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Purpose  Bone loss is a challenging problem during revision total knee arthroplasty (TKA). Several studies have been published on the use of metaphyseal sleeves during revision TKA. Therefore, the aim of this systematic review was to summarize the clinical and radiographic outcomes of the use of metaphyseal sleeves in the setting of revision TKA. Methods  A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar was performed, covering the period between January 1, 2000, and August 12, 2017. Various combinations of the following key words were used: "metaphyseal," "sleeves," "knee," and "revision." A total of 10 studies were included in the present systematic review. Results  A total of 904 patients with 928 implants were recorded with a mean age of 69 years. They were evaluated at a mean follow-up of 45 months. Overall 1,413 sleeves, 888 in the tibia and 525 in the femur, were implanted. There were 36 septic re-revisions of the prosthetic components (4%). Five sleeves were found loose during septic re-revision; therefore, the rate of septic loosening of the sleeves was 0.35%. An aseptic re-revision of the prosthetic components was performed 27 times (3%). Ten sleeves were found loose during aseptic re-revision; therefore, the rate of aseptic loosening of the sleeves was 0.7%. Intraoperative fractures occurred 44 times (3.1%). Finally, clinical outcome was improved at final follow-up. Conclusion  Metaphyseal sleeves demonstrate high radiographic signs of osteointegration, low septic loosening rate, low intraoperative fractures rate, and a good-to-excellent clinical outcome. Hence, they are a valid option to treat large metaphyseal bone defect during revision TKA. Level of Evidence  This is a systematic review of level IV studies.

One-stage or two-stage revision total knee arthroplasty (TKA) in periprosthetic joint infections has been at the center of scientific debate for many years. As regards two-stage revision TKA, cement spacers have a good infection control rate with successful results reportable up to 96%, though some studies describe related spacer complications such as stiffness and loss of bone stock. We report a case of a fracture close to the antibiotic-loaded cement spacer in a 74-year-old female patient. Due to the blood tests and high risk of infection, we performed a hybrid external fixator. Six months after the surgery, X-rays did not show signs of fracture consolidation and nonunion was considered as an impending complication; therefore, the decision was made to perform tumor-like total knee arthroplasty. The postoperative evolution was satisfactory and return to daily activity without pain. At the 5-year follow-up, the patient showed a good score of 36-Item Short Form Health Survey and a range of motion from 0 to 90° without pain. The X-rays did not show signs of mobilization, dislocation, recurrence of infection, or other complications.

Full-thickness articular cartilage defects do not heal spontaneously. Several techniques have been developed to address this issue, but none resulted in the restitutio ad integrum of the articular cartilage. The most frequent sites of chondral lesion in the knee are medial femoral condyle and patella. The patellofemoral lesions are characterized by outcomes that are generally worse than those of tibiofemoral ones. To date, it has been well recognized the chondrogenic potential of rib perichondrium, and costal cartilage grafts have been extensively used in reconstructive surgery. Considering the need to find a gold standard technique to restore articular defect, we developed and here described a new technique to repair cartilage lesions of the knee using autologous costal cartilage graft with its perichondrium. This innovative surgical approach can be used to treat full thickness articular defects using autologous hyaline cartilage, making it possible to cover wide defects. This one step technique is low invasive, not technically demanding with minimal donor site morbidity and it has low costs. The long-term clinical efficacy of the method remains to be evaluated.

Purpose  The primary aim of this study was to report the outcome of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in obese patients with a body mass index (BMI) > 35. Methods  This is a prospective cohort study, including patients referred with the aim of planning bariatric surgery between October 2015 and January 2017. The primary outcome measurement was KOOS. An experienced radiologist obtained and evaluated standard radiological osteoarthritis examinations of the knee joints. Results  The mean age was 43.1 years, and ages ranged from 24 to 69 years. The mean BMI was 48.3, and BMI ranged from 35 to 66. Results show that obese patients reported significantly worse in the KOOS subscales pain, activities of daily living, sport, and quality of life (QOL) compared with a reference population, due to nonoverlapping 95% confidence intervals. No significant differences between obese and superobese patients were observed on the KOOS subscales ( p  > 0.08). The KOOS subscales showed worse outcome with increasing severity of radiological knee osteoarthritis; however, only significant differences were observed for the KOOS subscales sport and QOL ( p  < 0.05). Conclusion  Results imply that the KOOS scores vary significantly with obesity. When utilizing KOOS outcome, considering obesity in the interpretation of outcome is highly recommended. Level of Evidence  This is an observational, level III study.

Purpose  The study aims to present the results at a mean 28-months follow-up of arthroscopic-guided balloon tibioplasty and to spot some technical tricks and some practice using tools and materials. Methods  The study relates to six patients with tibial plateau fractures type Schatzker III with tibial plateau depression more than 4 mm at preoperative computed tomography scan (CT-scan). The follow-up period ranged from 22 to 33 months, with a mean of 28 months. No patients were lost to follow-up. The patients were evaluated clinically using the Rasmussen score system and Lysholm score systems at 6 to 12 and 24 months, postoperatively. Radiographic evaluations (standard X-rays) were done preoperatively at 1, 3, and 12 months postoperatively while a CT-scan with 3D reconstruction was performed preoperatively, at the first day and 6 months, postoperatively. Results  The mean Rasmussen clinical score at 6 months postoperatively was 26.3 while at 1-year postoperatively the mean Rasmussen clinical score was 28.33. At 2-year postoperatively the mean Rasmussen clinical score was 28.83. Statistically significant difference was found in 6-months and 2-years results ( p  < 0.05). CT-scan achieved the first postoperative day showed the recovery of approximately 70% of the area of the interested tibial plateau, restoring of the joint surface without articular bone free fragments. Conclusion  The described surgical procedure, if correctly performed with proper indications (Schatzker III), respect the principles mentioned above and the clinical and radiological results confirm our purpose. Level of Evidence  This is a therapeutic case series, level IV study.

Purpose  The aim of this study is to present clinical results of a retrospective case series that includes patients treated with an extensive modification of the Kocher lateral approach to the elbow with surgical detachment of the anterior branches of the radial collateral ligament. Methods  From January 2016 to January 2018, nine patients with closed isolated displaced or multifragmentary radial head fractures (Mason type II, III, or IV) who underwent osteosynthesis or arthroplasty through a modified Kocher lateral elbow approach were available for follow-up. Results  There were six female and three male patients. The median age at the time of surgery was 52 years old (range: 26-70). The dominant upper limb was injured in 22.2% of patients. After a median follow-up of 8 (range: 6-27) months, all patients regained completely all their daily activities and no cases of infections were recorded. Conclusion  We believe that the approach proposed can be a useful choice to deal with these challenging injuries. Our strategy may represent a valid alternative to more popular approaches as the use of anchors decreases the risk of instability that is the major danger considered in the past when soft tissues as tendons and ligaments are detached. Level of Evidence  This is a level IV study (therapeutic case series).

Infection after total hip arthroplasty (THA) is a devastating complication with significant consequences for patients. In literature, single and two-stage revision, irrigation and debridement, Girdlestone resection arthroplasty, and arthrodesis and amputation are reported as possible treatments. Recently, two-stage revision has become popular as the gold standard treatment for chronic hip joint infections after THA. In this review, we evaluate the current literature about microbiology of periprosthetic joint infections and the use of antibiotic-loaded cement spacers. We aim to give an overview about indications, clinical results, and mechanical complications for spacers implantation, evaluating also selection criteria, pharmacokinetic properties, and systemic safety of the most frequently used antibiotics.

When performing diagnostic and surgical arthroscopic procedures on the shoulder, the importance of patient positioning cannot be understated. The optimum patient positioning for shoulder arthroscopy should enhance intraoperative joint visualization and surgical accessibility while minimizing potential perioperative risk to the patient. Most shoulder arthroscopy procedures can be reliably performed with the patient either in the lateral decubitus (LD) or beach chair (BC) position. Although patient positioning for shoulder arthroscopy has been subject of controversy, there is no conclusive evidence to suggest superiority of one position versus another. Each position offers advantages and disadvantages and surgeon's experience and training are pivotal on selecting one position versus another. Regardless of the position, a proper positioning of the patient should provide adequate access to the joint while minimizing complications. The purpose of this review is to summarize setup and technical aspects, the advantages and disadvantages, and the possible complications of the LD and BC positions in shoulder arthroscopy.

Traumatic lesions of the distal biceps brachii are uncommon. They often result from rapid elbow flexion against resistance. Conservative treatment is only indicated in low-demanding patient and in those who have severe comorbidities. Regarding the surgical approach, two options are available: the single- and the double-incision techniques. The former has been the first to be described and was associated with significant rate of neurologic complications. The second showed less frequent neurologic lesions, but considerable rate of heterotopic ossifications with reduced forearm movement. The choice of fixation device is another important issue. Cortical buttons, transosseous repair, suture anchors, and interference screws have shown satisfactory outcomes. However, cortical buttons have the best mechanical properties. Although a lack of high methodological quality studies emerges in the available literature, three recent systematic reviews and meta-analysis show interesting findings. Surgical reinsertion of the distal biceps brachii yields satisfactory clinical outcomes both with the single- and double-incision techniques. Higher prevalence of nerve injuries is associated with the single-incision techniques, whereas higher prevalence of heterotopic ossification is reported with double-incision techniques. Thus far, there is no sufficient evidence to support one option and the choice is mainly based on surgeon's experience.

Purpose  The aim of the present study was to evaluate different methods for the intraoperative seeding of chondrocytes on commercially available collagen I/III matrix, in the context of cell-seeded collagen matrix-supported autologous chondrocyte transplantation (ACT-CS). Methods  Human chondrocytes were enzymatically isolated from cartilage portion of discarded femoral heads of patients who underwent total hip replacement. Chondrocytes were cultured until passage 3, and then used for the experiments. The cells (5.0 × 10 ⁵ ) were suspended in two different volumes, 75 and 250 µL, and seeded on a matrix sample with a surface of 1 cm ² by means of a micropipette. Moreover, the direct immersion of the matrix in the cell suspension was evaluated as a possible protocol for chondrocyte seeding. Cell adhesion was allowed for 10, 30, or 60 minutes in all samples before evaluation. Results  Data showed that the seeding time did not affect cell viability and distribution, but there was a great difference between the two volumes of injection. In fact, the use of 75 µL significantly reduced cell viability with respect to both 250 µL seeding volume and the immersion protocol. Indeed, cell distribution resulted homogeneous in the samples seeded with the larger volume and with the immersion protocol. Conclusion  The use of 250 µL/cm ² volume or the immersion protocol for 10 minutes are valuable methods for chondrocyte seeding on collagen matrix in an intraoperative scenario. Clinical Relevance  The protocol of chondrocyte seeding in ACT-CS is extremely variable among available literature reports. Chondrocytes adhesion to the matrix represents a crucial step in this methodology, and the present study provides in vitro indication for the choice of the seeding protocol in the context of ACT-CS.