Mirco Lo Presti

Platelet-riCh plasma: New clinical application A pilot study for treatment of jumper's knee

This study describes a simple, low-cost, minimally invasive way to apply PRP growth factors to chronic patellar tendinosis; 20 male athletes with a mean history of 20.7 months of pain received treatment, and outcomes were prospectively evaluated at 6 months follow-up. No severe adverse events were observed, and statistically significant improvements in all scores were recorded. The results suggest that this method may be safely used for the treatment of jumpers knee, by aiding the regeneration of tissue which otherwise has low healing potential.

Anterior Cruciate Ligament Reconstruction Associated With Extra-articular Tenodesis A Prospective Clinical and Radiographic Evaluation With 10- to 13-Year Follow-up

Background This study was undertaken to prospectively analyze, at a mean 11-year follow-up, the clinical and radiographic outcomes in patients undergoing the authors’ intra-articular anterior cruciate ligament reconstructive procedure with extraarticular augmentation, and to compare these data with those at 5-year follow-up. Purpose The clinical and radiographic outcomes in patients undergoing anterior cruciate ligament reconstruction were analyzed at a mean 11-year follow-up. Study Design Case series; Level of evidence, 4. Methods The authors studied 54 of 60 consecutive high-level sports patients who underwent their anterior cruciate ligament reconstruction technique between 1993 and 1995. The surgical technique uses the hamstring tendons with intact tibial insertions for intra-articular double-stranded reconstruction plus an extra-articular plasty (augmentation) performed with the remnant part of the tendons. Clinical and radiographic evaluations were performed. Results After 11 years, the International Knee Documentation Committee score demonstrated good or excellent results (A and B) in 90.7% of patients. Ligament arthrometry using the KT-2000 arthrometer demonstrated that only 2 patients had >5 mm manual maximum side-to-side difference in laxity. The mean Tegner activity score was 4.5, while the mean Lysholm score was 97.3 and the mean subjective score was 90.0%. Radiographic evaluation demonstrated progressive joint narrowing only for the 20 patients having concomitant medial meniscal surgery. Conclusion The original technique demonstrates highly satisfactory results. Factors negatively affecting the outcomes are meniscectomy and laxity. In this series, anterior cruciate ligament reconstruction with lateral plasty shows maintenance of knee stability at long-term follow-up. Knee osteoarthritis after anterior cruciate ligament reconstruction with extra-articular tenodesis does not appear to be greater than after anterior cruciate ligament reconstructions without extra-articular augmentation as reported in historical controls.

Nonoperative Biological Treatment Approach for Partial Achilles Tendon Lesion

Tendon injuries, especially those of the Achilles tendon, are major concerns in sports medicine. The clinical presentation can be acute or chronic and the pathologic findings can range from peritendonitis to full-thickness tendon rupture. Nonsurgical treatment is not always successful; in particular, significant partial ruptures seem to respond poorly to conservative measures and do not improve with time. Surgery is most often considered the favored treatment option for this kind of lesion to obtain pain relief and full functionality with long-standing effects.This article describes a case of a partial tear of the Achilles tendon in a 34-year-old competitive athlete where surgical treatment was avoided in favor of a new biological approach. We applied autologous platelet growth factors through multiple platelet-rich plasma injections; approximately 6.5 billion platelets were injected into the lesion 3 times, 7 days apart. The treatment with platelet-rich plasma and a progressive rehabilitation program allowed the patient to play for 20 minutes in a basketball game 64 days after the trauma and in a full game 75 days after the trauma. To date, 18 months later, he has participated regularly in all the seasons games and received no further treatment for his tendon.The fast tissue repair, confirmed by magnetic resonance and ultrasound imaging, allowed a swift return to full functionality and competitive sports activity, suggesting a possible role of platelet growth factors in promoting rapid tendon healing with high-quality tissue. This biological approach may represent a less-invasive therapeutic option even in cases where severe tendon lesions are candidates for surgical treatment.

Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA

INTRODUCTION Knee arthrodesis can be an effective treatment after an infected revision Total Knee Arthroplasty (TKA). The main hypothesis of this study is that a two-stage arthrodesis of the knee using a press-fit, modular intramedullary nail and antibiotic loaded cement, to fill the residual gap between the bone surfaces, prevents an excessive limb shortening, providing satisfactory clinical and functional results even without direct bone-on-bone fusion. MATERIAL AND METHODS The study included 22 patients who underwent knee arthrodesis between 2004 and 2009 because of recurrent infection following revision-TKA (R-TKA). Clinical and functional evaluations were performed using the Visual Analogue Scale (VAS) and the Lequesne Algofunctional Score. A postoperative clinical and radiographical evaluation of the residual limb-length discrepancy was conducted by three independent observers. RESULTS VAS and LAS results showed a significant improvement with respect to the preoperative condition. The mean leg length discrepancy was less than 1cm. There were three recurrent infections that needed further surgical treatment. DISCUSSION This study demonstrated that reinfection after Revision of total knee Arthroplasty can be effectively treated with arthrodesis using a modular intramedullary nail, along with an antibiotic loaded cement spacer and that satisfactory results can be obtained without direct bone-on-bone fusion.

A new hinged dynamic distractor, for immediate mobilization after knee dislocations: Technical note

Knee dislocation is always a difficult topic mainly with regard to the structures that have been damaged and the best treatment option. The purpose of this study is to describe a new dynamic external fixator (EF) to be applied after knee dislocation, in combination with posterior cruciate ligament (PCL) reconstruction. This approach permits an immediate postoperative mobilization of the joint, with the possibility to perform a delayed ACL reconstruction and eventually reducing the complication rate related to multiple ligament surgery

The efficacy of dual-mobility cup in preventing dislocation after total hip arthroplasty: a systematic review and meta-analysis of comparative studies

PurposeAlthough long-term reports of total hip arthroplasty (THA) showed successful results, instability remains a major complication. Recently, dual-mobility cups (DMC) have gained more and more interest among clinicians, with encouraging results in terms of lower rate of dislocation associated with good clinical results, but a lack of evidence exists regarding the real efficacy of this implant design compared to traditional fixed-bearing total hip arthroplasties.MethodsA systematic search was performed in PubMed, Google scholar, Cochrane Library, and EMBASE by two independent reviewers for comparative studies available till December 2017, with the primary objective to demonstrate a real lower dislocation rate of DMC implants compared to unipolar fixed-bearing cup designs. A meta-analysis was conducted with the collected pooled data about dislocation rate, calculating the risk difference (RD) and relative risk (RR) with 95% CI for dichotomous variables. Heterogeneity was tested using the χ2 and Higgins’ I2 tests. A fixed-effect model was used because the statistical heterogeneity was below 50%.ResultsAfter performing a critical exclusion process, the number of eligible studies included for final synthesis considered was 15, describing the results of a total of 2408 total hip arthroplasties (50.6% with a dual-mobility acetabular cup design, 49.4% with a standard fixed-bearing design). The fixed-effect meta-analysis showed a slight significant risk ratio of 0.16 (95% CI, 0.09, 0.28; I2 = 0%, p < 0.00001); a statistically significant difference in favor of the DMC group was maintained also considering only primary or revision arthroplasties, traumatic fractures or elective patients with diagnosis of osteoarthritis, avascular osteonecrosis or rheumatic arthritis.ConclusionsWith the intrinsic limitations of our study design and based on the current available data, this study demonstrates that dual-mobility acetabular components decrease the risk of post-operative instability also in high-risk patients, both in primary and revision hip arthroplasties. However, new high-quality studies, possibly with a randomized control design, should be undertaken in order to strengthen the present data.Study designLevel of Evidence III, therapeutic study.

Early Viscosupplementation After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Background: Hyaluronic acid (HA) has been widely used to treat osteoarthritis given its biological and mechanical properties. Because HA is an “intra-articular” treatment approach that affects the joints, it could be used in the management of acute conditions, such as during the early postsurgical phase, to reduce inflammatory stress and improve articular function. Purpose: The aim of the present double-blind, randomized controlled trial was to evaluate pain control and functional recovery provided by a single injection of HA performed the day after anterior cruciate ligament (ACL) reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: The study enrolled 60 patients affected by primary, chronic, and symptomatic ACL tear requiring surgical reconstruction. All patients were treated with the same reconstructive technique and rehabilitation protocol. Exclusion criteria were (1) concurrent articular lesion requiring surgical treatment, (2) axial malalignment in the index limb, and (3) functional limitation or pain in the contralateral knee. The day after the procedure, the patients were randomized to receive a single injection of 3 mL HA or 3 mL saline solution after surgical drains were removed. All patients were evaluated at baseline and at 15, 30, 60, and 180 days and 12 months after surgery by use of the following tools: Short Form–36 Health Survey (SF-36), International Knee Documentation Committee (IKDC) subjective score, visual analog scale (VAS) for pain, VAS for general health status, and Tegner score. At each follow-up evaluation, the transpatellar circumference and active and passive range of motion (ROM) of both knees were recorded. Results: No severe adverse events were documented after early viscosupplementation. A significant improvement was documented in both treatment groups. Significant differences were documented in the transpatellar circumference at 60 days and in active ROM at 30 days postoperatively; patients who received HA had better values compared with the placebo group (P = .022 and .027, respectively). No statistically relevant intergroup differences were found in the clinical scores. Conclusion: The study documented no adverse events and had some positive findings in terms of active ROM recovery and transpatellar circumference reduction. However, the early postoperative application of viscosupplementation did not lead to significant improvement in clinical scores after ACL reconstruction. Registration: NCT02630407 (ClinicalTrials.gov identifier),

Early Failure in Medial Unicondylar Arthroplasty: Radiographic Analysis on the Importance of Joint Line Restoration

Survivorship of unicondylar knee arthroplasty (UKA) remains a drawback, especially compared with the outcome of total knee arthroplasty. This could be improved by identifying and correcting failure mechanisms. To this purpose, this study aimed at exploring failure modalities of UKA, with particular focus on the role of joint line (JL) position and alignment as variable to be optimized for a successful outcome. This study explored modes of failure in 266 medial UKAs. Radiological comparison was performed between 24 failures and 24 matched controls, to determine the importance of UKA positioning in terms of femorotibial angle (FTA), tibial plateau angle, and posterior tibial slope (PTS). Radiographic comparative analysis showed statistically significant differences in the failure group compared with the control group in terms of variation in FTA (p = 0.0222), PTS (p = 0.0025), and JL height (p = 0.0022). Variations not only in FTA but also PTS and JL height were correlated with failures observed in this series. Thus, based on the results of this study, it emerges that JL position should be carefully controlled in all planes while implanting a UKA. This is a Level III, case-control study.

Return to Sports after Unicompartmental Knee Arthroplasty: Reality or Utopia? A 48-Month Follow-Up Prospective Study

Abstract Unicompartmental knee arthroplasty (UKA) has increased in popularity in the last years, also in younger and more active patients with great expectancies. The purpose of our study was to investigate the change in sports activities before and after medial UKA. We surveyed 53 athletic patients; all underwent cemented medial UKA, to determine not only their subjective and objective evaluation of clinical status with Hospital for Special Surgery (HSS) and visual analog score (VAS) score, but also their sporting and recreational activities at a mean follow‐up of 48 ± 6 months (range, 18‐56 months). At the last follow‐up, 48 of 53 patients were engaged in sports and recreational disciplines, resulting in a return to activity rate of 90%. No early failure and no cases of revision were reported. The frequency of activities (sessions per week) and the time session remained constant at the time of survey. The most common activities after surgery were hiking, cycling, and swimming. Several high‐impact activities, as well as skiing and football, had a significant decrease in participating patients. There were no gender‐, age‐ and body mass index (BMI)‐related differences. UKA can be considered a viable alternative in relatively young patients with high functional requirements and the correct indications, however, warning the patients about the risks of polyethylene wear and early loosening of the prosthetic components as a result of the resumption of sporting activities in high impact. Level of Evidence Prospective case series, level 4.

No Effects of Early Viscosupplementation After Arthroscopic Partial Meniscectomy A Randomized Controlled Trial

Background: The management of the postoperative period after knee arthroscopic surgery may be challenging because surgical trauma deeply alters the joint microenvironment, causing the release of several catabolic molecules and proinflammatory factors that might slow down functional recovery. The possibility of using hyaluronic acid (HA) to promote postoperative pain relief and expedite functional improvement seems attractive, considering its biological properties. Purpose: The aim of the present double-blind randomized controlled trial was to evaluate the effects, in terms of pain control and functional recovery, provided by a single HA injection performed at the end of arthroscopic meniscectomy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 90 patients, 18 to 55 years old, were included according to the following criteria: (1) chronic, symptomatic meniscal tears requiring partial resection; (2) a healthy contralateral knee; (3) no previous surgery on the index knee; and (4) no other concurrent articular lesions requiring surgical treatment (eg, cartilage or ligament injuries). Patients were randomized into 2 treatment groups: one underwent meniscectomy alone, whereas the other also received an injection of 3 mL HA at the end of the procedure. All patients were evaluated at baseline and then at 15, 30, 60, and 180 days using the following tools: International Knee Documentation Committee (IKDC) subjective, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, VAS for general health status, and Tegner scores. The transpatellar circumference and active and passive ranges of motion were also recorded during the follow-up evaluations. Results: No major adverse events were reported using HA postoperatively. A statistically significant increase in all the clinical scores was reported in both treatment groups, but no significant intergroup difference was documented at any follow-up evaluation. No difference was observed also in the objective measurements. The mean time to return to full sports activity was not different between groups, and a comparable satisfaction rate was recorded in both treatment groups. Conclusion: Early postoperative viscosupplementation did not provide significant clinical benefits after arthroscopic meniscectomy. Despite the lack of major adverse events, the administration of a single HA injection at the end of the surgical procedure is not a successful strategy to provide either faster functional recovery or symptomatic improvement after meniscectomy. Trial Registration: ClinicalTrials.gov identifier: NCT02629380.