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Surgeons prepare for surgery in a reliable and reproducible manner and according to the guidelines published by the international health institutions. An epidemiological survey on 127 surgeons has shown that in everyday practice they have to follow the most recent knowledge based on evidence-based medicine (EBM) guidelines. However, more standardized approach to the surgical theater practices have to be defined by our health caregivers.

Large osteochondral allograft (OCA) transplant has become a valid alternative to restore articular surface in challenging articular lesions in young and active patients, either in primary or in revision procedures. Several studies support the effectiveness and safety of OCA, but costs and graft availability limit their use. The indications are the treatment of symptomatic full-thickness cartilage lesions greater than 3 cm ² , deep lesions with subchondral damage, or revision procedures when a previous treatment has failed. The goal of the transplant is to restore the articular surface with a biological implant, allow return to daily/sports activities, relieve symptoms, and delay knee arthroplasty. Grafts can be fresh, fresh-frozen, or cryopreserved; these different storage procedures significantly affect cell viability, immunogenicity, and duration of the storage. Dowel and shell technique are the two most commonly used procedures for OCA transplantation. While most cartilage lesions can be treated with the dowel technique, large and/or geometrically irregular lesions should be treated with the shell technique. OCA transplantation for the knee has demonstrated reliable mid- to long-term results in terms of graft survival and patient satisfaction. Best results are reported: in unipolar lesions, in patients younger than 30 years, in traumatic lesions and when the treatment is performed within 12 months from the onset of symptoms.

Purpose  The purpose of this study is to verify migration of mesenchymal stem cells of bursal tissue into the healing site after rotator cuff repair in rats. Methods  Fischer rats and green fluorescent protein (GFP)-transgenic rats were used. Bursal tissue from GFP rats was isolated and transplanted into tendon repair sites in Fischer rats. We examined the histology of the rotator cuff and the proportion of GFP-positive cells in the repaired rotator cuff 1, 3, and 6 weeks after surgery. Results  Cell migration was observed during the third and sixth week after surgery. We also found mesenchymal stem cells and formed bursal cluster patterns in the repaired rotator cuff tendons. Conclusion  Mesenchymal stem cells migrated from bursal tissue and infiltrated the repaired rotator cuff tendons. Clinical Relevance  Mesenchymal stem cells from bursal tissue can contribute to the healing progress of the repaired rotator cuff.

Purpose  The purpose of this study was to find out from the literature the difference in infection rates between patients who did and patients who did not receive prophylactic antibiotics in arthroscopic shoulder surgery. Methods  We conducted a comprehensive search of the literature using Medline Ovid for prospective studies that looked at infection as the primary outcome following shoulder arthroscopy. The articles were then assessed for study design, outcome, and relevance to the specific question as part of the critical appraisal. Results  Eight partially relevant articles were obtained from the search, but there were no prospective studies comparing infection in patients who had prophylactic antibiotics versus those who did not in shoulder arthroscopy. Conclusion  No compelling evidence exists on the role of prophylactic antibiotics in preventing infections in shoulder arthroscopy. Level of Evidence  Level IV, systematic review of level IV studies.

Purpose  To evaluate the long-term results of classical "à la carte" surgical treatment of objective patellar instability as proposed by Dejour in 1987. Methods  A multicentric retrospective study was conducted evaluating patients that underwent surgical procedure with a 10-year minimum follow-up (mean 12.7; range, 10-15). Surgical procedures were medial transfer of the tibial tubercle transfer according to Elmslie and Trillat et al in 38 cases, plasty of the vastus medialis obliquus according to Insall in 15 cases, open lateral retinacular release in 13 cases, capsuloplasty in 3 cases, and trochleoplasty in 1 case. Different combinations of surgical procedures were adopted according to the pathological features. Subjective outcome was assessed with the visual analog scale (VAS), Kujala score, subjective International Knee Documentation Committee (IKDC) score, Tegner score, and Crosby and Insall scale. Radiographic exams were used to assess the patellar tilt by the Laurin's angle and patellofemoral osteoarthritis (OA) according to the Iwano radiological OA scale. Results  Forty patients were evaluated. Subjectively, 60% of patients achieved a result judged good, 34% sufficient, and 6% poor. There were only two cases of recurrence of instability. Mean score results were Kujala score 73.4 ± 9.9 (range, 55-95), VAS 4.5 ± 1.2 (range, 1-6), IKDC 64.8 ± 7.9 (range, 51-88), and Tegner score 4. Only nine patients returned to sports activities). Ten patients developed a grade I patellofemoral OA, 8 patients a grade II, and 22 patients a grade III. Average patellar tilt was 10° ±  3.9°. Conclusion  This retrospective study showed that the traditional surgical procedure was successful for the treatment of patellar instability, but it did not prevent symptomatic patellofemoral OA. Level of Evidence  Level IV, retrospective case series.

Purpose  To analyze the prognostic factors influencing subjective and objective outcomes and return to play (RTP) after anterior cruciate ligament reconstruction (ACL-R). Methods  Primary ACL-Rs using a transtibial technique performed between 2008 and 2012 were included. Data regarding patients, surgery, sports, and rehabilitation, including an on-field rehabilitation (OFR) and duration of the rehabilitation program, were collected. The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms, and the Knee Injury and Osteoarthritis Outcome Score and Lysholm questionnaires were used for the assessment of subjective and objective outcomes. The Subjective Patient Outcome for Return to Sports and ACL-return to sport after injury (RSI) scores were used for RTP evaluation. Several potential predictors of outcome were tested with a univariate analysis. All the variables with p  < 0.1 were retested in a logistic regression model to evaluate their association with the outcomes. Results  In total, 176 cases were included with an average follow-up of 44.1 months. Of the patients, 92.2% were rated as normal or nearly normal at the IKDC evaluation. In addition, 90.1% of the patients returned to sport, with 57.6% returning to the same preinjury level. Objective outcomes were negatively influenced by late rehabilitation (odds ratio [OR] = 2.75). Performing an OFR phase during the rehabilitation was associated with better subjective outcomes (OR = 2.71). Length of rehabilitation strongly influenced the RTP rate (OR = 13.16). Conversely, higher ACL-RSI score was inversely related to RTP. Objective IKDC score was inversely related to the ACL-RSI (OR = 0.31), whereas subjective score was correlated with both the total ACL-RSI score (OR = 0.15) and the level of activity (OR = 0.20). Conclusion  This study confirmed the role of rehabilitation on subjective and objective outcomes and on RTP. Particularly, the complete adherence to a rehabilitation program, including an OFR phase, resulted in better subjective outcomes and higher RTP rate. The relationship between psychological factors, measured through the ACL-RSI score, and RTP was confirmed. Level of Evidence  Level III, observational study without a control group.

Purpose  The purpose of the present study was to investigate if the donor age of nonirradiated Achilles tendon allograft could influence the clinical results of revision anterior cruciate ligament (ACL) reconstruction. Methods  All patients that underwent ACL revision between 2004 and 2008 with at least 4 years of follow-up were included. For all the patients that met the inclusion criteria, the age of the graft donor was obtained from the tissue bank. Lysholm score was administered to patients that met inclusion criteria. In addition, patients were divided in two groups based on the donor age (<45 years vs. ≥45 years), and the baseline characteristics and outcomes were compared. Results  Fifty-two patients were evaluated at a mean 4.8 ± 0.8 years follow-up with Lysholm score. The Lysholm significantly improved from 62.3 ± 6.6 at preoperative status to 84.4 ± 12.3 at final follow-up. The mean donor age was 48.7 ± 8.4 years; a significant difference in Lysholm score was noted between patients that received an allograft with a donor age <45 years (14 patients; 27%) and those receiving an allograft with a donor age ≥45 years (38; 73%) (89.5 ± 3.2 vs. 80.1 ± 11.1, respectively; p  = 0.0469). The multiple regression model showed the donor age, the final follow-up, and the preoperative Lysholm score as significant predictors of postoperative Lysholm score ( p  < 0.0002). Conclusion  Donor age of nonirradiated Achilles tendon allograft influenced the mid-term results of revision ACL reconstruction, thus advising the use of grafts from young donors. Level of Evidence  Level III, retrospective comparative study.

Purpose  The aim of this study was to report the rate of survivorship in patients with osteonecrosis of the femoral head treated with core decompression in association with mesenchymal stem cells (MSCs) implantation, platelet-rich plasma (PRP) injection, and synthetic bone graft. Methods  We evaluated 24 hips in 16 patients, according to Ficat classification, treated by core decompression, injection of PRP and MSCs, and backfilling of the core tract with synthetic bone graft. Survivorship was estimated using Kaplan-Meier curves. Results  The survivorship of core decompression in association with the procedure is 50% at 75 months of follow-up. The survival rate was 80% for patients in early stage and 28.6% for patients in advanced stage at 75 months. When we compared Kaplan-Meier survival curves of patients in stage III + IV and patients in stage I + II, we noticed that the survival functions are statistically different ( p  < 0.05, log-rank test), particularly in stage I + II where we had a greater surviving core decompression, in comparison to patients in stage III + IV. Conclusion  This technique is safe and good preliminary results were obtained in patients with early stages of the disease with no reported complications. Level of Evidence  Level IV, therapeutic case series.

Purpose  The aim of this study was to evaluate the effectiveness and the safety of performing a four-bone arthrodesis (FBA) with dorsal locking plate in patients suffering from stage III scapholunate advanced collapse/scaphoid nonunion advance collapse (SLAC/SNAC) wrist. Methods  We evaluated retrospectively 20 patients surgically treated by a FBA with the use of locking dorsal plate. All the patients were clinically evaluated at follow-up for grip strength, range of motion, and pain (visual analog scale), and with the Disability of the Arm, Shoulder and Hand score and the Mayo wrist score. Imaging evaluation was performed on standard X-rays. Results  The mean follow-up was 6 years (range: 1-11 years). During follow-up, the patients showed good clinical outcomes in terms of pain relief and grip strength. Revision surgery was necessary only in one case because of screws loosening. In all cases, a solid bone fusion was achieved except in one patient, who presented a healing of lunocapitate joint. This condition did not affect the clinical outcomes. Conclusion  FBA performed using a dorsal locking plate is a salvage procedure effective in treating stage III SLAC/SNAC wrist. In our study, this technique provided good clinical outcomes at mid-term follow-up with a very low complication rate. Level of Evidence  Level IV, therapeutic case series.

[This corrects the article DOI: 10.1055/s-0037-1605583.].