Beyond the Patella: Treatment of Cam Femoroacetabular Impingement Syndrome Improves Anterior Knee Pain

OBJECTIVES

This study aimed to investigate if there is a relationship between cam femoroacetabular impingement syndrome (cam-FAIS) and chronic anterior knee pain (AKP).

METHODS

This is a pilot retrospective review of 12 AKP patients with no structural anomalies in the patellofemoral joint and no skeletal malalignment in the lower limbs. All the patients were resistant to proper conservative treatment for AKP (AKP-R). Subsequently, these patients developed pain in the ipsilateral hip several months later, and upon evaluation, were diagnosed with cam-FAIS. Arthroscopic femoral osteoplasty and labral repair were performed and clinical follow-up of hip and knee pain and function (Kujala Score and Non-arthritic Hip Score -NAHS-) was carried out.

RESULTS

All the patients showed improvement in the knee and hip pain scores with a statistically significant clinical difference in all of them at 69 months follow up (range: 18 to 115) except one patient without improvement in the groin VAS score post-operatively. Visual analogical scale (VAS) of knee pain improved from 6.3 (range: 5 to 8) to a postoperative 0.5 (range: 0 to 3.5), (p<0.001). The VAS of groin pain improved from 4.4 (range: 2 to 8) to a postoperative 0.9 (range: 0 to 3), (p<0.001). NAHS improved from a preoperative 67.9 (range: 28.7 to 100) to a postoperative 88 (range: 70 to 100), (p<0.015) and Knee Kujala's score improved from a preoperative 48.7 (range: 22 to 71) to a postoperative 96 (range: 91 to 100), (p<0.001).

CONCLUSION

This study's principal finding suggests an association between cam-FAIS and AKP-R in young patients who exhibit normal knee imaging and lower limbs skeletal alignment. Addressing cam-FAIS in these cases leads to resolution of both groin and knee pain, resulting in improved functional outcomes for both joints.

STUDY DESIGN

Retrospective cohort series with a single contemporaneous long-term follow-up.

LEVEL OF EVIDENCE

IV.

Anterior knee pain patients without structural knee abnormalities and normal lower limb skeletal alignment have a higher prevalence of cam-femoroacetabular impingement syndrome than the general population

OBJECTIVES

This study aimed to ascertain the prevalence of cam femoroacetabular impingement syndrome (cam-FAIS) in anterior knee pain (AKP) patients devoid of both structural patellofemoral joint abnormalities and lower limb skeletal malalignment. A secondary objective was to examine pain and disability differences between AKP patients with and without cam-FAIS.

METHODS

A total of 209 AKP patients were screened for eligibility. Inclusion criteria were normal imaging studies and normal lower limb alignment, and exclusion criteria were previous knee surgery and knee and/or hip osteoarthritis. Of those, 49 (23.4%) were eligible and this number matched a previous power analysis to detect statistically significant differences in prevalence of cam-FAIS in a population of AKP patients. The first step in the study sequence was to ask the patient whether they had groin pain. If so, the impingement test was done. Then, the femoral cam morphology defined by an alpha angle greater than or equal to 55° in a 45° Dunn axial view of the hip was ruled out. Additionally, patients completed Kujala and International Knee Documentation Committee (IKDC) functional knee scores for disability assessment. General population control group was obtained from literature.

RESULTS

The study included 9 males and 40 females, with an average age of 36 (20-50, ±SD 8.03) years. Groin pain and positive impingement test were found in 26/49 patients (53%). An alpha angle ≥55° was observed in 35/49 patients (71%). A combination of groin pain, positive impingement test and an alpha angle ≥55° was seen in 18/49 patients (37%). The AKP patients with groin pain, a positive impingement test and an alpha angle ≥55° exhibited statistically similar pain and disability levels as AKP patients without cam-FAIS.

CONCLUSION

The results of this study suggest that AKP patients without structural abnormalities in the patellofemoral joint and without lower limbs malalignment have a statistically significantly higher prevalence of cam-FAIS than the general population. Moreover, AKP patients with cam-FAIS have a statistically similar degree of pain and disability than AKP patients without it.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

IV.

Derotational distal femoral osteotomy corrects excessive femoral anteversion in patients with patellofemoral instability: A systematic review

PURPOSE

Patellofemoral instability (PFI) is a common condition that can be caused from multiple factors, including lower limb rotational malalignments. Determining precise criteria for performing corrective torsional osteotomy can be a daunting task due to the lack of consensus on normal and excessive values and the limited evidence-based data in the postoperative results. The purpose was to assess the clinical, functional and imaging outcomes following derotational distal femoral osteotomy (DDFO) in patients with PFI and/or anterior knee pain (AKP) associated with lower limb rotational malalignments.

METHODS

Searches were conducted on PubMed, EMBASE and Web of Science databases up to October 2023. Studies reporting outcomes after DDFO in patients with PFI and/or AKP were eligible for the systematic review. The primary outcome was imaging metrics, especially femoral anteversion. Secondary outcomes included the patient-reported outcome measures (PROMs) (clinical and functional). Quantitative synthesis involved the use of weighted averages to calculate pre- to postoperative mean differences (MD) and compare them against the minimal clinically important difference (MCID).

RESULTS

Ten studies (309 knees) were included with a mean follow-up of 36.1 ± 11.7 months. Imaging outcomes consistently indicated the correction of femoral anteversion (MD = -19.4 degrees, 95% confidence interval: -20.1 to -18.7) following DDFO. PROMs showed significant improvements in most studies, exceeding the MCID. Patient satisfaction with the DDFO was high (93.3%).

CONCLUSIONS

The DDFO was an effective treatment option for correcting excessive femoral anteversion in patients with PFI associated with clinically relevant functional and clinical improvement and a high satisfaction rate.

LEVEL OF EVIDENCE

Level IV, systematic review of level II-IV studies.

Derotational high tibial osteotomy in cases of anterior knee pain and/or patellofemoral instability: a systematic review

IMPORTANCE

Derotational high tibial osteotomy (HTO) is a surgical intervention for correcting rotational malalignments in the lower limb, which may contribute to anterior knee pain (AKP) and/or patellofemoral instability (PFI). This surgical technique is not yet widely implemented and requires a systematic evaluation of its outcomes.

AIM

To assess the effectiveness of derotational HTO in correcting rotational malalignments of the lower limb in patients with AKP and/or PFI through radiological, clinical, and patient-reported outcome measures.

EVIDENCE REVIEW

Searches were conducted in the PubMed, Embase, and Web of Science databases up to March 3, 2023, to identify studies utilizing derotational HTO in patients with AKP and/or PFI. The primary outcome measures of interest were measurements of lower limb angular correction. Other radiological, clinical, and patient-reported outcome measures were also analyzed. The risk of bias was judged with the RoBANS tool.

FINDINGS

A total of 8 studies were included, comprising 215 patients (27.0 ​± ​3.9 years) and 245 knees. The most reported angle was tibial torsion (k ​= ​6 studies, n ​= ​173 knees), with a mean difference between postoperative and preoperative values (postsurgical correction) ranging from -37.8° to -10.8°. Patient-reported outcome measures showed significant improvements in the postoperative moment, exceeding the minimal clinically important difference in almost all cases, and with high patient satisfaction (93.6%).

CONCLUSIONS AND RELEVANCE

Derotational HTO allows the correction of rotational malalignments of the lower limb (tibial torsion) and promotes patient satisfaction.

LEVEL OF EVIDENCE

Level IV.

Women show a positive response to platelet-rich plasma despite presenting more painful knee osteoarthritis than men

PURPOSE

The purpose of this study was to evaluate the impact of gender on the efficacy of platelet-rich plasma (PRP) in patients with knee osteoarthritis (KOA), comparing their short-term response between men and women.

METHODS

Four hundred-eighteen patients (529 knees) were included. Patients were treated with three injections of PRP on a weekly basis. Blood and PRP samples were randomly tested. Patients were asked to complete the knee injury and osteoarthritis outcome score (KOOS) and 12-item short form survey (SF-12), at baseline and 6 months. Success rates were calculated according to a reduction in the pain score of at least 9.3 points [minimal clinically important improvement (MCII)]. Comparative tests and multivariate regression were performed.

RESULTS

The PRP had a platelet concentration factor of 2.0X compared to blood levels, with no leucocytes or erythrocytes. KOOS scores showed an increase from baseline to 6 months (p < 0.0001). There was an increase in the physical component summary (PCS) (p < 0.0001) and mental component summary (MCS) (p < 0.01) of the SF-12. The number of knees of women with MCII was 156 out of 262 (59.6%), whereas the number of knees of men was 136 out of 267 (50.9%) (p = 0.0468). Women had worse baseline scores on pain (p = 0.009), PCS (p < 0.0001) and MCS (p < 0.0001).

CONCLUSION

Although the symptomatology generated by KOA was worse in women when compared to men, treatment with repeated injections of PRP was effective, ultimately achieving a higher improvement in women providing comparable final follow-up outcomes between men and women.

LEVEL OF EVIDENCE

Level IV.

Mid-Term Clinical and Radiological Outcomes of Lateral Meniscal Allograft Transplantation with Suture-Only Fixation Plus Capsulodesis

Meniscal allograft transplantation (MAT) is an effective reconstructive procedure for treating a symptomatic postmeniscectomy syndrome. It consists of replacing the lost meniscal tissue aiming to improve the clinical outcomes and prevent progressive deterioration of the joint. The aim of this study was to evaluate meniscal graft survivorship and report on the radiographic (in terms of graft extrusion and joint space width and alignment) and the functional results through a midterm follow-up of lateral MAT performed with a soft tissue fixation technique after capsulodesis. In total, 23 patients who underwent lateral MAT as a single procedure were included. The Knee injury and Osteoarthritis Outcome Score, Lysholm, Tegner, and visual analog scale scales were used for patient assessment. Magnetic resonance imaging and a complete radiographic protocol were conducted to determine the degree of meniscal extrusion and the changes in the degree of osteoarthritis and coronal alignment. Assessments were performed after 2 and 7 years of follow-up. A significant improvement in all the scores, relative to preoperative values, was found after 7 years of follow-up. This improvement remained consistent throughout the first and second follow-up periods. A mean absolute extrusion of 2.2 mm ± 1.6 and an extrusion percentage of 28.0% ± 11.43 were found, with no significant differences throughout the follow-up periods. There was no statistically significant difference in terms of the frontal mechanical axis and joint space narrowing between the preoperative value and at the first and second follow-up periods. A survival rate of 85.7% was found after 7 years of follow-up. Capsulodesis results in a low degree of meniscal extrusion in isolated lateral MAT fixed with a suture-only technique, which is maintained after 7 years of follow-up, with a high graft survival index (>85%) and satisfactory results on the functional scales.

Permanent Subluxation of the Lateral Meniscus in a 10-year-old Boy: A Case Report with Short Literature Review

Introduction

Locking of the knee attributed to non-discoid lateral meniscus in an atraumatic setting is a rare phenomenon. One such cause is permanent subluxation of lateral meniscus (PSLM). In the entire literature, there is only one documented case of a 37-year-old female.

Case Report

We present a case of a 10-year-old boy who suffered two episodes of knee locking reported radiologically as a bucket handle tear of the lateral meniscus. No tear was found during arthroscopy. The lateral meniscus was malformed with meniscocapsular discontinuity and irreducibly subluxated into the intercondylar space. No salvage procedure was possible. We ended up performing a subtotal meniscectomy.

Conclusion

This is the first case of PSLM reported in the pediatric age group and second overall. Management options are limited. Further genetic and fetal studies are needed in this area to determine the exact causality.

A modified Delphi consensus statement on patellar instability: part II

Aims

The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

Methods

This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous.

Results

Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus.

Conclusion

Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

The Role of Systemic Steroids in Sciatica Due to Herniated Lumbar Disc: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Evaluate the role of systemic steroids in treating patients with sciatica due to lumbar disk herniation (LDH).

SUMMARY OF BACKGROUND DATA

The association between LDH and sciatica has been well described. The use of steroids seems logical in this context; however, their efficacy is not well described, and their use remains controversial.

METHODS

A comprehensive search on PubMed, EMBASE, and Scopus databases (up to February 15, 2022) was performed to identify randomized clinical trials that included patients with symptoms of sciatica due to LDH that were treated with systemic steroids. The risk of bias was judged using the Cochrane risk-of-Bias2 tool. Meta-analysis was conducted using a random-effects model to estimate the between-group effect size for pain and functional outcomes. The risk of developing adverse events (AE) was computed using relative risks. All pooled results are reported with their 95% confidence interval (CI) and certainty of evidence analyzed using the Grading of Recommendations Assessment, Development, and Evaluation framework.

RESULTS

Ten studies met inclusion criteria, comprising a total of 1017 participants: 540 in the treatment group and 477 in the control group. Steroid treatment was associated with a significant superior reduction of pain (SMD = -0.42, 95% CI -0.76 to -0.08, weak effect, very-low certainty) and reduction in disability (SMD = -0.30, 95% CI -0.51 to -0.10, weak effect, very-low certainty). Corticosteroid administration was associated with a significant increased risk of developing an AE (relative risks = 2.00, 95% CI 1.40 to 2.85, low certainty).

CONCLUSION

The use of systemic steroids in the treatment of sciatica due to LDH seems reasonable despite a 2-fold higher risk of developing mild AEs. However, the effect size is small for reducing pain in the short term and improving functional outcomes at long-term follow-up.

A modified Delphi consensus statement on patellar instability: part I

Aims

The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

Methods

A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous.

Results

Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus.

Conclusion

The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

Meniscal extrusion in knees with and without osteoarticular pathology: A systematic review of normative values and cut-offs for diagnostic criteria

BACKGROUND

Meniscus extrusion is crucial for the diagnosis and treatment of meniscal injury, but the literature on this topic has not yet been systematized. The purpose of this systematic review was to compare diagnostic methods and summarize the data of medial and lateral meniscal extrusion in knees with and without osteoarticular pathology.

METHODS

This systematic review was conducted according to the PRISMA 2020 statement. Searches were conducted on PubMed, EMBASE and Cochrane databases to identify studies that measured meniscal extrusion using magnetic resonance imaging (MRI) or ultrasound (US). Meniscal extrusion data was summarized as weighted mean for medial and lateral meniscus, and stratified according to the method of measurement (MRI or US) and presence of knee osteoarticular pathology.

RESULTS

A total of 26 studies were included in this review. Weighted mean values of meniscal extrusion were always higher for the medial than the lateral meniscus, regardless of the method of measurement. The medial meniscus extrusion was always higher in knees with osteoarticular pathology than those without. For the lateral meniscus extrusion, the mean values were higher in those knees without osteoarticular pathology. When classifying pathological meniscal extrusion with pre-defined cut-off values, the higher the cut-off used, the lower the percentage of knees classified as pathological meniscal extrusion.

CONCLUSIONS

The medial meniscus presents on mean higher extrusion and extrusion is higher in knees with osteoarticular pathology. Based on summary data, the most suitable cut-offs for pathological meniscal extrusion for both MRI and US seem to fall within >2 and >3 mm.

The effect of short-term cryopreservation on the properties and functionality of platelet-rich plasma

Platelet Rich Plasma (PRP) is a biological treatment which, thanks to its enhanced growth factors content, is widely used in the field of regenerative medicine for its reparative effects. Although it is usually used fresh immediately after preparation, its freezing for preservation for future usage could be key in increasing its versatility and new applications. To assess the suitability of freezing, after collecting PRP and platelet lysates (PL) from 6 patients, they were preserved for 1 or 3 months at temperatures of -20ºC and -80°C. Measurements were then made on platelet number and integrity, growth factor levels, biomechanical properties of the clot and its bioactivity on cultured cells. Fresh PRP and PL were used as controls. The results showed an increase in platelet size (p < .01) and clot elasticity (p < .01), as well as decrease in levels of PDGF (P < .05) and VEGF (p < .05), though the overall bioactivity was not affected as culture cells showed the same responsiveness to both frozen and fresh PRP and PL in terms of cell viability. Based on these results, it could be assumed that preservation of PRP by freezing is a feasible and suitable option for its further use.

High survival rate after the combination of intrameniscal and intraarticular infiltrations of platelet-rich plasma as conservative treatment for meniscal lesions

PURPOSE

To evaluate the efficacy of applying a combination of intrameniscal and intraarticular infiltrations of Platelet-Rich Plasma (PRP) in patients with meniscal tears, analyzing its failure rate and clinical evolution, as well as factors that may influence the positive response to this treatment.

METHODS

Three hundred and ninety-two cases out of 696 met the inclusion criteria and were included in this work. Survival and patient-reported outcome measure (PROM) were collected and analyzed. Survival rate was defined as the percentage of patients who did not undergo meniscus surgery during their follow-up time. Patients were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline, 6 months and 18 months. Other patient- and pathology-related variables were collected. Blood and PRP samples were randomly tested as a quality control measure. Survival and comparative statistical tests, and multivariate regression were performed for the analysis of the variables.

RESULTS

The PRP applied had a platelet concentration factor of 1.9X in respect to blood levels, with no leukocytes or erythrocytes. Thirty-eight patients required surgical intervention after treatment reaching a survival rate of 90.3% with an estimated mean survival time of 54.4 months. The type of injury (P = 0.002) and the presence of chondropathy were risk factors for surgical intervention after PRP treatment (P = 0.043). All KOOS scores showed a significant statistical increase from baseline to 6 months (N = 93) and 18 months (N = 66) (P < 0.0001). The number of cases with minimal clinically important improvement (MCII) at 6 months and 18 months post-treatment was 65 (69.9%) and 43 (65.2%), respectively.

CONCLUSION

The combination of intrameniscal and intraarticular PRP infiltrations is a valid conservative treatment for meniscal injuries avoiding the need for surgical intervention. Its efficacy is higher in horizontal tears and decreases when joint degeneration is present.

LEVEL OF EVIDENCE

Level IV.

Inconsistency in Shoulder Arthrometers for Measuring Glenohumeral Joint Laxity: A Systematic Review

There is no consensus on how to measure shoulder joint laxity and results reported in the literature are not well systematized for the available shoulder arthrometer devices. This systematic review aims to summarize the results of currently available shoulder arthrometers for measuring glenohumeral laxity in individuals with healthy or injured shoulders. Searches were conducted on the PubMed, EMBASE, and Web of Science databases to identify studies that measure glenohumeral laxity with arthrometer-assisted assessment. The mean and standard deviations of the laxity measurement from each study were compared based on the type of population and arthrometer used. Data were organized according to the testing characteristics. A total of 23 studies were included and comprised 1162 shoulders. Populations were divided into 401 healthy individuals, 278 athletes with asymptomatic shoulder, and 134 individuals with symptomatic shoulder. Sensors were the most used method for measuring glenohumeral laxity and stiffness. Most arthrometers applied an external force to the humeral head or superior humerus by a manual-assisted mechanism. Glenohumeral laxity and stiffness were mostly assessed in the sagittal plane. There is substantial heterogeneity in glenohumeral laxity values that is mostly related to the arthrometer used and the testing conditions. This variability can lead to inconsistent results and influence the diagnosis and treatment decision-making.

Effectiveness of Conservative Interventions After Acute Hamstrings Injuries in Athletes: A Living Systematic Review

BACKGROUND

Hamstrings injuries are common in sports and the reinjury risk is high. Despite the extensive literature on hamstrings injuries, the effectiveness of the different conservative (i.e., non-surgical) interventions (i.e., modalities and doses) for the rehabilitation of athletes with acute hamstrings injuries is unclear.

OBJECTIVE

We aimed to compare the effects of different conservative interventions in time to return to sport (TRTS) and/or time to return to full training (TRFT) and reinjury-related outcomes after acute hamstrings injuries in athletes.

DATA SOURCES

We searched CINAHL, Cochrane Library, EMBASE, PubMed, Scopus, SPORTDiscus, and Web of Science databases up to 1 January, 2022, complemented with manual searches, prospective citation tracking, and consultation of external experts.

ELIGIBILITY CRITERIA

The eligibility criteria were multi-arm studies (randomized and non-randomized) that compared conservative treatments of acute hamstrings injuries in athletes.

DATA ANALYSIS

We summarized the characteristics of included studies and conservative interventions and analyzed data for main outcomes (TRTS, TRFT, and rate of reinjuries). The risk of bias was judged using the Cochrane tools. Quality and completeness of reporting of therapeutic exercise programs were appraised with the i-CONTENT tool and the certainty of evidence was judged using the GRADE framework. TRTS and TRFT were analyzed using mean differences and the risk of reinjury with relative risks.

RESULTS

Fourteen studies (12 randomized and two non-randomized) comprising 730 athletes (mostly men with ages between 14 and 49 years) from different sports were included. Nine randomized studies were judged at high risk and three at low risk of bias, and the two non-randomized studies were judged at critical risk of bias. Seven randomized studies compared exercise-based interventions (e.g., L-protocol vs C-protocol), one randomized study compared the use of low-level laser therapy, and three randomized and two non-randomized studies compared injections of platelet-rich plasma to placebo or no injection. These low-level laser therapy and platelet-rich plasma studies complemented their interventions with an exercise program. Only three studies were judged at low overall risk of ineffectiveness (i-CONTENT). No single intervention or combination of interventions proved superior in achieving a faster TRTS/TRFT or reducing the risk of reinjury. Only eccentric lengthening exercises showed limited evidence in allowing a shorter TRFT. The platelet-rich plasma treatment did not consistently reduce the TRFT or have any effect on the risk of new hamstrings injuries. The certainty of evidence was very low for all outcomes and comparisons.

CONCLUSIONS

Available evidence precludes the prioritization of a particular exercise-based intervention for athletes with acute hamstrings injuries, as different exercise-based interventions showed comparable effects on TRTS/TRFT and the risk of reinjuries. Available evidence also does not support the use of platelet-rich plasma or low-level laser therapy in clinical practice. The currently available literature is limited because of the risk of bias, risk of ineffectiveness of exercise protocols (as assessed with the i-CONTENT), and the lack of comparability across existing studies.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42021268499 and OSF ( https://osf.io/3k4u2/ ).

Isolated lateral extra-articular tenodesis in ACL-deficient knees: in vivo knee kinematics and clinical outcomes

PURPOSE

To carry out an in vivo kinematic analysis of isolated modified Lemaire lateral extra-articular tenodesis (LET) to explore its ability to modify the stability of anterior cruciate ligament (ACL) deficient knees. The secondary aim was to look at the clinical outcomes of the isolated LET to analyze whether biomechanical changes have an influence on clinical improvement or not.

METHODS

A total of 52 patients who underwent an isolated modified Lemaire LET were prospectively studied. Twenty-two were over 55-year-old patients with ACL rupture and subjective instability (group 1). They were followed up for 2 years postoperatively. Thirty were patients underwent a two-stage ACL revision (group 2). They were followed up for 4 months postoperatively (up to the second stage of the ACL revision). Preoperative, intraoperative, and postoperative kinematic analyses were carried out using the KiRA accelerometer and KT1000 arthrometer to look for residual anterolateral rotational instability and residual anteroposterior instability. Functional outcomes were measured with the single-leg vertical jump test (SLVJT) and the single-leg hop test (SLHT). Clinical outcomes were evaluated using the IKDC 2000, Lysholm, and Tegner scores.

RESULTS

A significant reduction of both rotational and anteroposterior instability was detected. It was present both with the patient under anesthesia (p < 0.001 and p = 0.007 respectively) as well as with the patient awake (p = 0.008 and p = 0.018 respectively). Postoperative analysis of knee laxity did not show any significant variation from the first to the last follow-up. Both the SLVJT and SLHT improved significantly at the last follow-up (p < 0.001 and p = 0.011 respectively). The mean values of both the IKDC and Lysholm and Tegner scores showed an improvement (p = 0.008; p = 0.012; p < 0.001).

CONCLUSION

The modified Lemaire LET improves the kinematics of ACL-deficient knees. The improvement in the kinematics leads to an improvement in subjective stability as well as in the function of the knee and in the clinical outcomes. At the 2-year follow-up, these improvements were maintained in a cohort of patients over 55 years. Following our findings, to reduce knee instability, an isolated LET in ACL-deficient knees may be used when ACL reconstruction in patients over 55 years is not indicated.

LEVEL OF EVIDENCE

Level IV.

Accuracy of Magnetic Resonance Imaging in the Diagnosis of Multiple Ligament Knee Injuries: A Multicenter Study of 178 Patients

BACKGROUND

Magnetic resonance imaging (MRI) has shown limited diagnostic accuracy for multiple ligament knee injuries (MLKIs), especially posterolateral corner (PLC) injuries.

HYPOTHESIS

The diagnostic accuracy of MRI for MLKIs will only be moderate for some knee structures. Patient-related factors and injury patterns could modify the diagnostic accuracy of MRI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients with MLKIs surgically treated between January 2014 and December 2020 in the centers participating in the study were reviewed. We recorded sex, age, mechanism of injury, time from injury to MRI, and vascular and neurological associated lesions. Lesions to the anterior cruciate ligament (ACL), posterior cruciate ligament, medial collateral ligament, lateral collateral ligament (LCL), popliteus tendon, popliteofibular ligament, iliotibial band, biceps tendon, medial and lateral meniscus, and articular cartilage from MRI reports and surgical records were also collected. The sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, diagnostic odds ratio, positive and negative likelihood ratio, and intraclass correlation coefficient of MRI were calculated for each knee structure. With logistic regression, associations between patient and injury characteristics and MRI accuracy were assessed.

RESULTS

A total of 178 patients (127 male; mean age, 33.1 years) were included. High-energy trauma was the most common mechanism of injury (50.6%), followed by sports trauma (38.8%) and low-energy trauma (8.4%). The ACL was the structure with the best diagnostic accuracy, diagnostic odds ratio, and positive predictive value (94.4%, 113.2, and 96.8%, respectively). PLC structures displayed the worst diagnostic accuracy among knee ligaments (popliteus tendon: 76.2%; LCL: 80.3%) and diagnostic odds ratio (popliteus tendon: 9.9; LCL: 17.0; popliteofibular ligament: 17.5). MRI was more reliable in detecting the absence of meniscal and chondral lesions than in identifying them. Logistic regression found that the diagnostic accuracy was affected by the Schenck classification, with higher Schenck grades having worse diagnostic accuracy for peripheral structures (iliotibial band, popliteus tendon, and biceps tendon) and improved diagnostic accuracy for the ACL and posterior cruciate ligament.

CONCLUSION

The diagnostic accuracy of MRI for MLKIs largely varied among knee structures, with many of them at risk of a misdiagnosis, especially PLC, meniscal, and chondral lesions. The severity of MLKIs lowered the diagnostic accuracy of MRI for peripheral structures.

Complications after total ankle arthroplasty- A systematic review

BACKGROUND

Total ankle arthroplasty was developed as an alternative option to ankle arthrodesis in patients with end-stage ankle osteoarthritis. Multiple trials have assessed the outcomes of ankle arthroplasty, but complication risk or relative effectiveness is not systematized in literature.

AIM

Review complications of new designs of total ankle arthroplasty and the relationship between their severity and failure rates.

METHODS

We reviewed complications and revision rates of prospective studies of primary total ankle arthroplasty that included more than 50 patients and with minimum 2 years follow-up.

RESULTS

We included 22 studies (4412 ankles, median age of 61.9 years) with an adjusted mean follow-up time of 66.6 ± 40.9 months. The adjusted mean complication rate was 23.7 % (2.4-52 %), mostly high-grade complications (35.6 %). We found a statistically significant positive correlation between high- and medium-grade complications and revision rates.

CONCLUSION

Patient selection is crucial to successfully treat end-stage ankle osteoarthritis. Further multicenter clinical trials with consistent reporting of complications are warranted.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

BACKGROUND

The increase in anterior cruciate ligament (ACL) injuries in pediatric patients and the high failure rate reported in the literature in this population are driving surgeons to search for specific techniques to better restore knee stability. Recent literature has reported that the combination of lateral extra-articular tenodesis (LET) and ACL reconstruction improves outcomes in high-risk patients. However, such advantages in pediatric patients have been infrequently evaluated.

PURPOSE

To assess whether adding LET to ACL reconstruction can significantly improve knee stability, clinical outcomes, and failure rates in pediatric patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicentric study involving 3 orthopaedic teaching centers was conducted to evaluate pediatric patients aged between 12 and 16 years who had undergone primary ACL reconstruction using a physeal-sparing femoral tunnel drilling technique. A minimum 2-year follow-up evaluation was required. Based on the surgical technique performed, the patients were divided into 2 group. The patients in group 1 underwent an isolated arthroscopic ACL reconstruction, while the patients in group 2 had an arthroscopic ACL reconstruction in combination with a modified Lemaire LET procedure. Group 1 was a historical control cohort of patients, whereas group 2 was prospectively enrolled. All the patients included in the present study were clinically evaluated using the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective score and the Pediatric Functional Activity Brief Scale (Pedi-FABS) score. Anteroposterior knee stability was measured using the KT-1000 knee ligament arthrometer, and the objective pivot-shift evaluation was documented using a triaxial accelerometer (Kinematic Rapid Assessment [KiRA]). The included patients also underwent a standardized radiological protocol to evaluate leg-length discrepancies, axial deviation, and degenerative signs preoperatively and at last follow-up.

RESULTS

This study included 66 pediatric patients with an anatomic hybrid ACL reconstruction using an autologous 4-strand hamstring graft. In group 1, there were 34 patients (mean age, 13.5 ± 1.2 years), while 32 patients (mean age, 13.8 ± 1.4 years) were included in group 2. The clinical outcome scores showed no difference between the 2 groups (Pedi-IKDC, P = .072; Pedi-FABS, P = .180). Nevertheless, the patients in group 2 had better anteroposterior stability measured using a KT-1000 arthrometer (1.9 ± 1.1 mm in group 1 vs 0.8 ± 0.8 mm in group 2; P = .031), as well as better rotational stability measured using the KiRA (-0.59 ± 1.05 m/s² in group 2 vs 0.98 ± 1.12 m/s² in group 1; P = .012). The patients in group 1 returned to sports at the same competitive level at a rate of 82.4%, while patients included in group 2 returned at the same competitive level in 90.6% of the cases without a significant difference between the 2 groups (P = .059). No leg-length discrepancies were found between the 2 groups at last follow-up (P = .881). Two patients displayed an increased valgus deformity of 3° on the operated limb at last follow-up (1 patient in group 1 and 1 patient in group 2). Group 1 had a significatively higher cumulative failure rate (14.7% vs 6.3%; P = .021). No intra- or postoperative complications was observed between the 2 groups.

CONCLUSION

Performing a modified Lemaire LET along with an ACL reconstruction with hamstring graft in pediatric patients reduced the cumulative failure rate and improved objective stability with no increase in intra- or postoperative complications. No significant difference was found between the 2 groups in terms of patient-reported outcomes or in the return-to-sports activity.

Integration of polyurethane meniscus scaffold during ACL revision is not reliable at 5 years despite favourable clinical outcome

PURPOSE

The aim of this study was to evaluate the clinical outcome at 5-year follow-up of a one-step procedure combining anterior cruciate ligament (ACL) reconstruction and partial meniscus replacement using a polyurethane scaffold for the treatment of symptomatic patients with previously failed ACL reconstruction and partial medial meniscectomy. Moreover, the implanted scaffolds have been evaluated by MRI protocol in terms of morphology, volume, and signal intensity.

METHODS

Twenty patients with symptomatic knee laxity after failed ACL reconstruction and partial medial meniscectomy underwent ACL revision combined with polyurethane-based meniscal scaffold implant. Clinical assessment at 2- and 5-year follow-ups included VAS, Tegner Activity Score, International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lysholm Score. MRI evaluation of the scaffold was performed according to the Genovese scale with quantification of the scaffold's volume at 1- and 5-year follow-ups.

RESULTS

All scores revealed clinical improvement as compared with the preoperative values at the 2- and 5-year follow-ups. However, a slight, but significant reduction of scores was observed between 2 and 5 years. Concerning the MRI assessment, a significant reduction of the scaffold's volume was observed between 1 and 5 years. Genovese Morphology classification at 5 years included two complete resorptions (Type 3) and all the remaining patients had irregular morphology (Type 2). With regard to the Genovese Signal at the 5-year follow-up, three were classified as markedly hyperintense (Type 1), 15 as slightly hyperintense (Type 2), and two as isointense (Type 1).

CONCLUSION

Simultaneous ACL reconstruction and partial meniscus replacement using a polyurethane scaffold provides favourable clinical outcomes in the treatment of symptomatic patients with previously failed ACL reconstruction and partial medial meniscectomy at 5 years. However, MRI evaluation suggests that integration of the scaffold is not consistent.

LEVEL OF EVIDENCE

Level IV.

Mechanical-based therapies may reduce pain and disability in some patients with knee osteoarthritis: A systematic review with meta-analysis

BACKGROUND

Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions.

METHODS

Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results.

RESULTS

We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect).

CONCLUSIONS

Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.

A Triple-Strand Anatomic Medial Collateral Ligament Reconstruction Restores Knee Stability More Completely Than a Double-Strand Reconstruction: A Biomechanical Study In Vitro

BACKGROUND

There are many descriptions of medial collateral ligament (MCL) reconstruction, but they may not reproduce the anatomic structures and there is little evidence of their biomechanical performance.

PURPOSE

To investigate the ability of "anatomic" MCL reconstruction to restore native stability after grade III MCL plus posteromedial capsule/posterior oblique ligament injuries in vitro.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric knees were mounted in a kinematic testing rig to impose tibial displacing loads while the knee was flexed-extended: 88-N anteroposterior translation, 5-N·m internal-external rotation, 8-N·m valgus-varus, and combined anterior translation plus external rotation (anteromedial rotatory instability). Joint motion was measured via optical trackers with the knee intact; after superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament transection; and then after MCL double- and triple-strand reconstructions. Double strands reproduced the sMCL and posterior oblique ligament and triple-strands the sMCL, dMCL, and posterior oblique ligament. The sMCL was placed 5 mm posterior to the epicondyle in the double-strand technique and at the epicondyle in the triple-strand technique. Kinematic changes were examined by repeated measures 2-way analysis of variance with posttesting.

RESULTS

Transection of the sMCL, dMCL, and posterior oblique ligament increased valgus rotation (5° mean) and external rotation (9° mean). The double-strand reconstruction controlled valgus in extension but allowed 5° excess valgus in flexion and did not restore external rotation (7° excess). The triple-strand reconstruction restored both external rotation and valgus throughout flexion.

CONCLUSION

In a cadaveric model, a triple-strand reconstruction including a dMCL graft restored native external rotation, while a double-strand reconstruction without a dMCL graft did not. A reconstruction with the sMCL graft placed isometrically on the medial epicondyle restored valgus rotation across the arc of knee flexion, whereas a reconstruction with a more posteriorly placed sMCL graft slackened with knee flexion.

CLINICAL RELEVANCE

An MCL injury may rupture the anteromedial capsule and dMCL, causing anteromedial rotatory instability. Persistent MCL instability increases the likelihood of ACL graft failure after combined injury. A reconstruction with an anteromedial dMCL graft restored native external rotation, which may help to unload/protect an ACL graft. It is important to locate the sMCL graft isometrically at the femoral epicondyle to restore valgus across flexion.

Improved Clinical Outcomes After Lateralized Reverse Shoulder Arthroplasty: A Systematic Review

BACKGROUND

Lateralized reverse shoulder arthroplasty (RSA) has emerged as an attempt to improve on some of the drawbacks of conventional RSA, such as glenoid notching and decrease in ROM. Although this new design is being used in clinical practice, the evidence is mostly limited to case series and has not been systematically reviewed.

QUESTIONS/PURPOSES

(1) How much did patient-reported outcome measures (PROMs) and ROM improve among patients who receive a lateralized RSA implant? (2) What proportion of shoulders experience complications, revision surgery, or scapular notching?

METHODS

The PubMed and EMBASE databases were searched from database inception to January 31, 2020. We included clinical studies that reported the PROMs and/or ROM of patients with insufficient rotator cuffs undergoing RSA with a lateralized implant. All other types of studies and those including patients with fractures, instability or escape, infection, rheumatologic disease, neurologic disease, or revision surgeries as an indication for RSA were excluded. PROMs and ROM were collected and are reported as mean values and ranges. Complications, revision surgery, and scapular notching are presented as proportions. The percentage of the mean change relative to the minimum clinically important difference (MCID) was calculated using the anchor-based value for each outcome. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. The initial search yielded 678 studies; 61 full-text articles were analyzed according to our eligibility criteria. After a detailed analysis, we included nine studies that evaluated 1670 patients (68% of whom [1130] were women) with a mean age of 71.8 ± 0.6 years. The mean follow-up period was 41.1 ± 5.6 months. The mean MINORS score was 12 ± 4.

RESULTS

Active ROM improved for forward flexion (mean change 47° to 82°; MCID 12°), abduction (mean change 43° to 80°; MCID 7°), external rotation (mean change 8° to 39°; MCID 3°), and internal rotation (mean change -2 to 1 points). PROM scores also improved, including the American Shoulder and Elbow Surgeons score (mean change 20 to 50; MCID 20.9 points), Constant score (mean change 28 to 40; MCID 5.7 points), Simple Shoulder Test score (mean change 3 to 7; MCID 2.4 points), and VAS score (mean change -1.8 to -4.9; MCID -1.6 points). The proportion of shoulders with complications ranged from 0% (0 of 44) to 21% (30 of 140), and the proportion of shoulders with scapular notching ranged from 0% (0 of 76) to 29% (41 of 140). The proportion of patients undergoing revision ranged from 0% (0 of 44) to 13% (10 of 76) at short-term follow-up.

CONCLUSION

Lateralized RSA is a reasonable alternative to medialized implants for patients with rotator cuff insufficiency because it might reduce the likelihood of scapular notching without apparently compromising PROMs or ROM. More studies are required to determine whether there is a direct correlation between the amount of lateralization and PROMs or ROM.

Hamstrings injuries in football

Background

Hamstrings injuries are a major concern in football (soccer), affecting both recreational players and professional athletes. Although being a recognized issue within the football community, its incidence has been increasing over the last years and still poses a challenge to all practitioners involved.

Study objectives and rationale

The goal of this narrative review is to outline hamstrings injuries epidemiology and mechanisms of injury, identify and discuss its risk factors, provide an approach to a proper early diagnosis, evaluate the efficacy of current treatment options and return to sports, and present the best strategies for hamstrings injury prevention. These guidelines will help the sports medicine staff team on how to better manage their players with or at risk of hamstrings injuries.

Conclusion

Despite several breakthroughs in research of hamstrings injuries, there is still heterogeneity across studies and lack of consensus in regards to classification, diagnosis, treatment and prevention. Hamstrings injuries compromise the athlete's performance with time loss due to injury, shortens their highest-level career longevity with higher risk of reinjury rates, and is a defying problem for clubs to balance financial losses due to having their players off the pitch. Further research is warranted to keep moving forward with evidence on treating and preventing hamstrings injuries to mitigate its high incidence and keep the players safe.

Cartilage Restoration of Patellofemoral Lesions: A Systematic Review

PURPOSE

This study aimed to systematically analyze the postoperative clinical, functional, and imaging outcomes, complications, reoperations, and failures following patellofemoral cartilage restoration surgery.

METHODS

This review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, EMBASE, and Cochrane Library databases were searched up to August 31, 2018, to identify clinical studies that assessed surgical outcomes of patellofemoral cartilage restoration surgery. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess study quality.

RESULTS

Forty-two studies were included comprising 1,311 knees (mean age of 33.7 years and 56% males) and 1,309 patellofemoral defects (891 patella, 254 trochlear, 95 bipolar, and 69 multiple defects, including the patella or trochlea) at a mean follow-up of 59.2 months. Restoration techniques included autologous chondrocyte implantation (56%), particulated juvenile allograft cartilage (12%), autologous matrix-induced chondrogenesis (9%), osteochondral autologous transplantation (9%), and osteochondral allograft transplantation (7%). Significant improvement in at least one score was present in almost all studies and these surpassed the minimal clinically important difference threshold. There was a weighted 19%, 35%, and 6% rate of reported complications, reoperations, and failures, respectively. Concomitant patellofemoral surgery (51% of patients) mostly did not lead to statistically different postoperative outcomes.

CONCLUSION

Numerous patellofemoral restoration techniques result in significant functional improvement with a low rate of failure. No definitive conclusions could be made to determine the best surgical technique since comparative studies on this topic are rare, and treatment choice should be made according to specific patient and defect characteristics.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.

In Vitro and In Vivo Effects of Light Therapy on Cartilage Regeneration for Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To analyze the effects of light therapy (LT) on cartilage repair for knee osteoarthritis (OA) treatment.

DESIGN

The PubMed, Embase, Scopus, and Web of Science databases were searched up to August 31, 2020 to identify in vitro and in vivo studies that analyzed the effects of LT on knee cartilage for OA treatment. The study and sample characteristics, LT intervention parameters and posttreatment outcomes were analyzed. Risk of bias was assessed using the Risk of Bias Assessment for Non-randomized Studies (RoBANS) tool.

RESULTS

Three in vitro and 30 in vivo studies were included. Most studies were judged as high risk of performance and detection bias. Biochemical outcomes were analyzed for both in vitro and in vivo studies, and histological and behavioral outcomes were analyzed for in vivo studies. LT reduced extracellular matrix (ECM) degradation, inflammation, and OA progression, promoting ECM synthesis. LT improved pain-like behavior in animal models, having no apparent effect on gait performance. There were conflicting findings of some of the biochemical, histological, and behavioral outcomes.

CONCLUSION

The included studies presented different strategies and LT parameters. LT resulted in positive effects on cartilage repair and may be an adequate therapy for OA treatment.

Lack of Definition of Chronic Ankle Instability With Arthrometer-Assisted Ankle Joint Stress Testing: A Systematic Review of In Vivo Studies

Despite extensive research on ankle instability a consensual and clear objective definition for pathological mechanical lateral ankle instability is yet to be determined. This systematic review aimed to summarize current available arthrometric devices, measuring methods and lateral ankle laxity outcomes in patients with chronic ankle instability that underwent objective arthrometric stress measurement. Sixty-eight studies comprising a total of 3,235 ankles with chronic ankle instability were included. Studies reported a wide range of arthrometric devices, testing position and procedures, and measuring methods. For the anterior drawer test, the average mean differences between injured and uninjured ankles ranged from -0.9 to 4.1 mm, and total translation in the injured ankle from 3.2 to 21.0 mm. Most common pathological threshold was ≥4 mm or ≥10 mm unilaterally and ≥3 mm bilaterally. For the talar tilt test, the average mean differences between injured and uninjured ankles ranged from 0.0° to 8.0°, and total tilt from injured ankle from 3.3 to 60.2°. Most common pathological threshold was ≥ 10° unilaterally and ≥ 6° mm bilaterally. It was found high heterogeneity in the scientific literature regarding the arthrometric devices, use of concomitant imaging and measuring methods of arthrometer-assisted anterior drawer and talar tilt tests which led to variable laxity outcomes in individuals with chronic ankle instability. Future studies should focus on standardizing the testing and measuring methods for an objective definition of mechanical ankle instability.

Mussel-Inspired Catechol Functionalisation as a Strategy to Enhance Biomaterial Adhesion: A Systematic Review

Biomaterials have long been explored in regenerative medicine strategies for the repair or replacement of damaged organs and tissues, due to their biocompatibility, versatile physicochemical properties and tuneable mechanical cues capable of matching those of native tissues. However, poor adhesion under wet conditions (such as those found in tissues) has thus far limited their wider application. Indeed, despite its favourable physicochemical properties, facile gelation and biocompatibility, gellan gum (GG)-based hydrogels lack the tissue adhesiveness required for effective clinical use. Aiming at assessing whether substitution of GG by dopamine (DA) could be a suitable approach to overcome this problem, database searches were conducted on PubMed^® and Embase^® up to 2 March 2021, for studies using biomaterials covalently modified with a catechol-containing substituent conferring improved adhesion properties. In this regard, a total of 47 reports (out of 700 manuscripts, ~6.7%) were found to comply with the search/selection criteria, the majority of which (34/47, ~72%) were describing the modification of natural polymers, such as chitosan (11/47, ~23%) and hyaluronic acid (6/47, ~13%); conjugation of dopamine (as catechol “donor”) via carbodiimide coupling chemistry was also predominant. Importantly, modification with DA did not impact the biocompatibility and mechanical properties of the biomaterials and resulting hydrogels. Overall, there is ample evidence in the literature that the bioinspired substitution of polymers of natural and synthetic origin by DA or other catechol moieties greatly improves adhesion to biological tissues (and other inorganic surfaces).

Posterolateral corner knee injuries: a narrative review

Limited knowledge of the anatomy and biomechanics of the posterolateral corner (PLC) of the knee, coupled with poor patient outcomes with non-operative management, resulted in the PLC often being labelled as the ‘dark side’ of the knee. In the last two decades, extensive research has resulted in a better understanding of the anatomy and function of the PLC, and has led to the development of anatomic reconstructions that have resulted in improved patient outcomes.

Despite considerable attention in the clinical orthopaedic literature (nearly 400 articles published in the last decade), a standardized algorithm for the diagnosis and treatment of the PLC is still lacking, and much controversy remains.

Considering the literature review, there is not a reconstruction technique that clearly prevails over the others. As anatomic, biomechanical, and clinical knowledge of PLC injuries continues to progress, finding the balance between re-creating native anatomy and safely performing PLC reconstruction provides a big challenge. Treatment decisions should be made on a case-by-case basis.

Cite this article: EFORT Open Rev 2021;6:676-685. DOI: 10.1302/2058-5241.6.200096

Medial collateral ligament release during knee arthroscopy: key concepts

Complete access to the posterior medial compartment of the knee may represent a technical challenge during arthroscopy in patients with a tight tibiofemoral joint space.

Medial collateral release reduces direct iatrogenic cartilage damage in the medial compartment of the knee through manipulation with instruments.

We recommend performing medial collateral release in surgeries that access the posteromedial compartment (e.g. partial meniscectomy for ruptures of the posterior horn of medial meniscus or posterior root repairs) when the patient has a tight tibiofemoral joint space.

There are two main techniques to perform medial collateral release: inside-out and outside-in. Regardless of the technique used, releasing medial ligament structures is a safe and effective method to be used in the diagnosis and treatment of injuries to the medial compartment.

Cite this article: EFORT Open Rev 2021;6:669-675. DOI: 10.1302/2058-5241.6.200128

Current Concepts on Subtalar Instability

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Clinical Outcome Evaluation of Anatomic Anterior Cruciate Ligament Reconstruction With Tunnel Positioning Using Gold Standard Techniques: A Systematic Review and Meta-analysis

Background:

There have been conflicting results about the theoretical advantages of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction.

Purpose:

To evaluate the clinical and functional outcomes comparing anatomic single- versus double-bundle techniques, anatomic versus nonanatomic techniques, and transportal versus outside-in tunnel drilling for ACL reconstruction.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A search was performed in the MEDLINE and EMBASE databases up to August 2018 for clinical trials comparing anatomic ACL reconstruction (with tunnel positioning demonstrated using gold standard radiologic techniques) with another technique, with a minimum functional and biomechanical follow-up of 6 months. A meta-analysis was performed to compare clinical and functional outcomes between anatomic single- versus double-bundle reconstruction and between anatomic versus nonanatomic techniques, using the risk difference or the mean difference. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale for cohort and case-control studies and the Cochrane Risk of Bias tool and Jadad Score for randomized controlled trials.

Results:

Included were 15 studies comprising 1290 patients (follow-up, 12-36 months). No significant differences favoring anatomic double-bundle over anatomic single-bundle reconstruction or outside-in over transportal techniques were found. The meta-analyses showed significant differences in the International Knee Documentation Committee (IKDC) objective score (risk difference, –0.14; 95% confidence interval, –0.27 to –0.01) favoring anatomic over nonanatomic reconstruction. No statistically significant differences were found between anatomic and nonanatomic surgical techniques on other functional scores or clinical examination outcomes, including the IKDC subjective score, Lysholm score, Tegner score, KT-1000 arthrometer test, or pivot-shift test.

Conclusion:

Double-bundle reconstruction was not superior to the single-bundle technique in clinical and functional outcomes. Anatomic ACL reconstruction shows significantly superior results over nonanatomic ACL reconstruction, reinforcing the anatomic technique as the gold standard choice for clinical practice.

Effect of physical activity and exercise on telomere length: Systematic review with meta-analysis

PURPOSE

To compare a physically active lifestyle or structured exercise program to physically inactive lifestyle or control groups on telomere length (TL).

METHOD

We searched PubMed, EMBASE, Cochrane Library, and Open Gray databases up to March 31, 2020. We calculated standardized mean differences (SMD) with 95% confidence intervals (CI) of TL comparing physically active to physically inactive individuals and exercise intervention to control groups. Risk of bias was judged using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS) for physical activity (PA) studies and the Cochrane risk-of-bias (RoB2) for exercise intervention studies. Certainty of evidence was judged using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

We included 30 studies (24 assessing the effects of PA and 6 assessing the effects of exercise interventions) comprising 7418 individuals. Physically active individuals had longer telomeres (SMD = 0.70, 95% CI 0.12-1.28, very-low certainty), especially in middle-aged individuals (SMD = 0.90, 95% CI 0.08-1.72, very-low certainty) and when considering only athletes (SMD = 0.54, 95% CI 0.18-0.90, very-low certainty). Trim-and-fill analyses revealed that most of the pooled effects were overestimated. Exercise interventions did not yield any significant effect on TL.

CONCLUSION

There is very-low certainty that physically active individuals have longer telomeres with a moderate effect, but this effect is probably overestimated.

The vascularization of the peroneal tendons: An anatomic study

BACKGROUND

Arterial vascularization is intimately related to the peroneal tendon ruptures. Our purpose is to describe the vascular anatomy of peroneal tendons and assess differences in the vascularization patterns between peroneus brevis tendon (PBT) and peroneus longus tendon (PLT).

METHODS

Anatomical study of 22 cadaveric lower extremities. We exposed tendons' vascularization by injecting latex. To systematize the vascular description, we considered four anatomical regions in the PBT and six in the PLT.

RESULTS

Vascularization was supplied by the peroneal, anterior tibial and lateral plantar arteries and from the deep plantar arch through the vincula connecting the tendons. No avascular areas were found in the PLT. 22.7% of specimens had avascular areas in the PBT. Two visual vascularization patterns were found (arcuate and weblike). Increasing age and a web-like vascularization were associated with a lower number of blood vessels at the tendons' post malleolus area.

CONCLUSION

Peroneal tendons are well vascularized throughout their course, running through a common vincula, with vascularization provided by various arteries. Avascular areas were observed in the PBT, but none at the PLT.

Vancomycin presoaking of hamstring autografts to prevent infection in anterior cruciate ligament reconstruction: a narrative review

Hamstring autograft use has been linked to an increased risk of infection after anterior cruciate (ACL) reconstruction compared to other grafts. The absolute reason for this remains unclear, with contamination after harvesting and preparation of the graft being the most accepted hypothesis.

Using the rationale that a contaminated graft could be the main factor in postoperative septic arthritis and in an effort to maximize the antibiotic efficacy of the graft, the Vancomycin presoaking technique was developed. It has shown success in decreasing the infection rate in ACL reconstruction. In recent years, an important number of research articles using this protocol have appeared, but the technique is still not widely implemented.

Recent literature shows that Vancomycin presoaking of the graft has shown a successful decrease in the infection rate after hamstring autograft ACL reconstruction. It has also shown efficacy decreasing the infection rate in other types of grafts (patellar tendon, quadriceps tendon, allograft) and also in patients with concomitant ligament procedures or open surgeries.

Despite the positive effects of Vancomycin presoaking reducing the infection rate after ACL reconstruction, the lack of prospective randomized control trials and the heterogeneity of the different studies mean it is not feasible to recommend Vancomycin presoaking of the graft universally for every ACL reconstruction patient.

Cite this article: EFORT Open Rev 2021;6:211-216. DOI: 10.1302/2058-5241.6.200059

Menstrual pattern and contraceptive choices of Portuguese athletes

OBJECTIVES

Menstrual symptoms are commonly cited barriers to physical activity in women. Delay or avoidance of menstruation through hormonal contraceptives may mitigate those barriers. Our purpose is to identify the uterine bleeding patterns of Portuguese athletes, their contraceptive choices and the impact of contraceptive methods in sports performance. We aim also to compare the outcomes between users and non-users of contraception.

METHODS

Observational, descriptive and comparative study based on a customised self-assessment online survey aimed at Portuguese athletes. Athletes had to be at least 16 years old and competing at a national, international or professional level.

RESULTS

A total of 256 athletes from 18 modalities were eligible. The mean age was 29 years and the mean age of menarche was 12.8 years. Monthly bleeding pattern was prevailing and 50% presented dysmenorrhoea. More than 85% experience fluctuations in sports performance throughout the month. The majority (71.5%) used contraceptive methods. Only 16% believed that contraception decreased sports performance. Contraceptive users exhibit a lower mean body mass index, blood loss and percentage of dysmenorrhoea than the non-users.

CONCLUSION

Most athletes had the perception that performance varies throughout the month. The majority of participants do not report amenorrhoea and have monthly menses. The use of contraceptive methods is reportedly high, benefit cycle control and apparently without any physical inconvenience.

Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis

PURPOSE

The goal of this systematic review and meta-analysis was to identify the main risk factors for periprosthetic joint infection (PJI) in patients undergoing total hip or knee arthroplasties.

METHODS

A systematic review was conducted of the potential risk factors for PJI in total hip or total knee arthroplasty. Risk factors were compared and grouped according to demographics, comorbidities, behavior, infections, native joint diseases and other patient-related and procedure-related factors. Meta-analysis (random-effects models) was conducted using odds ratio (OR) and mean difference (MD). Risk of bias (ROBBINS-I) and strength of the evidence (GRADE) were assessed.

RESULTS

The study included 37 studies (2,470,827 patients). Older age was a protective factor (MD = - 1.18). Male gender (OR 1.34), coagulopathy (3.05), congestive heart failure (2.36), diabetes mellitus (1.80), obesity (1.61), systemic neoplasia (1.57), chronic lung disease (1.52), and hypertension (1.21) increased the risk for PJI. Behavioral risk factors comprised alcohol abuse (2.95), immunosuppressive therapy (2.81), steroid therapies (1.88), and tobacco (1.82). Infectious risk factors included surgical site infections (6.14), postoperative urinary tract infections (2.85), and prior joint infections (2.15). Rheumatoid arthritis, posttraumatic native joint disease, high National Nosocomial Infections Surveillance (NNIS) system surgical patient index score, prior joint operation, American Society of Anesthesiologists score ≥ 3 and obesity were also significantly associated with higher risk of PJI. Osteoarthritis and blood transfusion were protective factors.

CONCLUSIONS

The main risk factors for PJI in each category were male gender, coagulopathy, alcohol abuse, surgical site infection (highest score) and high NNIS system surgical patient index score. Protective factors were age, female gender in TKA, osteoarthritis and blood transfusion. Optimization of modifiable risk factors for PJI should be attempted in clinical practice.

LEVEL OF EVIDENCE

II.

Hamstring muscle injury in the athlete: state of the art

Hamstring injuries (HSI) are the source of significant impairment and disability for both professional and recreational athletes. The incidence and prevalence of HSIs has been well documented in the literature, as they are among the most common soft tissue injuries reported. The significant time loss due to injury and the inherent risk of reinjury pose a significant issue to the athlete, their career longevity and the success of their respective team. This review will deal predominantly with describing the prevalence and incidence of HSI in athletes, discuss risk factors and the mechanisms of injury for HSI, how to properly diagnose, image and prognosticate appropriate return to sport (RTS) for individuals who have sustained an HSI, prescribe treatment and prevention strategies and to discuss relevant options to decrease overall risk of primary and secondary recurrence of HSI.Current treatments of acute HSI necessitate a thorough understanding of the mechanism of injury, identifying muscle imbalances and/or weakness, inclusion of eccentric and concentric hamstring (HS) and hip extension (HE) exercises, evaluation of pathokinematic movement patterns and use non-surgical methods to promote healing and RTS. This methodology can be used prospectively to mitigate the overall risk of HSI. Injection therapies for HSI, including ultrasound-guided platelet-rich plasma and corticosteroids, may impart some short-term benefit, but the existing literature is largely inconclusive with respect to long-term functional outcomes. Future directions should prioritise injury prevention, early diagnosis and targeted interventions that combine both non-surgical and minimally invasive orthobiological approaches and identifying biomechanical risk factors prospectively to mitigate risk.

Enhanced microfracture using acellular scaffolds improves results after treatment of symptomatic focal grade III/IV knee cartilage lesions but current clinical evidence does not allow unequivocal recommendation

PURPOSE

To systematically analyse post-operative outcomes following enhanced microfracture procedures in focal cartilage injuries of the knee.

METHODS

Database searches were conducted in PubMed, EMBASE and Cochrane Library databases up to 30 November 2018, for clinical studies in humans that assessed surgical outcomes of enhanced microfracture procedures in focal cartilage injuries of the knee. The clinical, functional and imaging outcomes were assessed and summarized. The MINORS scale was used to assess the methodological quality of the studies included.

RESULTS

Ten studies were included comprising a total of 331 patients (mean age of 37.0 ± 5.5 years, body mass 25.2 ± 1.7 kg m², 56% male and 42% left knee), 278 femoral condyle chondral defects (147 medial, 35 lateral and 78 undefined) and 43 chondral defects distributed by the tibial plateau, patella and femoral trochlea. The chondral defects were mostly Outerbridge grade III or IV and the mean defect size was 3.2 ± 0.6 cm². Studies consistently demonstrated significant improvement in the patient-reported outcome measures from baseline to final follow-up. Overall, imaging outcomes showed inconsistent results. Treatment-related adverse events were poorly reported.

CONCLUSION

Enhanced microfracture techniques significantly result in improved patient-reported outcome measures over the MCID, but provide inconsistent imaging results. Current clinical evidence does not allow for unequivocal recommendation of enhanced microfracture to treat symptomatic focal grade III/IV knee cartilage lesions.

LEVEL OF EVIDENCE

IV.

The cement-in-cement technique is a reliable option in hip arthroplasty revision surgery: a systematic review

INTRODUCTION

The cement-in-cement technique for revision hip arthroplasty has many potential advantages and has recently gained widespread interest but still lacks evidence to support it. Our aim was to examine the surgical and patient-reported outcomes after cement-in-cement revision hip arthroplasty.

MATERIALS AND METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE databases were searched up to February 2019 for original studies reporting the outcomes of revision hip arthroplasty surgeries using the cement-in-cement technique. The methodological quality was assessed using the methodological index for non-randomized studies scale.

RESULTS

Sixteen non-comparative studies met the eligibility criteria, comprising 1899 hips in 1856 patients (72.2 mean age, 37% male), with a mean follow-up of 7.2 years. Most studies reported only primary revisions and focused on the stem component. Intraoperative complications such as femoral or acetabular fractures (5.3%) were low and easily manageable with no relevant sequelae, as were dislocation rates (2.8% of uncomplicated events and 1.6% of cases requiring re-revision). Failure (considered if there was aseptic loosening of the cement-in-cement revised component, 2%), re-revision (9.3%), implant survival and late complication rates were favourable. Functional patient-reported outcomes showed an overall improvement above the minimal clinically important difference at final follow-up.

CONCLUSION

The cement-in-cement technique is a viable option for hip arthroplasty revision surgery with low intraoperative and late complication rates, dislocations and immediate post-operative morbidity, resulting in good functional patient-reported outcomes and favourable medium-term implant survival.

Intra-articular injection of culture-expanded mesenchymal stem cells with or without addition of platelet-rich plasma is effective in decreasing pain and symptoms in knee osteoarthritis: a controlled, double-blind clinical trial

PURPOSE

To compare the clinical and laboratory outcomes of intra-articular injections of culture-expanded bone-derived mesenchymal stem cells (MSCs) with or without platelet-rich plasma (PRP) to intra-articular corticosteroid injections for the treatment of knee osteoarthritis (OA).

METHODS

Forty-seven patients with radiographic and symptomatic knee OA were randomized into three groups for intra-articular injections: autologous bone marrow-derived culture-expanded MSCs (n = 16); autologous bone marrow-derived culture-expanded MSCs + PRP (n = 14); and corticosteroid (n = 17). The outcomes were assessed by the Knee Injury and Osteoarthritis Outcome Score (KOOS) and range of motion (ROM) at baseline, 1, 2, 3, 6, 9 and 12 months and intra-articular cytokines analysis at baseline, 6 and 12 months postoperatively.

RESULTS

The three groups showed significant improvement in most KOOS domains and global score at 1st month and all domains and global score at 12-month follow-up (p < 0.05). At the 1st month, only the MSCs group showed significant differences in KOOS symptoms domain (p = 0.003). The MSCs and MSCs + PRP groups showed the highest percentage of improvement in most KOOS domains and global score compared to the corticosteroid group. All three groups showed a significant reduction in intra-articular levels of human interleukin-10 cytokine, from baseline to 12 months (p < 0.05).

CONCLUSION

An intra-articular injection of bone marrow-derived culture-expanded MSCs with or without the addiction of PRP is effective in improving the function and decreasing symptoms caused by knee OA at 12-month follow-up.

LEVEL OF EVIDENCE

II.

Graft choice in combined anterior cruciate ligament and medial collateral ligament reconstruction

There is a concern regarding which grafts should be used in combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) reconstructions, with a paucity of recommendations focused on this specific topic.

Expert opinions suggest the use of allograft-only reconstructions to limit donor-site morbidity or using at least one allograft and one autograft.

When a hamstring tendon autograft is harvested, techniques that maintain both the integrity of the sartorius fascia and the gracilis are recommended because of the role that the ST-G-S (semitendinosus-gracilis-sartorius) complex plays in valgus stability in the setting of an MCL-deficient knee.

Cite this article: EFORT Open Rev 2020;5:221-225. DOI: 10.1302/2058-5241.5.190049

Computational Modelling of the Bioheat Transfer Process in Human Skin Subjected to Direct Heating and/or Cooling Sources: A Systematic Review

The purpose of this systematic review is to analyze characteristics and methodologies utilized in bioheat transfer models of human skin to provide state-of-the-art knowledge on the topic. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, EMBASE and Web of Science databases were searched up to May 30th, 2019 for bioheat transfer models focusing on direct contact between skin and temperature (heat and/or cold) source. Ten studies were included. A 16-item checklist was used to assess their methodological quality. Four studies analyzed healthy skin and six included pathological conditions. All determined skin's thermal behavior, and studies including pathological conditions also analyzed burn damage. Studies did not present a wide variety of mathematical formulation, emphasizing on modelling equations of well-established models from the literature, such as the Pennes' bioheat transfer equation, and the Henriques and Moritz model to quantify skin damage. Reporting of modelling characteristics and formulation of the computational models is not standardized and there is shortage of implementation of validation procedures, hindering representative conclusions. The lack of validation procedures led to low methodological quality. However, all studies provided strategies and parameters as starting points for future developments in this research area.

Entrapped in cage (EiC) scaffolds of 3D-printed polycaprolactone and porous silk fibroin for meniscus tissue engineering

The meniscus has critical functions in the knee joint kinematics and homeostasis. Injuries of the meniscus are frequent, and the lack of a functional meniscus between the femur and tibial plateau can cause articular cartilage degeneration leading to osteoarthritis development and progression. Regeneration of meniscus tissue has outstanding challenges to be addressed. In the current study, novel Entrapped in cage (EiC) scaffolds of 3D-printed polycaprolactone (PCL) and porous silk fibroin were proposed for meniscus tissue engineering. As confirmed by micro-structural analysis the entrapment of silk fibroin was successful, and all scaffolds had excellent interconnectivity (≥99%). The EiC scaffolds had more favorable micro-structure compared with the PCL cage scaffolds by improving the pore size while keeping the interconnectivity almost the same. When compared with the PCL cage, the entrapment of porous silk fibroin into the PCL cage decreased the high compressive modulus in a favorable matter in the wet state thanks to the silk fibroin's high swelling properties. The in vitro studies with human stem cells or meniscocytes seeded constructs, demonstrated that the EiC scaffolds had superior cell adhesion, metabolic activity, and proliferation compared to the PCL cage scaffolds. Upon subcutaneous implantation of scaffolds in nude mice, all groups were free of adverse incidents, and mildly invaded by inflammatory cells with neovascularization, while the EiC scaffolds showed better tissue infiltration. The results of this work indicated that the EiC scaffolds of PCL and silk fibroin are favorable for meniscus tissue engineering, and the findings are encouraging for further studies using a larger animal model.

Fascia Lata Autograft Versus Human Dermal Allograft in Arthroscopic Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review of Clinical Outcomes

PURPOSE

To determine the clinical outcomes of arthroscopic superior capsular reconstruction (ASCR) using either fascia lata autograft or human dermal allograft for irreparable rotator cuff tears (IRCTs).

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines by searching the MEDLINE, Embase, and Cochrane Library databases through January 31, 2019. The inclusion criteria were as follows: 5 or more consecutive patients who underwent ASCR for IRCTs; clinical outcome measures reported at a minimum follow-up of 12 months; and magnetic resonance imaging assessment at a minimum follow-up of 6 months. The methodologic quality was evaluated using the Methodological Index for Non-randomized Studies (MINORS). A narrative synthesis of data was performed. Mean outcome improvements were compared with minimal clinically important differences.

RESULTS

We identified 7 eligible studies that included 344 shoulders in 338 patients who underwent ASCR for IRCTs (all Level IV studies). The mean MINORS score was 12.3 ± 1.60. Of the 7 studies, 5 had a high risk of bias (MINORS score ≤12): 2 studies using only fascia lata autograft and 3 studies using only human dermal allograft. The mean age of patients ranged from 59.4 to 66.9 years. The mean follow-up time ranged from 12 to 48 months. All studies reported statistically significant and clinically important mean improvements in active elevation (range of means, 28°-56°), the Constant score (range of means, 12-47.1 points), or the American Shoulder and Elbow Surgeons score (range of means, 29.3-56 points). In total, 218 shoulders underwent postoperative magnetic resonance imaging. The graft tear rate reported in studies using fascia lata autograft (181 shoulders) ranged from 5% to 32%, whereas the values reported in studies using human dermal allograft (37 shoulders) ranged from 20% to 75%.

CONCLUSIONS

ASCR using either fascia lata autograft or human dermal allograft leads to significant and clinically important improvements in clinical outcomes in IRCT patients at 12 months or later.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Unilateral anterior knee pain is associated with increased patellar lateral position after stressed lateral translation

PURPOSE

To objectively compare side-to-side patellar position and mobility in patients with idiopathic unilateral anterior knee pain (AKP) using a stress-testing device concomitantly with magnetic resonance imaging. It is hypothesized that the painful knees present greater patellar mobility than the contralateral non-painful knees.

METHODS

From a total sample of 359 patients, 23 patients with idiopathic unilateral AKP (30.9 years, 23.4 kg/m², 43% males) were included within the present study. Both knees of all the patients were examined by conventional imaging, including the measurement of trochlear sulcus angle, Caton-Deschamps index, tibial tuberosity to trochlear groove distance, patellar tilt angle and patellar subluxation (both at rest and upon quadriceps contraction). Additionally, the same patients underwent stress testing (Porto Patella Testing Device); these measurements were taken with the patella at rest, after lateral patellar translation and after lateral patellar tilt. Clinical and functional outcomes were obtained using physical examination and the Kujala and Lysholm scores.

RESULTS

Painful knees showed statistically significant higher patellar lateral position after stressed lateral translation than non-painful knees (p = 0.028), 9.8 ± 3.6 mm and 7.1 ± 6.3 mm, respectively. The adjusted multivariate logistic model identified the patellar position after lateral displacement to be significantly associated with AKP (OR = 1.165) and the model (AUC = 0.807, p < 0.001) showed reasonable sensitivity (67%) and specificity (73%).

CONCLUSION

Patients with idiopathic unilateral AKP with morphologically equivalent knees showed statistically significant increased patellar lateral position after stressed lateral displacement in their painful knee. The greater lateral patellar mobility quantified by the PPTD testing brings more objectivity to the diagnosis.

LEVEL OF EVIDENCE

II.

Anatomic and non-anatomic reconstruction improves post-operative outcomes in chronic acromio-clavicular instability: a systematic review

PURPOSE

To systematize the surgical outcomes of anatomic and non-anatomic reconstruction in patients with chronic acromio-clavicular joint (ACJ) instability and determine which technique is superior.

METHODS

This review was conducted according to the PRISMA guidelines. PubMed and Cochrane Library databases were searched up to April 30th, 2018 for original articles that assessed the outcomes of one or more surgical techniques of anatomic and non-anatomic reconstruction in patients with chronic ACJ instability. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Pre-to-post meta-analysis was performed for both anatomic and non-anatomic reconstructions.

RESULTS

Twenty-eight studies were included comprising 799 patients (mean age of 36.6 years old and 84% males) with a mean follow-up of 34.6 months (range 13 to 74). Surgical techniques included anatomic (tendinous or synthetic grafts/constructs) and non-anatomic reconstruction (Weaver-Dunn or Modified Weaver-Dunn, conjoined tendon transfer, or temporary hook plate). There were significant pre-to-post improvements on the constant score with an average improvement ranging from 11.1 to 50.7 (p < 0.01). Average failure rate was 7.6% (7.5% for anatomic and 8.5% for non-anatomic reconstruction). Non-comparative studies had a mean MINORS score of 9 points (out of 16) and comparative studies 17 (out of 24) with excellent interrater agreement (k = 0.910).

CONCLUSION

Both anatomic and non-anatomic ACJ reconstructions provide significant post-operative improvements, but definitive conclusions on optimal technique remain elusive. Notwithstanding, comparative studies support the use of anatomic ACJ reconstruction which should be preferably used. However, until superiority is demonstrated by robust studies, surgeons should supplement their decision-making with experience and patient preference.

LEVEL OF EVIDENCE

IV.