Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: The main purpose was to determine cut-off values for absolute (Q_Nm/kg) and relative (Q_LSI) isokinetic knee extensor (KE) strength for achieving a patient-acceptable symptom state (PASS) in the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and for different age groups to determine the association between Q_Nm/kg and Q_LSI and PASS, at 1 and 3 years after an anterior cruciate ligament reconstruction (ACLR).

Methods: PASS was defined as reaching cut-off values for all KOOS subscales. Data from follow-ups were extracted from a rehabilitation registry. Male and female patients were divided into two age groups based on their age at primary ACLR: 16-24 years and 25-65 years. Odds Ratios between the Q_Nm/kg and Q_LSI cut-off values and achieving PASS were calculated. Receiver Operating Characteristic curves were constructed to determine the individual predictive capacity for achieving PASS of Q_Nm/kg and of Q_LSI using the area under the curve (AUC).

Results: Results from 755 and 145 patients (females = 51% and 52%; preinjury Tegner Activity level ≥6 = 82% and 74%) were used in the 1- and 3-year follow-up analyses. Reaching the cut-off values for the Q_Nm/kg, ranging between ≥2.1 and ≥2.7, entailed between 2.09 and 5.12 times the odds of achieving PASS, across all groups at the 1-year follow-up. At the 3-year follow-up, the cut-off values of ≥3.4 and ≥2.6Q_Nm/kg were associated with patients achieving PASS with acceptable accuracy (AUC = 0.700-0.780) in 16-41 year-old males and females.

Conclusion: At 1 year after ACLR, patients of both sexes and age groups reaching cut-off values for absolute KE strength had two to five times the odds, that were clinically relevant, to achieve PASS. Acceptable discriminative capacity was found for the absolute KE strength among male and female patients 16-24 years old, at 3 years after ACLR.

Level of evidence: Level III.

Purpose: To adapt the current D. Dejour trochlear dysplasia classification (v2.0) to only rely on quantitative magnetic resonance imaging (MRI) measurements (v3.0) to maximize objectivity and repeatability.

Methods: A consecutive series of adult knee MRIs were divided into objective patellar instability (OPI, n = 127) or controls (n = 103; isolated meniscal tears) and postprocessed with multiplanar reconstruction (MPR) to standardize the sagittal plane and ensure true lateral views. Thresholds for sulcus angle, lateral trochlear inclination (LTI) and central bump were established using regression tree models to distinguish OPI from controls. The sensitivity and specificity of sulcus angle and LTI combinations to diagnose OPI were then evaluated, and the combination yielding the highest sensitivity was selected as basis for trochlear dysplasia classification. Finally, sulcus angle and LTI measurability and presence of a central bump >5 mm were used to grade dysplasia as low, moderate or high.

Results: The regression tree models produced thresholds of ≥157° for sulcus angle and <14° for LTI to distinguish OPI from controls. 'Sulcus angle ≥157° OR LTI < 14°' yielded the highest sensitivity (87%) to diagnose OPI. The quantitative MRI classification was sulcus angle <157° AND LTI ≥ 14° for Type 0 (No dysplasia); (sulcus angle ≥ 157° OR LTI < 14°) AND central bump <5 mm for Type 1 (Low-grade dysplasia); (sulcus angle OR LTI are 'unmeasurable') AND central bump <5 mm for Type 2 (Moderate-grade dysplasia); (sulcus angle ≥ 157° OR 'unmeasurable' OR LTI < 14° OR 'unmeasurable') AND central bump ≥5 mm for Type 3 (High-grade dysplasia).

Conclusion: This MRI classification depends exclusively on quantitative measurements, has excellent interobserver agreement, and yields high sensitivity to diagnose OPI. The MRI imaging protocol with MPR mode and standardized measurements could be quickly adopted and correctly applied by clinicians worldwide in any type of institution to determine the ideal treatment plan.

Level of evidence: Level III.

Total knee arthroplasty (TKA) is a widely performed surgical intervention designed to relieve pain and restore function in patients with severe knee joint degeneration, most commonly due to osteoarthritis. This procedure involves replacing the damaged knee joint with a prosthetic implant, providing significant improvements in mobility and quality of life. While TKA is beneficial for many, the individuals who stand to gain the most are those with advanced knee arthritis unresponsive to conservative treatments, typically aged 60 and above, experiencing activity-related pain and functional limitations. Identifying patients with the highest potential for positive outcomes is critical to maximizing the benefits of this transformative surgery. Goal of this editorial is to give a critical view on today's common practice of arthroplasty surgery.

Purpose: Patients undergoing total knee arthroplasty (TKA) with prior knee cartilage surgery have unclear outcomes in the literature. This study compared outcomes after TKA in patients with or without prior knee cartilage surgery, and we hypothesized there would be equivocal outcomes between groups.

Methods: A retrospective matched case-control study was conducted on patients from our institution who underwent ipsilateral cartilage procedure(s) and TKA (cases) or TKA alone (controls) from 2000 to 2022. Cartilage procedures included Autologous Chondrocyte Implantation (ACI), Osteochondral Allograft (OCA) and Microfracture (MFx). Matching was performed in 1:3 (case:control) ratio for age, sex, body mass index, Charlson Comorbidity Index, pre-TKA Kellgren-Lawrence osteoarthritis grade and follow-up for knee injury and osteoarthritis outcome score for joint replacement (KOOS-JR). Mann-Whitney U and χ² analyses were conducted, with significance being a p < 0.05. A priori power analysis required 29 patients per cohort to reach a clinically detectable difference of 11 for KOOS-JR.

Results: Forty-three cases (one ACI, eight OCA and 34 MFx) and 129 controls were included after matching, with no significant demographic differences. Cases underwent TKA after cartilage surgery at a mean of 4.6 years. No significant differences existed between cases and controls for the preoperative KOOS-JR (45.2 vs. 47.8; p = 0.353), postoperative KOOS-JR (69.8 vs. 69.9; p = 0.974) or Delta KOOS-JR (30.4 vs. 26.0; p = 0.387). No significant differences existed for 90-day readmission rates (4.7% vs. 2.3%; p = 0.600) or revision TKA rates (11.6% vs. 5.4%; p = 0.177).

Conclusion: Patients with and without prior cartilage surgery experience similar functional outcomes, readmission rates and revision rates after TKA on the same knee. Patients who are candidates for TKA with a history of cartilage surgery may be counselled that their surgical history on that knee does not convey the risk of worse functional outcomes.

Level of evidence: Level III case-control study.

Purpose: This study aimed to assess the short-term clinical efficacy of combining posterior meniscal root repair with meniscal centralization technology in the treatment of medial meniscus posterior root tears (MMPRTs) and notable meniscus extrusion.

Methods: In this retrospective analysis, patients aged 43-76 years with only chronic posterior root tears of the medial meniscus and notable extrusion were followed up for 12-14 months.

Inclusion criteria: (1) persistent medial knee joint pain affecting daily life, presenting with joint space tenderness; (2) showing the ineffectiveness of conservative treatment for a minimum of 3 months; conservative treatment includes non-invasive methods such as nonsteroidal anti-inflammatory drugs, physical therapy and massage, but does not include intra-articular injections. (3) Kellgren-Lawrence Grades 0-II osteoarthritis (OA) of the knee joint; and (4) diagnosis of a posterior root tear of the medial meniscus with notable meniscus extrusion confirmed through knee-joint plain magnetic resonance imaging (MRI) scans, where coronal image revealed a meniscus body extrusion of ≥3 mm.

Exclusion criteria: (1) Kellgren-Lawrence Grades III-IV OA in the knee joint; (2) presence of knee joint infection or other structural damage to the knee joint; (3) history of previous knee joint surgery; (4) demonstrating joint instability or abnormal lower-limb alignment (varus deformity >5°); and (5) presence of severe mental illness, coagulation disorders, or other serious medical conditions. The Lysholms score, the Hospital for Special Surgery (HSS) knee score, the visual analogue scale (VAS) score and meniscal extrusion values were evaluated before and after surgery in 23 patients through a comparative analysis.

Results: The results of the follow-up conducted 12-14 months post-operatively indicated a significant improvement in the patients' conditions. In particular, the Lysholms scores (preoperative: 50.9 ± 10.2; 1-year post-surgery: 72.0 ± 8.4), HSS knee scores (preoperative: 45.9 ± 10.6; 1-year post-surgery: 79.1 ± 11.1) and VAS scores (preoperative: 4.0 ± 1.1; 1-year post-surgery: 0.9 ± 0.7) exhibited notable enhancements. Furthermore, compared to the preoperative values, the degree of meniscus extrusion measured by coronal MRI of the knee joint significantly improved post-operatively (preoperative: 3.7 ± 0.8 mm; 1-year post-surgery: 2.2 ± 0.6 mm). These findings all yielded a p < 0.05, signifying statistical significance.

Conclusion: In patients with chronic MMPRTs and notable extrusion, a combination of posterior meniscal root repair and centralization technology can effectively restore meniscus function and rectify the medial meniscus displacement, resulting in favourable short-term clinical outcomes.

Level of evidence: Level IV.

Purpose: The aim of this systematic review and survival analysis was to quantify the benefits of orthobiologic augmentation therapies for the treatment of avascular necrosis (AVN) of the femoral head and identify the most effective approach to delay the need for total hip arthroplasty (THA).

Methods: A systematic review of the literature was performed on PubMed, Scopus, and Cochrane on clinical studies on orthobiologic therapies used alone or as an augmentation to core decompression or other procedures to address hip AVN. A qualitative analysis of the different biological therapies applied was performed. Afterward, the results of these procedures were quantitatively analysed to document their survivorship from THA compared to treatment groups without orthobiologics. Kaplan-Meier analysis was performed for all studies and then by categorising orthobiologics into treatment subgroups.

Results: A total of 106 studies were included (4505 patients). Different orthobiologic approaches have been evaluated: cell-based therapies including bone marrow aspirate concentrate (BMAC) and bone marrow mesenchymal stromal cells (BM-MSCs), platelet-rich plasma (PRP), or other bioactive molecules applied in the osteonecrotic area or as intra-arterial injections. The survival analysis at 120 months documented a higher (p < 0.0005) cumulative survivorship with orthobiologics (69.4%) compared to controls (48.5%). The superiority was shown specifically for BMAC (p < 0.0005), BM-MSCs (p < 0.0005), intra-arterial (p < 0.0005) and PRP (p = 0.011) approaches, but the direct comparison of these approaches with their controls confirmed benefits only for BMAC (p < 0.0005).

Conclusion: This systematic review and survival analysis demonstrated that orthobiologics have the potential to improve survivorship in patients affected by hip AVN. In particular, the specific analysis of different orthobiologic products supported relevant benefits for BMAC augmentation in terms of survival from the need for THA, while no clear benefits were confirmed for other orthobiologics.

Level of evidence: Level III.

Purpose: Using time-driven activity-based costing (TDABC), we sought to compare the total facility costs, comprising supply and personnel costs during the episode of care for the index procedure, in patients with isolated medial compartmental knee osteoarthritis (OA) undergoing unicompartmental knee arthroplasty (UKA) versus total knee arthroplasty (TKA).

Methods: We conducted a retrospective analysis of 100 UKAs and 100 TKAs from 2019 to 2022. From a larger sample of 4899 TKAs and 137 UKAs, patients with isolated medial OA (Kellgren-Lawrence Grade <2 in other compartments) were radiographically identified. Demographic data included age, sex and body mass index, with comorbidities controlled using the Charlson comorbidity index. Facility costs were calculated using TDABC and standardized in cost units (CUs), a metric for comparing costs across procedures. Multiple regression analysis was used to assess the independent effect of TKA versus UKA on facility costs.

Results: TKA patients had similar operative times (TKA vs. UKA: 1.01×, p = 0.783) and supply costs (1.00×, p = 0.866), where 'x' denotes the relative cost ratio. However, TKA was associated with higher personnel costs (260.0 vs. 222.5 CUs [1.17×], p < 0.001) and total facility costs, both including (706.3 vs. 667.5 CUs [1.06×], p = 0.007) and excluding implants (353.8 vs. 312.5 CUs [1.13×], p < 0.001). Adjusted for demographics and comorbidities, TKA had increased facility costs, including (32.2 CUs, 95% confidence interval [CI]: 2.9-61.5, p = 0.031) and excluding implants (37.8 CUs, 95% CI: 15.2-60.3, p = 0.001).

Conclusions: TDABC analysis revealed higher total facility costs for the index procedure in TKA, suggesting UKA may be a cost-saving alternative for isolated medial compartment knee OA.

Level of evidence: Level III, retrospective comparative study.