Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: To evaluate the functional outcomes of surgical treatment for proximal hamstring avulsion injuries in patients aged over 50 years and to compare the results across another matched group of patients under 50.

Methods: This was a retrospective analysis of prospectively collected data in a matched case-control design targeting patients with proximal hamstring avulsion injuries who underwent surgical treatment at a sports surgery referral centre. Patients over 50 years with complete avulsion or partial injury (>2 cm retraction) were included. Two age groups were formed (18-50 and over 50), matched by the following variables: gender, rupture type (complete or partial), injury chronicity (chronic: more than 4 weeks from the injury or acute) and the preinjury Tegner score. The primary outcome was the Parisian Hamstring Avulsion Score (PHAS), with secondary outcomes, including the Tegner Activity Scale, University of California, Los Angeles (scale) (UCLA) scale, return to sport and complication rates.

Results: The study included 298 patients, with a mean age of 41.8 (7.2) years for the younger group and 58.0 (5.7) years for the older group. The follow-up duration in the younger group, 4.7 years (3.2), was slightly longer than that of the older group, 4.1 years (2.5), (p < 0.001). At the last follow-up, significant improvements were observed in PHAS, UCLA and Tegner scores in both groups (p < 0.001) compared to preoperative scores. The differential gain was higher in the younger group in all three scores (p < 0.05). The rerupture rate was 8.1% in the younger group and 4.7% in the older group (p > 0.05), with no significant differences in complication and return to sports rates (p > 0.05).

Conclusion: This study shows that surgical treatment of proximal hamstring avulsion injuries is associated with significant improvements in functional outcomes in both younger and older patients, with greater magnitude of improvements in younger patients. Complication rates were similar between the age groups.

Level of evidence: Level of evidence III, Cohort Study.

Purpose: The aims of this study were to compare (1) the rate of anterior cruciate ligament (ACL) revision and (2) subjective knee function using the Knee injury and Osteoarthritis Outcome Score (KOOS) between isolated ACL reconstruction (ACL-R) and ACL-R and concurrent meniscal injury, based on graft selection and meniscal treatment.

Methods: Data from the Swedish National Knee Ligament Registry were extracted in November 2022 for patients who underwent primary ACL-R. Patients were divided into two main groups based on graft choice: hamstring tendon (HT) or patellar tendon (PT) autograft, with four meniscal sub-groups: no injury, resection, repair or left in situ. The primary outcome was the rate of ACL revision within 5 years of primary ACL-R, and the secondary outcome was subjective knee function measured with the mean KOOS subscale scores and the rate of patients achieving a patient-acceptable symptom state (PASS) at the 1-, 2- and 5-year follow-up.

Results: The analysis of ACL revision was performed on 45,656 patients, and 7639 patients for the analysis of subjective knee function. The overall rate of ACL revision was 2.4% and 4.9% at 2 and 5 years, respectively. There were no differences in the rate of ACL revision within 5 years of primary surgery irrespective of graft choice or meniscal injury treatment. Patients with ACL-R and concurrent meniscal resection or meniscal injury left in situ achieved a PASS at the 1 (∆ = -11.3% to -29.5%), 2 (∆ = -12.7% to -40.3%) and 5-year (∆ = -12.0% to -30.6%) follow-up to a greater extent when receiving HT autograft compared to PT autograft.

Conclusion: Graft selection was not associated with ACL revision in patients with ACL-R and concurrent meniscal injury, regardless of meniscal injury treatment. Superior subjective knee function was reported by patients who underwent ACL-R with HT autograft compared with PT autograft where the injured meniscus was resected or left in situ.

Level of evidence: Level III.

Purpose: In functionally aligned (FA) total knee arthroplasty (TKA), femoral component rotation (FCR) is personalised to optimise flexion gap balance. As axial malalignment has been attributed to patellofemoral complications, this study assessed FA FCR in relation to the surgical transepicondylar axis (TEA) and early implant survivorship.

Methods: We analysed 446 robotic-assisted primary TKAs in 393 patients using FA with preresection gap balancing. Femoral and tibial coronal resection boundaries were 6° valgus to 3° varus and 6° varus to 3° valgus, respectively. The TEA and posterior condylar axis (PCA) were identified on preoperative computed tomographic scans. Intraoperatively, FCR was initially set parallel to the PCA, then rotated to achieve flexion balance within 6° boundaries to the TEA. The primary outcome was the mean angular difference between the TEA and final FCR and the proportion of patients with FCR within 2°, 4° and 6° from the TEA. Secondary outcomes included all-cause revisions for the robotic-assisted TKAs in this series from our in-house database and a national joint replacement registry at a mean of 3.3 years postoperatively (range 2.2-5.5).

Results: Mean FCR was 0.0° (SD 2.1°) relative to the TEA and 1.8° (SD 1.4°) externally rotated to the PCA. Final FCR was within 2° in 74.9%, within 4° in 97.3% and within 6° in 99.6% of patients relative to the TEA. There were seven postoperative procedures (1.6%) within the study period: two reoperations (0.5%) for early arthrotomy failure requiring repair (both exhibiting FCR within 1° to the TEA) and three revisions (0.7%) for deep surgical site infection (one after early traumatic arthrotomy failure, one revision for instability and one manipulation for stiffness).

Conclusion: In FA TKA, femoral components more closely align to the TEA than the PCA to achieve a balanced flexion gap. In conjunction with a low incidence of revision surgeries, this suggests the FA technique does not result in significant patellofemoral complications.

Level of evidence: Level III.

Purpose: The medial collateral ligament (MCL), and posterior oblique ligament (POL) are the primary valgus stabilisers of the knee, and clinical examinations in grading valgus instability can be inherently subjective. Stress radiography of medial-sided knee injuries provides objective diagnosis and was analysed in this study. We hypothesised that (1) medial joint space opening would increase cutting the superficial MCL (sMCL), POL and anterior cruciate ligament (ACL); (2) isolated deep MCL (dMCL) injury would not increase medial joint space opening; (3) medial joint space opening would increase at higher flexion angles.

Study design: Controlled laboratory study.

Methods: Ten human cadaveric knees were dissected, preserving ligamentous structures, muscles and fascia. The femur was secured, and the tibia was attached to the six-degree-of-freedom robot. A 10 Nm valgus torque was applied at 0°-45° of flexion and anterior-posterior (a.p.) radiographs were taken. Sequential sectioning was performed on the dMCL, sMCL, POL and ACL. Medial joint space opening was measured on a.p. radiographs (midpoint technique). Statistical analysis was conducted using a mixed model with post hoc correction (p < 0.05). Intra- and interobserver reliability was assessed by calculating the intraclass correlation coefficient (ICC).

Results: Medial joint space opening significantly increased with cutting state (p < 0.0001) and flexion angle (p < 0.0001). Although isolated dMCL injury did not significantly increase medial joint space opening, sMCL resection gradually increased joint space opening 3.2 ± 1.9 to 6.9 ± 2.7 mm (p = 0.039) between 0° and 45° knee flexion. Following POL deficiency, medial joint space opening further increased 6.4 ± 2.7 to 11.4 ± 6.2 mm between 0° and 45° knee flexion (p = 0.0035). A combined injury (dMCL/sMCL/POL/ACL) increased medial joint space opening 12.0 ± 4.9 to 21.8 ± 7.9 mm (p < 0.0001) between 0° and 45° knee flexion, compared to the intact state. The intraobserver ICC was 0.995 and the interobserver ICC was 0.955 showing excellent intra- and interobserver reliability.

Conclusion: Deficiency of the medial stabilisers of the knee increased medial joint space opening in stress radiography, whereas isolated dMCL deficiency did not significantly affect valgus gapping. This study demonstrated a good concordance between valgus stress radiography and clinical scores (International Knee Documentation Committee and Hughston). Our findings support performing valgus stress tests at 0° and at least 20° of flexion.

Level of evidence: There is no level of evidence as this study was an experimental laboratory study.

Purpose: The treatment of patellar dislocation is tailored based on the presence or absence of osseous risk factors. The purpose of this scoping review was to investigate whether existing research addresses patient differences by mapping the use of osseous risk factors and patient-reported outcome measures (PROMs) in studies investigating the treatment of patellar dislocation.

Methods: This study was a scoping review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews. Studies published between 1 January 2013 and 3 April 2023 were included if they investigated the treatment of patellar dislocation and registered osseous risk factor(s). Case series with fewer than 10 patients, reviews and meta-analyses were excluded.

Results: A total of 8923 records were identified, of which 1007 articles underwent full-text screening, and 300 met the inclusion criteria. A twofold increase in articles investigating patellar dislocation treatment was observed between the years 2013 and 2022. This review identified 176 osseous risk factors and 56 PROMs. Among the included articles, 131 (44%) utilized osseous risk factors as in- or exclusion criteria, and 26 (9%) employed a PROM specifically developed for patellar instability evaluation. The most frequently investigated treatment was medial patellofemoral ligament reconstruction (231 articles, 77%), followed by tibial tubercle osteotomies (87 articles, 29%).

Conclusion: There is considerable heterogeneity among studies investigating the treatment of patellar dislocation. Less than half of studies define the patient population according to osseous risk factors, and only 1 in 10 studies use a PROM designed for patellar dislocation. This complicates the evaluation of treatment effects in relation to osseous risk factors.

Level of evidence: Level III.

Purpose: Functional alignment (FA) in total knee arthroplasty (TKA) prioritizes soft tissue balancing and anatomical restoration without systematic correction to neutral alignment. Most studies have focused on varus deformity, with little evidence available about FA in valgus deformity. The hypothesis of the present study was that FA in robotic-assisted TKA for valgus deformity would demonstrate correction of the coronal alignment and yield satisfactory short-term outcomes.

Methods: This retrospective study included 58 patients with valgus coronal alignment (hip-knee-angle [HKA] ≥ 183°) who underwent robotic-assisted TKA using the FA technique with a minimum of 1-year follow-up. Outcomes were assessed through the Knee Society Score (KSS), Oxford Knee Score (OKS), Forgotten Joint Score (FJS) and radiographic measurements of alignment and phenotypes. Complication and revision rates were also analyzed.

Results: The cohort included 39 females and 19 males with a median age of 70. Post-operatively, 86.2% of cases achieved coronal alignment within the safe zone (HKA 177-183°). Significant improvements were observed in KSS (part 1: 69.5-95, part 2: 65-94, p < 0.001), while OKS and FJS exhibited optimal outcomes. Two complications were recorded: one aseptic loosening (1.7%) and one early infection (1.7%). Kaplan-Meier survival analysis indicated favourable implant survivorship at a median follow-up of 18 months.

Conclusion: FA in image-based robotic TKA is a safe and effective approach for patients with valgus deformity. This procedure resulted in a modest correction of the coronal alignment, where no soft tissue releases were needed. The majority of the cases fell within the target coronal alignment boundaries by only accommodating the individual laxities, suggesting the aim of FA to restore each knee's pre-pathological alignment.

Level of evidence: Level IV.

Purpose: To investigate return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR), differences based on sex and concomitant meniscal repair, and identify reasons why patients do not RTS.

Methods: Overall, 232 patients undergoing ACLR, with or without concomitant meniscal repair, that were actively participating in pivoting sports at the time of injury, were prospectively recruited. At 2 years, return to preinjury pivoting sport was investigated and, if they had returned, whether they felt their performance was at (or better) or below preinjury status. Specific reasons for not returning were identified. RTS rates and reasons for not returning were compared based on sex and meniscal repair.

Results: Overall, 140 patients (60.3%) had returned to their preinjury pivoting sport, of which 98 (70.0%) felt they were performing at (or beyond) preinjury status. While a significantly greater (p = 0.024) percentage of males (66.9%) versus females (52.4%) had returned to pivoting sports by 2 years, no differences (p = 0.708) were seen based on concomitant meniscal repair. Overall, 92 patients (39.7%) had not RTS, with primary reasons being loss of interest (21.7%), too busy due to their work and/or family environment (22.8%), or fear of reinjury or lacking confidence (17.4%). Other less-reported reasons included ongoing knee issues (6.5%) or not feeling physically ready (5.4%).

Conclusions: This study outlined specific reasons why community-level patients do not RTS, with RTS status (and reasons for not returning to preinjury pivoting sports) differing between males and females, with the latter returning at a significantly lower rate overall.

Level of evidence: Level IV.