Federico Raggi

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.

Anterior cruciate ligament reconstruction with a novel porcine xenograft: The initial Italian experience

At the current state of the art in anterior cruciate ligament (ACL) reconstruction, multiple techniques have been presented but none has given clearly defined and improved results. One of the main issues concerns the choice of graft. The concept of using xenograft tissue, defined as a graft tissue from one species and destined for implantation in an unlike species, was introduced in order to try to overcome the mechanical and biological concerns associated with synthetic materials and the safety and quality concerns and availability problems of allograft tissue. Xenograft tissue carries the risk of producing an immunological reaction. In order to try to overcome or attenuate the immune response against porcine xenograft tissue, the Z-Process® (Aperion Biologics Inc, San Antonio, Texas, USA) has been developed and used to produce the Z-Lig® family of devices for ACL reconstruction procedures. Z-Lig® is a tendon graft with or without bone blocks, sourced from animal tissue in a manner consistent with what has normally been sourced from human tissue, and processed to overcome anti-Gal-mediated rejection and to attenuate other immunological recognition in humans. All this while ensuring sterility, viral inactivation and preservation of mechanical proprieties appropriate for an ACL reconstruction device. The Z-Lig® device has been tested in skeletally mature monkeys and given interesting and promising results from the preclinical performance and safety profile point of view. On this basis, it was possible to proceed with the first clinical trial involving humans, which gave similar encouraging results. The Z-Lig® device has also been implanted in Italy at the Rizzoli Orthopaedic Institute in Bologna, as a part of international multicenter prospective randomized blinded controlled study aimed at comparing xenograft with allograft tissue.

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.

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.

Residual rotatory laxity after anterior cruciate ligament reconstruction: How do we diagnose it and prevent it?

Despite the continuous advances in anterior cruciate ligament surgery, residual rotatory laxity still represents a concrete issue that could be responsible for unsatisfactory results in over 10% of patients. Rotational laxity has been correlated with poor outcomes, degenerative changes, meniscal lesions, and premature graft failure. Residual rotatory laxity is quite difficult to diagnose, and new noninvasive devices have been developed to improve clinical diagnosis and permit an individualized approach based on constant evaluation of the specific condition. Anterior cruciate ligament reconstruction with a lateral plasty has been proposed for better rotational control and is gaining acceptance in the last few years. The menisci are secondary restraints to tibial anteroposterior translation and when lacking require attention to improve clinical results. This article is focused on the importance of the residual rotatory laxity after anterior cruciate ligament surgery, how to improve it, how to diagnose it using new available tools, and finally how this information influences the surgical approach in order to decrease the failure rate.

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.

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°.

In-vivo pivot-shift test measured with inertial sensors correlates with the IKDC grade

Objectives Kinematic Rapid Assessment (KiRA) is a wireless, non-invasive, inertial system with a single tibial sensor developed to measure the pivot-shift (PS) test. The purpose of this study was to in-vivo compare acceleration values acquired by KiRA to the objective International Knee Documentation Committee (IKDC) clinical grading of PS. The comparison was performed in non-anaesthetised patients before and after anterior cruciate ligament (ACL) reconstruction. We hypothesised the existence of a correlation between the side-to-side difference in the measured acceleration range by KiRA and the objective IKDC clinical grading of the PS. Methods Between 2010 and 2014, 60 non-professional football players (male/female ratio: 42/18; mean age 34±15.4 years, range 14–51 years) with ACL lesion were enrolled. They underwent over-the-top ACL reconstruction plus lateral extra-articular plasty with autologous hamstrings. All the patients were evaluated before the reconstruction and re-evaluated at 12-month follow-up. Each patient underwent a clinical examination and then was subjected to the instrumental PS examination by KiRA. The difference in the acceleration range between injured/reconstructed and contralateral limb (Δarange) was used in the analysis. Correlations between Δarange values and objective IKDC clinical grades of PS were calculated using Spearman correlation analysis. Results All subjective scores improved from preoperative to follow-up (P≤0.01). Objective IKDC clinical grading of the PS improved from 4B, 40C and 16D to 50A, 8B and 2C (P<0.0001). The mean Δarange measured by KiRA improved from 2.0±1.0 to 0.2±0.4 m/s2 (P<0.0001). A very strong correlation was displayed between the overall Δarange measured by KiRA and overall objective IKDC clinical grading of the PS (r=0.86, P<0.0001); correlation was strong for preoperative data (r=0.71, P<0.0001) and moderate for postoperative data (r=0.53, P<0.0001). The mean Δarange resulted 0.3±0.3 m/s2 for the IKDC A subgroup, 0.8±0.3 m/s2 for the IKDC B subgroup, 1.7±0.8 m/s2 for the IKDC C subgroup and 2.9±0.9 m/s2 for the IKDC D subgroup. Conclusion The side-to-side difference in the measured acceleration range by KiRA shows a correlation with objective IKDC clinical grading of PS. Study design Case series; level of evidence: 4.

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.

Periarticular Tendinopathies of the Knee

There are several knee diseases; the most cases during clinical practice concern meniscal and ligament lesions, but we must remember various disorders related to periarticular tendon inflammation, which can mime different conditions.