Edoardo Monaco

Background: Injuries to the medial collateral ligament (MCL) and the posterior oblique ligament (POL), isolated or associated with cruciate ligament tear, are common in cases of knee sprains and often cause valgus instability. Although there are many surgical techniques for MCL reconstruction, not all are anatomical, and not all involve reconstruction of the deep and superficial bundles of the MCL and POL with an autologous autograft. Indications: We propose this technique in cases of chronic anterior cruciate ligament (ACL) tear associated with POL and MCL injury grade III according to the Hughston-Eilers classification. Technique Description: This technique involves an on-lay anatomical reconstruction of the superficial and deep bundles of the MCL and POL using hamstring tendons. The patient is in a supine position with the knee flexed at 90°. An incision is made in the medial compartment of the knee, at the level of the medial collateral ligament, after which the hamstring tendons are harvested with an open tendon stripper so that they can be left inserted at their tibial insertion. Three soft tissue self-punching anchors are positioned at the anatomical insertion of the MCL and POL bundles. Care must be taken not to involve the joint surface, which is easily visible through a needle. The tendons are secured using the previously positioned anchors to reconstruct the MCL and POL. Results: After 5 months, the patient returned to her daily activities, fully recovered knee range of motion, and achieved good recovery of muscle strength without discomfort or functional limitations. Discussion/Conclusion: This technique provides an anatomical reconstruction of the MCL and POL using on-lay all suture anchors for chronic lesions. Hastring autografts are used for MCL and POL reconstruction, leaving other autografts available for ACL reconstruction. There is no need for an additional tunnel for MCL and POL reconstruction, thus avoiding tunnel convergence in multiligament reconstructions. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Purpose: The purpose of this study was to quantify return‐to‐play (RTP) time, post‐operative performance and market‐value trends after proximal hamstring repair in top‐tier European league soccer players. It was hypothesized that surgery would achieve a high RTP rate but be accompanied by reductions in player performance and valuation. Methods: Male first‐team players from the five major European leagues who underwent surgical repair of proximal hamstring ruptures between 2019 and 2022 were identified collaboratively with the InjuryMechanisms platform. Publicly available data (Transfermarkt) was accessed to extract demographics and season‐by‐season metrics for two seasons before and two seasons after injury. Outcomes were RTP time, matches missed, percentage of minutes played per season (MPS), goals, assists and market value. Non‐parametric Friedman test with Dunn–Bonferroni post hoc test assessed longitudinal changes. Results: Twenty players (mean age, 25.3 ± 4.4 years) met the inclusion criteria. All returned to professional competition without reoperation. Mean RTP was 160 ± 76 days, with 21.5 ± 11.5 matches missed. Goals and assists were unchanged across seasons ( p > 0.05). MPS showed a non‐significant reduction from 50.2 ± 15.5% pre‐injury to 34.5 ± 16.3% in the first post‐operative season and partially recovered to 43.0 ± 23.9% in the second season. Mean market value significantly declined from €22.1 ± 36.7 and €20.4 ± 34.4 million in the two pre‐injury seasons to €15.2 ± 27.4 million two seasons post ( p < 0.001). Conclusion: Surgical repair of proximal hamstring rupture allowed reliable return to competition in elite soccer players, with preserved performance. However, players experienced a transient, non‐significant reduction in competitive involvement during the first post‐operative season and market value significantly declined despite favourable performance outcomes. Level of Evidence: Level IV.

Purpose: To compare MRI-based graft maturation and tibial tunnel behavior in all-inside anterior cruciate ligament (ACL) reconstruction using either a quadrupled semitendinosus (ST4) graft or a standard doubled semitendinosus–gracilis (DSTG) technique and to assess mid-term clinical outcomes. Materials and methods: This is a single-center prospective comparative cohort with sequential, non-randomized allocation. Primary imaging endpoints were graft signal-to-noise quotient (SNQ, PD-FS) and tibial tunnel cross-sectional area (CSA) change; clinical endpoints included PROMs and laxity at ≥ 24 months. Reliability was assessed with two independent evaluators and reported using ICC (two-way random, absolute agreement) with 95% CIs. Results: Forty patients ( n = 20 per group) completed MRI at 12 months and clinical follow-up at 24 months. SNQ was similar between groups (ST4 1.94 [95% CI 1.28–2.60] vs DSTG 2.84 [1.93–3.75]; difference − 0.90 [− 1.99 to 0.19], P = 0.39). Tibial tunnel widening was lower with ST4 (45.5% [23.7–67.3]) versus DSTG (106.7% [78.3–135.1]); difference − 61.2% [− 95.8 to − 26.6]; P = .02. PROMs and laxity were comparable. Conclusions: AI-ST4 and DSTG ACL reconstruction demonstrated similar graft maturation at 12 months, with less tibial tunnel widening after AI-ST4. At 24 months, clinical outcomes were equivalent between groups; although SNQ and tibial tunnel CSA demonstrated good reproducibility, these imaging differences were not demonstrably associated with functional superiority.

Background: Lateral extra-articular tenodesis (LET) combined with anterior cruciate ligament reconstruction (ACLR) has been shown to reduce graft failure. While the benefits of techniques such as the modified Lemaire procedure and anterolateral ligament reconstruction are well documented, the literature on other LET techniques is more limited. Purpose: To evaluate the clinical outcomes and risk factors for failure in patients undergoing ACLR combined with LET using the Coker-Arnold modification of the MacIntosh technique. Study Design: Case series; Level of evidence, 4. Methods: This retrospective case series included patients who underwent primary ACLR using a hamstring tendon autograft along with concurrent LET at a single institution between 2013 and 2022. Clinical evaluations included subjective outcome measures (International Knee Documentation Committee [IKDC] score, Knee Injury and Osteoarthritis Outcome Score [KOOS], Lysholm score, and Tegner score) and objective KT-1000 arthrometer testing. Risk factors for graft failure were identified using multivariate logistic regression. Results: The final study cohort consisted of 328 patients. At a mean follow-up of 72.4 ± 30.3 months, 11 patients (3.4%) experienced graft failure. The mean side-to-side difference according to the KT-1000 arthrometer was 1.45 ± 1.04 mm. Patients showed excellent outcomes, with 91.5% achieving the patient acceptable symptom state (PASS) for the IKDC score and >90.0% achieving the PASS for all KOOS subscales, except for the Activities of Daily Living subscale (79.6%). High Tegner scores (≥8) and the presence of chondral lesions were independently associated with graft failure (odds ratio, 6.82 and 5.89, respectively; P < .01). Age, sex, pivot-shift grade, meniscal status, and timing of surgery were not predictive of failure. Conclusion: Combined ACLR and LET using the Coker-Arnold modification of the MacIntosh technique led to a 3.4% failure rate at a mean follow-up of >5 years. Higher Tegner scores and the presence of chondral lesions were found to be independently associated with reruptures.

Purpose: The purpose of this study was to evaluate the clinical outcomes of acute anterior cruciate ligament reconstruction (ACLR) performed within 14 days of injury with a minimum follow‐up of 2 years. The hypothesis was that early ACLR would result in favourable clinical outcomes without a significant increase in complications. The secondary aim was to identify predictors of graft failure and complications, with the hypothesis that younger age and higher activity level would be associated with increased risk. Methods: A retrospective analysis was performed on patients who underwent ACLR within 14 days at a single institution. Potential risk factors for graft rupture and other post‐operative complications were analyzed. Knee stability was assessed using KT‐1000 and pivot shift test, and range of motion (ROM) with a goniometer. Patient‐reported outcome measures (PROMs), including IKDC (International Knee Documentation Committee), Lysholm, Tegner activity scale and KOOS (Knee injury and Osteoarthritis Outcome Score), were evaluated. Results: The final population consisted of 203 patients. At a mean follow‐up of 53.4 months (range: 24–85), the graft rupture rate was 1.9%. Age 20 years or younger was the only significant risk factor for graft rupture (odds ratio = 6.02, p = 0.013). Post‐operative negative pivot shift was achieved in 93.6%. The mean post‐operative KOOS was 91.7 ± 8.8, the mean IKDC score was 88.1 ± 13.4, and the mean Lysholm score was 93.2 ± 9.9. In addition, 75% of patients returned to their pre‐injury level of sports activity or higher. The mean loss of side‐to‐side extension was 1.3°, and flexion was 4.6°. The overall complication rate was 10.2%, with an incidence of post‐operative stiffness requiring re‐intervention of 1.5% and a 3.4% incidence of septic arthritis. Conclusion: Early ACLR resulted in favourable clinical outcomes, including high rates of return to sport, minimal ROM deficits, and high PROM scores, with a low graft failure rate (1.9%), despite a 3.4% incidence of septic arthritis. Level of Evidence: Level IV.

Purpose: The aim of this study was to compare gene expression and cell biology in biopsy specimens from repaired and reconstructed anterior cruciate ligaments Methods: A biopsy of the repaired and reconstructed anterior cruciate ligaments was performed. Gene expression analysis of alpha smooth muscle alpha actin via immunofluorescence and gene expression analysis of Collagen I, Collagen III, Collagen I–III ratio, and p16 via reverse transcription polymerase chain reaction was performed. In addition, cell motility and migration were quantitatively assessed. Data analysis was performed using analysis of variance (ANOVA) and Tukey's multiple comparison tests. Results: Twenty‐five biopsies, 15 from repaired anterior cruciate ligaments and 10 from reconstructed anterior cruciate ligaments were obtained. Gene expression analysis showed a higher expression of Collagen I in the reconstruction group ( p = 0.0027) while the expression of alpha smooth muscle actine, was significantly greater for the repair group ( p = 0.001). Quantitative analysis demonstrated significantly higher cell motility in the cells from repaired ligament compared to cells cultured from grafts (43 vs. 54% residual open area from scratch, p = 0.0001 at 24 h; 10 vs. 17% residual open area from scratch, p = 0.001 at 48 h). Conclusions: Molecular analysis of repaired and reconstructed anterior cruciate ligaments demonstrates significant differences with respect to collagen quality, α‐SMA, and p16. dPCs cultured from biopsies tissue showed a greater cellular activation and migration capacity in the repaired ligament. The clinical importance of these findings is a confirmation that repaired anterior cruciate ligament tissue exhibits a cellular behaviour consistent with excellent biological healing potential. Level of Evidence: Level III, case–control study.

Purpose: To analyze the clinical and radiographic outcomes of patients who underwent anterior cruciate ligament (ACL) primary repair within 15 days of the index injury. Methods: All patients undergoing acute (within 15 days of the injury) ACL primary repair between January 2019 and June 2020 were eligible. Inclusion criteria were ACL injuries classified as Sherman I and II (proximal tears) and as Marshall grades A and B (good and moderate tissue quality). Patients underwent sequential magnetic resonance imaging (MRI) scanning at 1, 3, 6, and 12 months postoperatively. Patients had to have had at least 2 of the 4 scheduled MRIs to be included. The ligamentization process was evaluated using signal‐to‐noise quotient (SNQ) and Howell scale. SNQ was analyzed via repeated‐measures analysis of variance with Bonferroni corrections for multiple comparisons, whereas the Howell scale progression was analyzed with a Friedman test and post hoc Wilcoxon tests. Clinical outcomes were recorded at the final follow‐up, 24 months after surgery, using the following patient‐reported outcome measures: Lysholm Knee Scoring Scale (LKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Anterior Cruciate Ligament Return to Sport after Injury, the Forgotten Joint Score‐12, Manual Maximum KT‐1000, the International Knee Documentation Committee, and the Tegner Score. Results: The study included 50 patients (mean age, 31.7 ± 12.7 years), 21 male (42%) and 29 female (58%). The mean time from injury to surgery was 9.2 ± 2.9 days. A total of 47 patients had MRI at 1 month after surgery (mean 30 days, range 28‐32 days); 47 patients had MRI at 3 months after surgery (mean 91 days, range 88‐95 days); 45 patients had MRI at 6 months after surgery (mean 181 days, range 178‐184 days); and 49 patients had MRI at 12 months after surgery (mean 361 days, range 356‐365 days). Mean SNQ and Howell scale scores showed a consistent decrease—representing an improved ligament maturation—over the 4 time points. Significant reductions of SNQ values occurred between 1 and 6 months ( P < .001), 1 and 12 months ( P < .001), 3 to 6 months ( P < .001), and 3 to 12 months ( P < .001). No significant difference was found between 1 and 3 months ( P = .075) or 6 and 12 months ( P = .436). The Howell scale scores showed a significant overall reduction over time (χ ² [3] = 28.253; P < .001), with significant improvements occurring between 1 and 6 months ( P < .001), 1 and 12 months ( P < .001), 3 to 6 months ( P = .005), and 3 to 12 months ( P = .008). No significant difference was found between 1 and 3 months ( P = .05) 6 and 12 months ( P = .303). Clinical outcomes were recorded at 24 months after surgery (mean 1095 days, range 745‐1486 days). The average Lysholm score was 84.73 ± 14.47 and the average KOOS score was 85.29 ± 13.97; 86.3% of patients achieved Patient Acceptable Symptom State for the KOOS subscales. A significant correlation between Howell grade and SNQ ( r = 0.483, P < .001) was found, but not between Howell grade or SNQ and other functional outcome measures. Conclusions: Patients who underwent acute primary ACL repair had good clinical outcomes on both patient‐reported outcomes and Manual Maximum KT‐1000 at a minimum 24 months of follow‐up. A correlation was found between the signal on MRI and the healing phase. Continuous healing was observed during the first postoperative year, with consistent decreases in SNQ and Howell scale scores. In addition, patients had good clinical outcomes, as evidenced by high mean scores and percentage of patient‐acceptable symptom state achievement on PROMs. Level of Evidence: Level IV, case series.

Article: Needle arthroscopy in orthopedics - Minerva Orthopedics 2024 April;75(2):145-52 - Minerva Medica - Journals

In tandem con il socio Alessandro Martini, Edoardo Monaco ha proseguito l’opera dello studio fondato dal padre Vincenzo e da Amedeo Luccichenti, ma imprimendogl...