Stefano Zaffagnini

Arthroscopic autologous condrocyte transplantation: technical note

Abstract.We describe an arthroscopic surgical technique for tissue engineered cartilage grafting. A three-dimensional hyaluronic acid support is used for autologous chondrocyte culturing. The technique reduces morbidity of classic autologous implant and avoids open surgery and the use of a periosteal flap. The procedure includes the advantages of arthroscopic osteochondral grafting without donor site morbidity. With this technique is possible to reduce the patient morbidity, time and cost of surgery.

ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up

Several investigators have reported the presence of biomechanical, kinematic, anatomic, fiber orientation patterns and biological differences between the anteromedial bundle and the posterolateral bundle of ACL. The purpose of this prospective randomized study was to compare the clinical, instrumental and X‐ray outcome of two ACL reconstruction techniques with hamstring tendons: one with a single intra‐articular bundle associated to an extra‐articular sling, the second with a more anatomic double‐bundle technique that reproduces better the native ACL function. From an initial group of 100 patients who underwent ACL reconstruction, 72 patients (35 single bundle plus lateral plasty and 37 double bundle) were evaluated with IKDC, Tegner score, KT2000 arthrometer, Activity Rating Scale, Psychovitality Questionnaire and Ahlback radiographic score at a mean 3 years follow‐up. Double‐bundle group showed significantly better results regarding IKDC, ROM, Activity Rating Scale and time to return to sport. Also KT 2000 showed significant differences in objective stability. The double‐bundle technique for ACL reconstruction described in this paper has demonstrated significantly better subjective, objective and functional results compared with a double‐stranded hamstrings plus extra‐articular sling at a minimum 3‐year follow‐up.

Return to sport after anterior cruciate ligament reconstruction in professional soccer players

BACKGROUNDnTo investigate time to return to sport and rate of professional sport activity in a homogenous group of competitive soccer players 4 years after anterior cruciate ligament (ACL) reconstruction and rehabilitation.nnnMETHODSnTwenty-one male professional soccer players (mean age 22.9±5.4 years) underwent non-anatomical double-bundle autologous hamstring ACL reconstruction and followed the same rehabilitative protocol. Clinical evaluation was performed preoperatively and at 3, 6 and 12-month follow-up. Data regarding return to train and official match, sport activity, complications and revision surgeries were collected at 4-year follow-up.nnnRESULTSnLaxity test (KT-2000) and total KOOS mean score resulted in a significant improvement from the preoperative status to the 12-month follow-up (p<0.0001). The KOOS mean value showed a significant progressive improvement from the preoperative status to 6-month follow-up (p=0.0010) as well, while values collected at 6 and 12-month follow-up were comparable (p=0.2349). Returned to official matches 186±53 days after surgery. After 12 months, 95% came back to the same activity level performed before injury. Four years after ACL reconstruction, 15 patients (71%) were still playing competitive soccer. One patient (5%) underwent ACL failure and subsequent revision.nnnCONCLUSIONSnThe ACL reconstruction with the presented technique followed by patient-tailored rehabilitation, allowed 95% and 62% professional male soccer players to return to the same sport activity 1 year and 4 years after surgery respectively. However, 71% were still able to play competitive soccer at final follow-up. Clinical scores were restored after 6 months.nnnLEVEL OF EVIDENCEnIV, case series.

Knee functional flexion axis in osteoarthritic patients: comparison in vivo with transepicondylar axis using a navigation system

PurposeNo study, up to now, has examined the effect of arthritis on pathologic subjects using functional flexion axis (FFA). The purpose of this study is to understand whether arthritis affects somehow the FFA evaluation and to assess whether the FFA could be considered a usable reference for implant positioning for osteoarthritic knees.MethodsUsing a navigation system, FFA orientation was evaluated intraoperatively (computed with the mean helical axis method) in three different ranges of motion (0°–120°; 35°–80°; 35°–120°) and in two different planes (coronal and axial), for 111 osteoarthritis patients undergoing total knee arthroplasty. The results were compared with a control group of 60 patients that underwent ACL reconstruction. The angle between the transepicondylar axis (TEA) and FFA was computed.ResultsResults showed in arthritic knees on frontal plane, an average difference between TEA and FFA of −2.8°xa0±xa05.0° while on axial plane it was 0.6°xa0±xa04.7°. No statistical difference was found between the three ranges in axial view, whereas some difference was found in frontal view (Pxa0<xa00.0001). The TEA–FFA angle was not correlated with limb alignment on axial plane, while it was, even if poor, in frontal plane. In the control group, in frontal and in axial view, no statistical difference was found for the angle between TEA and FFA.ConclusionsFFA can be used as reference for implant positioning in axial plane also in pathologic knees, while for the frontal plane further investigations are required.

Results of the original Putti-Platt procedure for shoulder instability: review of Putti's scholar experience

Twenty patients who underwent Putti-Platt shoulder capsulorraphy were retrospectively evaluated at long-term follow-up (24–34 years). The aim of this study was to analyse the efficacy and possible degenerative changes associated with this procedure. Patients charts were reviewed to analyse the pre-operative picture, surgical technique and post-operative program. All patients were re-examined using ASES, Rowe and Lysholm scales. Range of movement (ROM) of the shoulder operated on was compared with the non-operated one. A-P, axillary and outlet views were taken for radiographic control. Samilson criteria were followed to determine the degree of arthrosis. Clinical outcome was satisfactory in 85% of the cases with only three cases with fair results (15%). No recurrence was present in this series. The mean limitation of external rotation in abduction was 9°with respect to the contra-lateral shoulder. Severe degenerative changes were observed in two cases. In conclusion, after a long follow-up period, the Putti-Platt technique has shown highly satisfactory results, with an incidence of loss of motion and joint degeneration changes similar to other procedures.

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26–35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.

The adductor tubercle as an important landmark to determine the joint line level in total knee arthroplasty: from radiographs to surgical theatre

AbstractPurposenThe restoration of the normal joint line (JL) is important both in primary and revision total knee arthroplasty (TKA). However, the assessment of the femoro-tibial JL is still controversial. A strong correlation between femoral width (FW) and distance from adductor tubercle (AT) to JL was found on radiographs, with a ratio of 0.54. The hypothesis was that this ratio was applicable also in the surgical theatre by using measurements obtained intra-operatively with a caliper.MethodsFemoral width, AT to JL distance and the RATIO between AT to JL distance and FW of 40 patients who underwent TKA were measured on radiograph and intra-operatively. Bland–Altman agreement tests with repeated measurements and linear regression analysis were used. The ratio was used to estimate the distance between JL and AT.ResultsThe AT to JL distance/FW ratio calculated with linear regression resulted 0.54 for radiographic measurements and 0.53 for intra-operative measurements. There was no difference (0.009xa0±xa00.03) between the calculated ratios on radiographic and intra-operative measurements, and the correlation between intra-operative and radiographic measurements was 0.5 (pxa0=xa00.0016).ConclusionsThis study shows that the validity of the radiographic method which uses an AT to JL distance/FW ratio to determine the level of the JL is confirmed also when using intra-operatively acquired measurements. Thus, this ratio represents a reliable tool to determine the JL level even in challenging prosthetic revision cases when the anatomical JL is missing.Level of evidenceCase series, Level IV.

An update on the grading of muscle injuries: a narrative review from clinical to comprehensive systems.

Muscle injuries are recognized to be among the most frequent injuries occurring in the sporting and athletic population, and they account for more than 30% of all injuries in professional soccer players. Despite their considerable frequency and impact, there is still a lack of uniformity in the categorization, description and grading of muscle injuries. Dozens of systems based on clinical signs, ultrasound imaging (US) appearance or magnetic resonance imaging (MRI) findings have been proposed over the years. Most of them are three-grade systems that take into account pain, ROM limitation, swelling and hematoma, hypoechoic or hyperintense areas on US or MRI, and muscle gap or tendon involvement; however, they still lack evidence-based prognostic value. Recently, new comprehensive classification systems have been proposed, with the aim of developing uniform muscle injury terminology and giving each severity grade prognostic value. The systems that combine detailed MRI and US features with the clinical presentation, such as the Munich Muscle Injury Classification, the ISMuLT classification, and the British Athletic Classification, if used extensively, could improve the diagnosis, prognosis and management of muscle injuries.

Total knee arthroplasty without patellar resurfacing in active and overweight patients

Abstract Overweight patients are often considered poor candidates for total knee arthroplasty (TKA). A retrospective study of this was done on 47 osteoarthritic knees treated by TKA without patella resurfacing between March 1991 and June 1993. The Hospital for Special Surgery (HSS) rating system was used for clinical evaluation, and radiographs to study the degree of osteoarthritis and radiolucency. Correlations between overweight, range of motion (ROM) and stage of patellar damage and other measured variables (HSS score, patellar pain and radiolucency) were studied. Overweight was not correlated with HSS score, radiolucency or patellar pain. ROM was significantly correlated with patellar pain and HSS score, with better results in patients with ROM between 90° and 110°. Therefore, we believe that TKA in osteoarthritic knees can lead to successful results, even in active or overweight patients.

Percutaneous treatment of hallux valgus: What’s the evidence? A systematic review

Hallux and first MTP joint have a fundamental role in the transfer of the weight-bearing load during the normal ambulation. The aim of this paper is to review and analyze the available literature about the percutaneous surgical management of the hallux valgus to highlight its strengths and weakness, also comparing with other minimal invasive techniques. A systematic search of PubMed and Google Scholar databases has been performed, covering the period between 1981 and 2016. Various combinations of the keyword terms “PDO,” “hallux valgus,” “bunion,” “percutaneous,” “surgery,” “non-invasive,” “minimal invasive,” “burr,” “osteotomy,” “distal,” “linear,” “saw” have been used.Four papers, published from 2005 to 2015, fulfilled the inclusion criteria. A total of 464 hallux valgus has been treated with a properly percutaneous distal first metatarsal osteotomy. Mean AOFAS score, retrieved from the 4 studies included in our review, has been recorded. There are different aspects that the foot and ankle non-experienced surgeon has to consider about percutaneous surgery: limitation of the tools, radioexposure, lack of direct visual control of the osteotomy and higher costs and patient risk due to surgical time.