° of knee flexion, highlighted a significant difference at time zero after surgery among the three study groups. The results showed that the SBLP technique had the highest reduction values compared to SB (PIE90 = 0.001) and DB (PAP90 = 0.012; PIE30 = 0.021; PIE90 = 0.003) techniques. INTERPRETATION: SBLP technique showed significantly superior results in terms of antero-posterior and internal-external laxity reduction at time-zero after ACL reconstruction.

Patients With Failed Anterior Cruciate Ligament Reconstruction Have an Increased Posterior Lateral Tibial Plateau Slope: A Case-Controlled Study.

PURPOSE: To compare knee anatomical parameters of patients with failed anterior cruciate ligament reconstruction (ACL-R) with those of a control group of sex-matched patients with successful ACL-R. METHODS: Forty-three patients (34 male, 9 female) who experienced graft failure after ACL-R were enrolled in the failed group. These patients were matched to a control group of 43 patients who underwent primary ACL-R with a minimum follow-up of 24 months. On magnetic resonance imaging, the following parameters were evaluated: transepicondylar distance, lateral and medial femoral condyle widths, tibial plateau width, notch width index, and the ratio of width and height of the femoral notch, ratio between the height and depth of the lateral and medial femoral condyle, lateral and medial posterior tibial slopes, and anterior subluxation of the lateral and medial tibial plateau. Multivariate regression with backward elimination, including only the previously identified significant variables, defined the independent predictors for revision surgery. RESULTS: The anatomical variables that were significantly different between the 2 study groups were lateral and medial posterior tibial slopes, anterior subluxation of the lateral and medial tibial plateau, medial tibial plateau width, lateral tibial plateau width, medial femoral condyle width, and transepicondylar distance; however, the multivariate regression analysis identified the lateral posterior tibial slope (LTPs), the anterior subluxation of the medial tibial plateau, and the medial femoral condyle width as significant independent predictors (P < .05). The LPTs had the highest coefficient and the highest sensitivity (88%) and specificity (84%) to identify failures when considering the optimal cutoff value of 7.4°. CONCLUSIONS: Several anatomical parameters have been identified that differ significantly between patients with failed ACL-R and those without a documented failure. The most accurate predictor of ACL failure was an LTPs >7.4°, with a sensitivity of 88% and specificity of 84%. Surgeons should consider measuring LTPs during preoperative assessment of ACL-injured patients, and patients with values >7.4° should be considered at high risk of ACL-R failure. LEVEL OF EVIDENCE: Level III retrospective prognostic trial.

Triaxial accelerometer can quantify the Lachman test similarly to standard arthrometers.

PURPOSE: To assess the relationship between the KiRA triaxial accelerometer and the KT-1000 measurements in the intact, anterior cruciate ligament (ACL) deficient, and ACL reconstructed knee joint for the quantification of the Lachman test. Moreover, the intra- and inter-examiner repeatability of the KiRA device will be determined. It was hypothesized that the side-to-side difference of the anterior tibial translation as measured by the KiRA device would be equivalent to the one measured by the KT-1000 during the Lachman test. METHODS: Sixty patients were divided into three groups and have been prospectively included in the present study. Group_A composed of 20 patients with a diagnosis of an isolated ACL tear. Group_B composed of 20 patients who underwent ACL reconstruction with a Single-Bundle Lateral Plasty (SBLP) technique with at least 20 years of follow-up. Group_C was the control group and included 20 patients with no history of ACL lesion. Lachman test has been performed at manual-maximum load on both sides, the involved and the contralateral and analyzed with the two different devices. RESULTS: The KiRA device in terms of side-to-side difference resulted not statistically different from the measurement of the KT-1000 arthrometer for the three study groups (n.s): Group_A: (4 ± 2 mm KiRA, 4 ± 2 mm KT1000), Group_B: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), Group_C: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), an excellent intra- (ICC = 0.88-0.89) and inter-examiner (ICC = 0.79) agreement was found for KiRA measurements. CONCLUSION: The KiRA (I+, Italy) device offers a valid method to quantify the Lacham test. LEVEL OF EVIDENCE: II.

Anterior cruciate ligament reconstruction with an all-epiphyseal "over-the-top" technique is safe and shows low rate of failure in skeletally immature athletes.

PURPOSE: The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique. METHODS: Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile]. RESULTS: Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed. CONCLUSION: This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life. LEVEL OF EVIDENCE: Case series, IV.

Anatomic Anterior Cruciate Ligament Reconstruction Using Hamstring Tendons Restores Quantitative Pivot Shift.

BACKGROUND: It is still uncertain how surgical reconstruction of the anterior cruciate ligament (ACL) is able to restore rotatory laxity of the involved joint. The desired amount of restraint applied by the ACL graft, as compared with the healthy knee, has not been fully clarified. PURPOSE: To quantify the ability of single-bundle anatomic ACL reconstruction using hamstring tendons in reducing the pivot-shift phenomenon immediately after surgery under anesthesia. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: An inertial sensor and image analysis were used at 4 international centers to measure tibial acceleration and lateral compartment translation of the knee, respectively. The standardized pivot-shift test was quantified in terms of the side-to-side difference in laxity both preoperatively and postoperatively with the patient under anesthesia. The reduction in both tibial acceleration and lateral compartment translation after surgery and the side-to-side difference were evaluated using the Wilcoxon signed-rank test. Alpha was set at P < .05. RESULTS: A total of 107 patients were recruited for the study, and data were available for 89 patients. There was a statistically significant reduction in quantitative rotatory knee laxity between preoperatively (inertial sensor, 2.55 ± 4.00 m/s2; image analysis, 2.04 ± 2.02 mm) and postoperatively (inertial sensor, -0.54 ± 1.25 m/s2; image analysis, -0.10 ± 1.04 mm) between the involved and healthy joints, as measured by the 2 devices (P < .001 for both). Postoperatively, both devices detected a lower rotatory laxity value in the involved joint compared with the healthy joint (inertial sensor, 2.45 ± 0.89 vs 2.99 ± 1.10 m/s2, respectively [P < .001]; image analysis, 0.99 ± 0.83 vs 1.09 ± 0.92 mm, respectively [P = .38]). CONCLUSION: The data from this study indicated a significant reduction in the pivot shift when compared side to side. Both the inertial sensor and image analysis used for the quantitative assessment of the pivot-shift test could successfully detect restoration of the pivot shift after anatomic single-bundle ACL reconstruction. Future research will examine how pivot-shift control is maintained over time and correlation of the pivot shift with return to full activity in patients with an ACL injury.

Anatomical features of tibia and femur: Influence on laxity in the anterior cruciate ligament deficient knee.

BACKGROUND: Until now, there has been a lack of in vivo analysis of the correlation between bony morphological features and laxity values after an anterior cruciate ligament (ACL) injury. METHODS: Forty-two patients who underwent ACL-reconstruction were enrolled. Static laxity was evaluated as: antero-posterior displacement and internal-external rotation at 30° and 90° of flexion (AP30, AP90, IE30, IE90) and varus-valgus rotation at 0° and 30° of flexion (VV0, VV30). The pivot-shift (PS) test defined the dynamic laxity. Using magnetic resonance imaging, we evaluated the transepicondylar distance (TE), the width of the lateral and medial femoral condyles (LFCw and MFCw) and tibial plateau (LTPw and MTPw), the notch width index (NWI) and the ratio of width and height of the femoral notch (N-ratio), the ratio between the height and depth of the lateral and medial femoral condyle (LFC-ratio and MFC-ratio), the lateral and medial posterior tibial slopes (LTPs and MTPs) and the anterior subluxation of the lateral and medial tibial plateau with respect to the femoral condyle (LTPsublx and MTPsublx). RESULTS: Concerning the AP30, LTPs (P=0.047) and MTPsublx (P=0.039) were shown to be independent predictors while for the AP90 only LTPs (P=0.049) was an independent predictor. The LTPs (P=0.039) was shown to be an independent predictor for IE90 laxity, while for the VV0 test it was identified as the LFCw (P=0.007). CONCLUSIONS: A higher antero-posterior laxity at 30° and 90° of flexion was found in those with a lateral tibial slope <5.5°.

Association between incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the infra-patellar branch of the saphenous nerve: a meta-analysis.

PURPOSE: To determine how the incision technique for hamstring tendon (HT) harvest in anterior cruciate ligament (ACL) reconstruction affects the risk of injury to the IPBSN and clinical outcome. METHODS: A systematic literature search of the MEDLINE/Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCOhost electronic databases and clinicaltrials.gov for unpublished studies was performed to identify comparative studies investigating injury to the IPBSN after HT ACL reconstruction by comparing at least two different incision techniques. Data were extracted for the number of patients with evidence of any neurologic deficit corresponding to injury to the IPBSN, area of sensory deficit, the Lysholm score and patient satisfaction. The mean difference (MD) in study outcome between incision groups was assessed. The relative risk (RR) and the number needed to treat (NNT) were calculated. The Chi-square and Higgins' I2 tests were applied to test heterogeneity. Data were pooled using a Mantel-Haenszel random-effects model if the statistical heterogeneity was > 50% and a fixed-effects model if the statistical heterogeneity was < 50%. The risk of bias was evaluated according to the Cochrane Database questionnaire and the quality of evidence was graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS: A total of eight studies (three randomized controlled trials (RCTs) and five comparative studies) were included, of which six compared vertical and oblique incisions, one horizontal and vertical incisions, and one compared all three techniques. HT harvest was performed through a vertical incision in 329 patients, through an oblique incision in 195 patients and through a horizontal incision in 151 patients. Considering the meta-analysis of the RCTs, the performance of a vertical incision significantly increased the risk of causing IPBSN deficiency compared with both oblique and horizontal incision [RR 1.65 (CI 1.10-2.49, p = 0.02) and RR 2.45 (CI 1.73-3.47, p < 0.0001), respectively]. A significantly larger area of sensory deficit was found with vertical incisions compared with oblique ones, with an MD of 22.91 cm2 (95% CI 7.73-38.08; p = 0.04). No significant differences were found between the incision techniques in relation to patient-reported outcomes. The same trend was obtained after the performing a meta-analysis of all eight included studies. The quality of evidence in this meta-analysis was determined as "low" to "moderate", mostly due to inadequate methods of randomization and high heterogeneity among the included studies. CONCLUSION: The performance of a vertical incision to harvest HTs for ACL reconstruction significantly increased the risk of iatrogenic injury to the IPBSN compared with both oblique and horizontal incisions. LEVEL OF EVIDENCE: Level I-III, meta-analysis of comparative studies.

The Anterolateral Ligament Does Exist: An Anatomic Description.

The debate around the existence, anatomy, and role of the so-called anterolateral ligament of the knee represents one of the main sources of recent controversy among orthopedic surgeons. In the modern era of sports medicine, several content experts have contributed to the understanding of the anatomy of the anterolateral aspect of the knee. This article analyzes the historical, phylogenetic, anatomic, arthroscopic, and radiological evidence regarding the anterolateral ligament. The existence of the anterolateral ligament as a distinct ligamentous structure and its exact anatomic features are still matters of controversy and ongoing study.

Over-the-top ACL Reconstruction Plus Extra-articular Lateral Tenodesis With Hamstring Tendon Grafts: Prospective Evaluation With 20-Year Minimum Follow-up.

BACKGROUND: There are few published studies with very long-term follow-up of combined intra- and extra-articular anterior cruciate ligament (ACL) reconstruction. PURPOSE: To analyze clinical and radiographic outcomes of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with autologous hamstrings at minimum 20-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 60 originally eligible patients who underwent over-the-top ACL reconstruction with double-stranded hamstring tendon (leaving intact graft tibial insertions) and extra-articular lateral plasty (performed with the remnant part of tendons), 52 were prospectively evaluated at a minimum 20-year follow-up (mean follow-up, 24 years; 41 men, 11 women; mean age at time of surgery, 25.5 ± 7.6 years). Twenty-nine patients were available for prospective evaluations: clinical (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC]), instrumented (KT-2000), and radiographic (standard, long-standing, and Merchant views). Subjective KOOS (Knee injury and Osteoarthritis Outcome Score) and objective inertial sensor pivot-shift analysis (KiRA) were carried out at final follow-up. Twenty-three patients were investigated by phone interview for subjective Tegner score and documented complications, rerupture, or revision surgery. RESULTS: At final follow-up, mean Lysholm score was 85.7 ± 14.6; median Tegner score, 4 (range, 3-5); sport activity resumption, 86.2%; and objective IKDC score, good or excellent in 86% of patients (31%, A; 55%, B). Only 3 of 26 patients (12%) had >5-mm manual maximum KT-2000 side-to-side difference. KiRA system documented positive pivot-shift (>0.9-m/s2 tibial acceleration side-to-side difference) in these 3 of 26 patients (12%). Statistically significant changes were as follows: decrease in Tegner score from 7 (range, 6-8) at 5-year follow-up to 4 (range, 3-5) at 10 years ( P < .0001) and decrease in Lysholm score from 96.1 ± 7.3 at 10-year follow-up to 85.7 ± 14.6 at 20 years ( P = .0003). Radiographic evaluation demonstrated significant difference of medial joint space between injured and healthy knees in patients with concomitant medial meniscectomy (n = 8, 3.2 ± 0.6 vs 5.0 ± 1.8 mm, P = .0114). No significant differences were reported regarding lateral or patellofemoral joint space. One patient (2%) experienced rerupture, with 3 of 52 (5.8%) having a contralateral ACL injury (excluded from KT-2000 and radiographic evaluations). Overall, 4 of 29 clinical failures (objective IKDC, KT-2000) and 1 rerupture among 52 patients were registered at final follow-up. CONCLUSION: Studied surgical technique demonstrated good results in laxity control at 20-year minimum follow-up. The lateral extra-articular plasty associated with ACL reconstruction did not generate lateral knee or patellofemoral osteoarthritis. The factor increasing osteoarthritis was meniscectomy.

Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study.

PURPOSE: The main goal of this work was to evaluate the pivot shift test in awake and anesthetized patients by using two different quantitative methodologies and comparing the results with the standard clinical grading, taking advantage of a multicenter international study. METHODS: Patients between 16 and 50 years of age undergoing primary unilateral single-bundle anterior cruciate ligament (ACL) reconstruction were considered eligible. The pivot shift test was performed pre-operatively, with the patient awake and again with the patient under general anaesthesia. The pivot shift test was clinically graded as defined by the International Knee Documentation Committee. The instrumented assessment was performed by using two non-invasive acquisition systems; specifically, a system exploiting an inertial sensor and a video-based application developed on a commercial tablet using skin markers. Lateral compartment translation and the tibial acceleration reached during joint reduction were used as quantitative parameters. RESULTS: A total of 103 patients were enrolled in the study. Statistically significant difference was found between the distributions of clinical grade evaluated in awake patients and those under general anaesthesia (P < 0.01). Comparing awake patients to those under general anaesthesia, lower values were found both for tibial acceleration (3.7 ± 1.5 vs 6.0 ± 4.6 m/s2, P < 0.01) and lateral compartment translation of the involved limb (2.2 ± 1.7 vs 3.0 ± 2.2 mm, P < 0.01). CONCLUSIONS: This study indicated that significant differences in the grading of the pivot shift test exist between awake and anesthetized patients, regardless of the use of quantitative instruments during the evaluation. Actual clinical assessment reported indeed its weakness, presenting subjective variability and dependence on tester's experience. However, several factors might influence the validity of awake examination such as experience level of examiner and cultural factors, as seen in this international multicenter study. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Soft tissues contribution to hip joint kinematics and biomechanics.

PURPOSE: To quantitatively describe the kinematic behaviour of the hip joint with particular interest in the contribution of the periarticular soft tissues to the stability. To quantitatively assess the sealing function of the acetabular labrum of an intact labrum, the effect of a labral-chondral separation and different surgical approaches. The biomechanics of the joint during specific clinical examinations was also assessed. METHODS: All the kinematics tests, manually performed, have been acquired using a navigation systems. For the first part of the study, 4 hemi-corpse specimens were evaluated with the hip in 36 different positions with all the soft tissues intact, after removal of skin and muscles and after partial capsulectomy. During the second and the third part of the analysis 8 fresh frozen hips were analysed. They were tested during 3 different positions used for femeroacetabular impingement (FAI) diagnosis, during pivoting motion and distraction test. Contact area between acetabulum and femoral head, range of movement (RoM) and hip joint centre (HJC) displacement were evaluated. RESULTS: Femoral head displacement occured in all 3 directions and increased as more tissue was removed. Considering both pivoting motion and distraction test there was an increase of the HJC displacement after labral tear. Analogously, the tested surgical approaches showed different results compared to intact condition. Our analysis confirmed that the hip position with Hyperextension-External Rotation is specific for the analysis of the posteriorsuperior region of the acetabulum. CONCLUSIONS: The study showed that hip joint does not act as a true ball-and-socket joint and the femoral head anatomical displacement is strongly affected by the removal of periarticular soft tissues, labral repair as well as labrectomy.

Assessment of the pivot shift using inertial sensors.

The pivot shift test is an important clinical tool used to assess the stability of the knee following an injury to the anterior cruciate ligament (ACL). Previous studies have shown that significant variability exists in the performance and interpretation of this manoeuvre. Accordingly, a variety of techniques aimed at standardizing and quantifying the pivot shift test have been developed. In recent years, inertial sensors have been used to measure the kinematics of the pivot shift. The goal of this study is to present a review of the literature and discuss the principles of inertial sensors and their use in quantifying the pivot shift test.

Is Sport Activity Possible After Arthroscopic Meniscal Allograft Transplantation? Midterm Results in Active Patients.

BACKGROUND: Meniscal allograft transplantation (MAT) has produced good to excellent results in the general population; however, few investigations have examined MAT in athletes and sport-related outcomes. PURPOSE: To report midterm clinical outcomes of MAT and the rate of return to sport in a physically active population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study included all physically active patients who underwent arthroscopic MAT without bone plugs and had a minimum of 2 years of follow-up at a single institution. Clinical evaluation was performed with the Knee injury and Osteoarthritis Outcome Score (KOOS), the Tegner activity scale, and a 0- to 100-point subjective scale for knee function and satisfaction. Outcomes evaluated included ability to return to sport, time to return to sport, level of sport activity upon return compared with preinjury level, and level of decrease in sport participation or reasons for not returning to sport participation. Comparisons were made between patients who did or did not return to sport and between patients who returned to the same level or a decreased level. Regression analysis was performed to determine the variables affecting the outcomes. RESULTS: Eighty-nine patients, whose mean ± SD age at surgery was 38.5 ± 11.2 years, were evaluated to a mean follow-up of 4.2 ± 1.9 years. Total KOOS improved from a mean ± SD of 39.5 ± 18.5 preoperatively to 84.7 ± 14.8 at the latest follow-up (P < .001). The Tegner score improved significantly from a median of 2 (interquartile range [IQR], 1-4) preoperatively to a median of 4 (IQR, 3-6) at the latest follow-up (P < .001), although it did not reach the preinjury level of 6 (IQR, 5-7) (P < .001). Older age at surgery was correlated with the worst clinical results. Sixty-six patients (74%) were able to return to sport after 8.6 ± 4.1 months. Forty-four (49%) returned to the same level as preinjury. Patients who did not return to sport activity and those who reduced their activity level at follow-up had inferior subjective outcomes compared with those who returned to sport and those who returned to their preinjury levels, respectively. Only 11 patients (12%) underwent a surgical procedure during the follow-up period. CONCLUSION: Arthroscopic MAT without bone plugs improved knee function and reduced pain, allowing sport resumption in 74% of patients and return to the preinjury activity level in 49% of patients at midterm follow-up. Of all the demographic and surgical variables, only age at surgery seemed to affect outcomes.