Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: The dynamic alignment of the lumbar spine, pelvis and femur is increasingly studied in hip preservation surgery. However, the interaction between lumbopelvic alignment, acetabular and femoral morphology and its influence on patients' preoperative symptom burden remains poorly understood. The aim of this study was to evaluate whether lumbopelvic malalignment affects osseous hip morphology and exacerbates preoperative patient-reported joint functionality in patients undergoing periacetabular osteotomy (PAO).

Methods: One hundred thirteen patients were prospectively enroled in this single-centre study. Sagittal lumbopelvic radiographs were used to divide the patients in accordance with their lumbopelvic alignment (pelvic incidence [PI]-lumbar lordosis [LL] mismatch) into a balanced (PI-LL: 10° and 10°/n = 60) and unbalanced alignment (PI-LL: <10° and >10°/n = 53) group. Intergroup analyses were performed for acetabular and femoral morphology as well as various patient-reported outcome measures (PROMs) scores (modified Harris-Hip, Hip Osteoarthritis Outcome, International Hip Outcome tool-12 and University of California Los Angeles activity scale).

Results: Patients with concomitant unbalanced lumbopelvic alignment due to hyperlordosis showed higher femoral head coverage and lower femoral anteversion (lateral centre-edge angle 20.2° vs. 15.8°, p = 0.012/anterior wall index 0.47 vs. 0.36, p = 0.001/acetabular inclination 10.2° vs. 13.6°, p = 0.008/Femoral anteversion 21.3° vs. 28.2°, p = 0.041). Furthermore, these patients were significantly younger at the time of PAO (28.7 vs. 32.4 years, p = 0.020), even when there were no intergroup differences in all analyzed PROMs.

Conclusion: Concomitant lumbopelvic deformity affecting the hip joint morphology could aggravate clinical symptoms leading to earlier presentation in patients undergoing PAO. Thus, the lumbopelvic balance needs to be carefully evaluated in clinical decision-making in PAO patients and future research should focus on long-term outcomes of patients with concomitant unbalanced lumbopelvic alignment.

Level of evidence: Level III, prognostic study.

Purpose: Arthrogenic muscle inhibition (AMI) is a reflexive shutdown of the quadriceps muscles following a knee injury or surgery that presents with or without hamstring contracture. This complication can be classified according to the SANTI classification, but the reproducibility of this clinical classification has not yet been demonstrated.

Methods: This single-centre longitudinal observational study included 140 patients who were within 6 weeks of an ACL rupture. The presence of AMI was assessed separately and blindly during the preoperative consultation and at 3 weeks post-operative by an Orthopaedic Surgeon, an Orthopaedic Resident, a Sports Medicine Physician and a Physiotherapist. AMI was also assessed a second time by the physiotherapist, 10 days after the first assessment, before and after reconstruction surgery, in order to measure intra-rater reliability. The inter-rater and intra-rater reliability of the AMI classification was determined by calculating the intraclass correlation coefficient (ICC).

Results: Agreement for the AMI classification between different examiners was excellent pre-operatively (ICC = 0.99 [95% confidence interval, CI: 0.99-0.99]) and post-operatively (ICC = 0.98 [95% CI: 0.98-0.99]). Agreement in the AMI classification, when determined repeatedly by the same assessor (physiotherapist), was excellent pre-operatively (ICC = 0.92 [95% CI: 0.89-0.94]) and post-operatively (ICC = 0.98 [95% CI: 0.97-0.99]).

Conclusion: Excellent intra-rater and inter-rater reliability of the AMI classification system was found in patients with recent ACL rupture and post-operatively.

Level of evidence: Level II, diagnostic study prospective cohort study.

Purpose: >The aim of this multicenter study was to analyze the potential impact of patient demographics and cementation technique towards the development of radiolucent lines (RLLs) in primary total knee arthroplasty (TKA). It was hypothesized that cementation techniques, including higher cement volume, double-layer cementation technique and hardening in full extension, reduce RLL incidence by improving stability, whereas demographic factors such as age, BMI and smoking may increase RLL risk by affecting bone quality and mechanical loading.

Methods: Altogether, 776 patients (median age: 70.7 years; 39.2% males) underwent TKA at five tertiary orthopaedic centres between 11/2013 and 04/2023. X-rays were analyzed retrospectively for the evaluation of RLLs taken between 6 and 36 months from surgery. RLLs on anterior-posterior and lateral X-rays taken at a median of 14 months (range: 6-36) from primary surgery were evaluated using the Knee Society roentgenographic evaluation and scoring system. Potential associations of demographics and cementation technique on the occurrence of RLLs during follow-up were analyzed with uni- and multivariate logistic regression models.

Results: The overall incidence of RLLs around the TKA amounted to 37.4% (n = 290), with the tibial component (29.4%) being more commonly affected than the femoral component (15.0%). Patient age, gender, BMI and smoking habits were not significantly associated with higher incidence of RLLs (p > 0.05). The amount of cement used (odds ratio: 0.99; 95% confidence interval: 0.98-0.99; p = 0.028) was independently associated with a lower incidence of RLLs, irrespective of the double- versus single-layer cementation technique, cement hardening in full extension and time required for the X-ray.

Conclusions: No influence of demographic data on the incidence of RLL was found, yet specific cementation techniques appeared beneficial. Future studies with longer follow-up periods are required to provide further insight into the herein-made preliminary findings and to assess potential associations with long-term aseptic loosening rates.

Level of evidence: Level III, retrospective observational study.

Purpose: To investigate kneeling tolerance in patients undergoing hamstring (HT) versus quadriceps (QT) anterior cruciate ligament reconstruction (ACLR) and investigate correlation with patient-reported outcome measures (PROMs).

Methods: After recruitment and randomisation, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed at 6, 12 and 24 months using the Kneeling Tolerance Test, which evaluates patient-reported pain in a position of both 90 (KT90) and 110 (KT110) degrees of knee flexion. PROMs collected included the International Knee Documentation Committee (IKDC) questionnaire and the ACL Return to Sport after Injury (ACL-RSI) questionnaire.

Results: Kneeling tolerance at KT90 and KT110 improved (p < 0.05) for both graft types across all time points. There was no difference in KT90 scores between groups at 6 or 12 months. At 24 months, kneeling tolerance was superior in the QT group (mean HT 93 ± 9 vs. QT 98 ± 5; p = 0.003). For KT110 scores, a statistically significant difference was noted at 6 (mean HT 80 ± 25 vs. QT 89 ± 12; p = 0.027), 12 (mean HT 90 ± 13 vs. QT 95 ± 10; p = 0.040) and 24 months (mean HT 92 ± 10 vs. QT 97 ± 5; p = 0.003). The ACL-RSI was significantly correlated with KT90 and KT110 at 24 months (r = 0.40, p < 0.001; r = 0.40, p < 0.001). Other PROMs demonstrated significant weak-to-moderate correlations with kneeling tolerance.

Conclusion: Patients undergoing ACLR with a QT versus HT autograft report superior kneeling tolerance up to 2 years postsurgery, more prominent in deeper (110°) knee flexion. A strong correlation with ACL-RSI was demonstrated at 2 years.

Registration: ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).

Level of evidence: Level 1.

Purpose: Revision knee replacement (RevKR) for infection is rare but increasing. It is hypothesised that higher hospital volume reduces adverse outcomes. The aim was to estimate the association of surgical unit volume with outcomes following first, single-stage RevKR for infection.

Methods: This population-based cohort study merged data from the United Kingdom National Joint Registry, Hospital Episode Statistics, National Patient Reported Outcome Measures and the Civil Registrations of Death. Patients undergoing procedures between 1 January 2009 and 30 June 2019 were included. Early outcomes were chosen to reflect the quality of the surgical provision and included re-revision at 2 years, mortality, serious medical complications, length of stay and patient-reported outcome measures (PROMs). Adjusted fixed effect multivariable regression models were used to examine the association between surgical unit mean annual caseload and the risk of adverse outcomes.

Results: A total of 1477 patients underwent first-time single-stage RevKRs for infection across 267 surgical units and 716 surgeons. Following adjustment for age, gender, American Society of Anaesthesiologists grade, surgeon volume, year of surgery and operation funder and modelling surgical unit volume with restricted cubic spline, a greater mean annual volume was associated with a lower risk of re-revision at 2 years. The odds of re-revision in hospitals performing fewer than or equal to 12 cases per year was 2.53 (95% confidence interval = 1.50-4.31) times more likely than hospitals performing three to four cases per month. Annual variation in surgical unit volume was not associated with mortality and serious medical complications within 90 days. Only 99 out of 1477 (7%) of patients had linked PROMs which precluded subsequent analysis.

Conclusion: Overall, higher volume surgical units had lower rates of early re-revision following the first RevKR for infection. We were unable to provide recommended specific volume thresholds for units; however, the probability of re-revision appears to be lowest in the highest volume units.

Level of evidence: Level III, retrospective cohort study of prospectively collected data.

Purpose: To propose a new sign of patellar maltracking in recurrent patellar dislocation (RPD) and compare the differences in lower limb rotational and bony structural abnormalities among the different signs.

Patients and methods: A retrospective study included 279 patients (mean age: 22 years; female: 81%) who underwent primary surgery for RPD over the past 4 years was performed. The patients were grouped based on the characteristics of patellar tracking: low-, moderate- and high-grade J-sign. Patients were further divided into 'jumping' and 'gliding' subgroups based on whether the patella exhibited a 'jumping' sign during flexion-extension motion. All patients received bilateral standard hip-knee-ankle CT scans. The rotational and bony structural parameters of affected knees were measured, and the differences in these variables among the groups were described and analyzed. Reliability analysis was performed to test the consistency of J-sign grading and measurements.

Results: There were 92, 100 and 87 patients in the low-, moderate- and high-grade J-sign, respectively. The overall incidence of the jumping sign is 37%. The incidence of the 'Jumping sign' in the high-grade J-sign was significantly higher than in the other two groups (82% vs. 32% vs. 0, p < 0.001). Compared to those with the gliding sign, patients with the jumping sign have higher proportions of increased femoral anteversion (40.8% vs. 24.4%, p = 0.004), excessive knee torsion (61.2% vs. 15.3%, p < 0.001), trochlear dysplasia (95.1% vs. 69.3%, p < 0.001), pronounced supratrochlear spur (73.1% vs. 32.3%, p < 0.001), increased tibial tuberosity-trochlear groove distance (68% vs. 43.3%, p < 0.001), flatter lateral trochlear inclination (81.3% vs. 27.5%, p < 0.001) and excessive sulcus angle (68.7% vs. 35.3%, p = 0.003). No significant morphological differences were found in various bony structural parameters between knees with jumping sign and high-grade J-sign (all p > 0.05). The inter-observer reliability kappa values were 0.65 for the quadrant classification and 0.83 for the new patellar sign.

Conclusion: In RPD patients, the rotational and bony structural abnormalities in the jumping sign are highly consistent with the high-grade J sign. This finding may assist the surgeon and their patients in making informed decisions about further imaging tests and osteotomy procedures in the treatment of RPD.

Level of evidence: Level IV, cross-sectional study.

Purpose: To compare football players who have undergone one anterior cruciate ligament (ACL) reconstruction (ACLR) with those who have undergone a subsequent ACLR (revision or contralateral) regarding (1) demographics, (2) football-related factors and (3) injury-specific data.

Methods: Players who voluntarily completed a football-specific questionnaire available at the Swedish National Knee Ligament Registry website between April 2017 and September 2020 at the time of their primary ACL injury were included in the study. The questionnaire covered demographics, football-related activities and injury-specific factors. Subsequent ACLR registrations within 4 years of the primary ACLR were identified in December 2023. Data on game participation post-primary ACLR were retrieved from the Swedish Football Association's administrative system in September 2022.

Results: A total of 992 football players (66% men) were included, of whom 99 (10%) were registered for subsequent ACLRs. Univariable analysis showed that the following factors significantly increased the odds of a subsequent ACLR: female sex, younger age, a lower weight and body mass index, fewer years played, use of knee control exercises during warm-up, more likely to plan a return to football, more game participation registered following the primary ACLR, and shorter time between injury and ACLR. Multivariable logistic regression analysis indicated that the odds of undergoing subsequent ACLR decreased significantly with each additional year of age (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.83‒0.92, p < 0.01). Players using knee control exercises during warm-up (OR, 1.71; 95% CI, 1.08‒2.72, p = 0.02), planning to return to football (OR, 2.74; 95% CI, 1.27‒5.91, p = 0.01), and participating in games after primary ACLR (OR, 1.81; 95% CI, 1.13‒2.91, p = 0.01) increased the odds of undergoing a subsequent ACLR.

Conclusions: Younger age and returning to play after an ACLR significantly increase the likelihood of undergoing a subsequent ACLR in football players.

Level of evidence: Level IV.

Purpose: To quantify the effect of increasing the posterior tibial slope (PTS) on knee kinematics and the resultant medial and lateral meniscal forces.

Methods: In this controlled laboratory study, a 6 degrees of freedom (DOF) robotic testing system was used to apply external loading conditions to seven fresh-frozen human cadaveric knees: (1) 200-N axial compressive load, (2) 5-N m internal tibial +10-N m valgus torque and (3) 5-N m external tibial + 10-N m varus torque. Knee kinematics and the resultant medial and lateral meniscal forces were acquired for two PTS states: (1) native PTS and (2) increased PTS. Resultant forces in the medial and lateral meniscus were calculated using the principle of superposition.

Results: In response to 5-N m external tibial + 10-N m varus torque, significantly more internal tibial rotation was observed after increasing PTS at 60° (p = 0.0156) and 90° (p = 0.0156) flexion. Increasing PTS caused significantly more medial tibial translation from 30° to 90° flexion in response to 5-N m internal tibial + 10-N m valgus torque. In response to 5-N m external tibial + 10-N m varus torque, the resultant force in the medial meniscus at 60° flexion decreased significantly after increasing PTS (32.8%, p = 0.016). Resultant forces in the lateral meniscus decreased significantly after increasing PTS at 30° (34.5%; p = 0.016) and 90° (29.7%; p = 0.031) flexion in response to 5-N m internal tibial + 10-N m valgus torque.

Conclusion: Increasing PTS in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads. Therefore, increasing PTS during high tibial osteotomy in a knee with intact cruciate ligaments does not increase the force carried by the entire meniscus at time zero.

Level of evidence: N/A.

Purpose: Medial meniscus ramp lesions (MMRLs), lateral meniscus posterior root tears (LMPRTs), and anterolateral complex injuries (ALCIs) are major secondary stabiliser injuries associated with anterior cruciate ligament (ACL) injuries. This study aimed to investigate the effect of the number of secondary stabiliser injuries on knee instability in ACL injuries.

Methods: Patients who underwent primary ACL reconstruction between January 2017 and May 2023 were enroled in this study. Exclusion criteria encompassed patients with other ligament injuries, a history of contralateral knee injury, hyperextension, flexion contracture and meniscus injuries other than MMRL or LMPRT. Ultimately, 158 patients (mean age: 25.3 years; 81 males and 77 females) were included in this study, and the presence of MMRL, LMPRT and ALCI was investigated. Patients were categorised into four groups based on the number of ACL and secondary stabiliser injuries: single (isolated ACL injury), dual, triad and tetrad. Subsequently, the groups were compared regarding pivot shift grade, quantitative rotational instability measured using an inertial sensor, and anterior tibial translation (ATT).

Results: Secondary stabiliser injuries identified included ALCI 85 (53.8%), MMRL 58 (36.7%) and LMPRT 23 (14.6%). The distribution of patients in the single, dual, triad and tetrad groups was 45 (28.5%), 68 (43.0%), 37 (23.4%) and 8 (5.1%), respectively. High-grade pivot shifts were observed in 33.3% (15 out of 45) of the single group, 63.2% (43 out of 68) of the dual group, 67.6% (25 out of 37) of the triad group, and 100% (8 out of 8) of the tetrad group. Quantitative evaluations using the inertial sensor revealed significantly lower acceleration in the isolated ACL injury group compared to the other groups (p < 0.05). No significant difference was observed in ATT measurements (n.s.).

Conclusion: The combination of secondary stabiliser injuries led to higher instability. Therefore, it is important to carefully diagnose these injuries and devise appropriate treatment plans, particularly in cases of high knee instability.

Level of evidence: Level III diagnostic.

Background: The INtensive diet versus Knee Arthroplasty (INKA) trial is a randomised trial assessing weight loss as an alternative to knee arthroplasty (KA) in obese patients with severe knee osteoarthritis (OA) awaiting KA (NCT05172843). The external validity of the INKA trial may be hampered if the patients who participate differ from those who decline participation.

Objective: To compare baseline characteristics between patients who enrol in the INKA trial and those who decline participation (i.e., non-INKA [nINKA] group).

Methods: We applied a cross-sectional study design, collecting and comparing baseline characteristics among all patients eligible for enrolment in the INKA trial from two clinics in Copenhagen. Imbalance between accepting (INKA) and declining (nINKA) groups was assessed using standardised differences (StdDs). We were prespecified that StdD values < 0.20 would indicate a clinically insignificant imbalance between groups, whereas values > 0.80 indicate incomparability.

Results: Of the 913 patients scheduled for KA, 888 were screened for INKA trial eligibility. Of the 217 eligible patients, 92 (42%) were enroled in the INKA trial, while 37 (17%) participated in the nINKA cross-sectional sample only. Patients enroled in INKA had on average a less severe Oxford knee score (OKS) of 22.0 (standard deviation = 6.7) compared to declining participants in nINKA with 18.6 (7.2), corresponding to an StdD of 0.50, and an absolute difference of 3.45 (95% confidence interval = 0.64-6.26, p = 0.017). A consistent similar pattern was noted across all secondary patient-reported outcomes applied in the INKA trial.

Conclusions: We observed discrepancies in patient-reported outcomes, with those who declined enrolment reporting more severe symptoms. These differences, however, were below the minimally important difference between groups for OKS, which is set to 4.84 points.

Level of evidence: Level II-III cross-sectional study in a randomised control trial.