Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Current anterior cruciate ligament reconstruction (ACLR) rehabilitation practice guidelines lack updates in key areas: open kinetic chain (OKC) quadriceps strengthening, neurocognitive training and psychological interventions. Recent research shows that OKC exercises, when combined with closed kinetic chain exercises, improve strength without compromising graft integrity, though careful monitoring for knee pain and effusion is essential. Neurocognitive training, targeting reaction times, visual attention and dual-tasking, is promising for reducing reinjury risk but remains underutilized. Similarly, psychological responses, often assessed via patient-reported outcomes, are a critical part of the recovery process after ACLR, but how to address these responses for the individual patient remains unclear, emphasizing the need for individualized support. The European Society for Sports Traumatology, Knee Surgery, and Arthroscopy (ESSKA) is developing an ACL rehabilitation consensus to integrate these insights into actionable, evidence-based guidelines, ensuring tailored, patient-centered care that optimizes recovery and reduces reinjury risks. LEVEL OF EVIDENCE: Level V.

Purpose: The aim of this study is to investigate the impact of increased posterior tibial slope (PTS) on pressure distribution in the medial and lateral tibial plateau. The focus is on compartment-specific effects and potential correlations with cartilage damage, due to altered anterior tibial translation caused by increased PTS.

Method: Ten freshly frozen knee specimens were prepared and subjected to biomechanical testing. PTS was modified by inserting 5°, 10°, 15° and 20° polylactic acid wedges into osteotomy gaps. Pressure distribution was measured using Tekscan's Pressure Mapping Sensor 5040™ beneath the menisci at varying PTS angles. The kinetic data were tracked using the Optotrak Certus® system. Statistical analyses were employed to evaluate the pressure shifts and their significance.

Results: The study revealed that increased PTS significantly shifted the pressure point anteriorly on the lateral tibial plateau, while no significant changes were observed on the medial plateau. The analysis of tibial translation showed a corresponding rise in anterior translation with increasing PTS, especially at higher angles.

Conclusion: Increased PTS, particularly above 10°, induces significant anterior translation and altered pressure distribution, primarily affecting the lateral tibial plateau. These findings support the hypothesis that elevated PTS contributes to biomechanical stresses in the knee, potentially increasing the risk of lateral compartment cartilage degeneration. These results highlight the importance of considering PTS in clinical assessments and interventions aimed at optimizing knee joint health.

Level of evidence: Level IV.

Purpose: To analyse biomechanical determinants for radiological and clinical outcomes of posterior horn longitudinal vertical meniscal tear (LVMT) repairs.

Methods: Patients undergoing primary repair of vascular zone traumatic full-thickness posterior horn LVMT were enroled. We hypothesized four potential factors would influence mid-term outcomes: malalignment (varus/valgus ≥5° for medial/lateral tears), meniscal laterality (medial vs. lateral), concomitant anterior cruciate ligament reconstruction (ACLR) and cartilage damage (Outerbridge grade ≥ II). The primary outcome was posterior horn nonhealing rate 6 months postoperatively (T1), evaluated using computed tomography arthrography (CTA) and Henning's criteria. Secondary outcomes were patient-reported outcomes measures (PROMs) assessed at T1 and ≥24 months postoperatively (T2). Univariate and multivariate logistic regression models estimated the marginal relative risk (MRR) of nonhealing for each determinant, while fractional logit regression assessed determinants' impact on PROMs at T1 and T2.

Results: Seventy-eight patients (median age 29 years, interquartile range [IQR]: [21-37]); 76% male), were followed for ≥2 years (median 2.5 years, IQR: [2.1-3.6]). LVMTs extended to the middle horn in 81% and to the anterior horn in 52%. Posterior horn nonhealing rates (53%) were higher than in the middle (35%, p = 0.013) and anterior horn (7%, p < 0.001). Malalignment was present in 14%, medial meniscal involvement in 77%, ACLR in 55% and cartilage damage in 37%. Malalignment (MRR = 1.48, 95% confidence interval (CI): [0.84, 2.09]) and medial laterality (MRR = 1.7, 95% CI: [0.93, 3.6]) were independently identified as potential nonhealing risk factors. But it is the combination of varus malalignment and medial laterality that significantly increased the risk of nonhealing (MRR = 2.54, 95% CI: [1.09, 6.01], p = 0.033) and negatively impacted all Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales and International Knee Documentation Committee (IKDC) score at T1 and/or T2.

Conclusion: Combined varus malalignment and medial meniscus involvement strongly predicted repair nonhealing and poorer outcomes after posterior horn LVMT repair.

Study design: Prospective cohort pilot study.

Level of evidence: Level III.

Purpose: This study aimed to evaluate the clinical and functional outcomes of autologous bone grafting with spheroid-based matrix-induced autologous chondrocyte implantation (MABCI) for osteochondral defects of the knee by analysing pre- and postoperative patient-reported outcome measures (PROMs). Postoperative gait analysis was conducted and compared with a matched healthy control group to investigate biomechanical deviations.

Methods: A total of 35 patients (m: 21, f: 14; mean defect size: 4.2 ± 2.4 cm², localisation: femoral condyle: 31, patellofemoral: 5) were analysed. The mean follow-up was 42.6 ± 22.8 months. International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), PROMIS 29 profile, and a questionnaire on patient perception of treatment success were assessed to evaluate PROMs. 3D-instrumented gait analysis (GRAIL, Motek) was used to assess lower extremity kinematics, kinetics and vertical ground reaction forces, compared to sex-, age- and body mass index-matched healthy controls.

Results: All clinical scores showed significant improvement compared to the preoperative condition (IKDC: 73.1 ± 10.1 vs. 56.6 ± 17.2, p < 0.01; KOOS subcategories: pain 82.0 [±12.7] vs. 70.7 [±16.7] [p < 0.01], symptoms 79.1 [±20.3] vs. 68.9 [±13.9] [p < 0.01], activities of daily living 90.1 [±11.2] vs. 80.5 [±15.6] [p < 0.01], sport and recreational function: 65.3 [±19.3] vs. 51.3 [±26.29] [p < 0.01], quality of life 52.2 [±18.6] vs. 42.6 [±18.6] [p < 0.01]; numeric pain rating scale: 2.7 ± 2.0 vs. 5.0 ± 2.5, p < 0.01). The analysed patients reported a high satisfaction rate (94.3%). Self-selected walking speed was significantly lower than in healthy controls (1.17 ± 0.17 m/s vs. 0.98 ± 0.18 m/s, p < 0.01). Peak knee flexion angle (PKA) during loading response was significantly smaller (9.6° ± 7.0 vs. 17.7° ± 4.6, p < 0.01), and knee extension moment was significantly reduced (0.1 Nm/kg ± 0.2 vs. 0.4 Nm/kg ± 0.2, p < 0.01).

Conclusion: MABCI is an effective treatment for osteochondral knee defects, showing significant improvements in all evaluated PROMs. Postoperative gait analysis revealed abnormal gait patterns, including reduced PKA and lower knee extension moment, suggesting a need for further rehabilitation to optimise functional recovery.

Level of evidence: Level III.

Tailored surgical strategies for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients are presented, emphasizing techniques to minimize growth plate damage and ensure stability. As ACL injuries in youth increase, delaying surgery can lead to joint damage and poor recovery outcomes. Using magnetic resonance imaging-based assessments of skeletal maturity, the authors propose the 'over-the-top (OTT)' approach with lateral tenodesis, adapted for three growth stages: prepubescents, young adolescents and older adolescents. For prepubescents, the extra-physeal approach avoids growth plate drilling; for young adolescents, the supra-physeal technique places tunnels above the growth plate; and for older adolescents, the trans-physeal method mirrors adult techniques, as growth plates are closing. The minimally invasive OTT technique preserves hamstring insertion, ensures isometric graft placement, and allows for combined intra- and extra-articular procedures to improve rotational control and protect the graft. Clinical outcomes highlight high return-to-sport rates, minimal growth disturbances, and low failure rates, although older adolescents show higher graft failures due to activity levels. Various adaptations of the OTT and lateral tenodesis techniques utilizing hamstring tendons provide promising solutions for addressing ACL injuries in skeletally immature patients, ranging from prepubescence to late adolescence. Assessing skeletal age and estimating remaining bone growth are essential for selecting the most appropriate surgical method. The biomechanical principles and positive clinical results observed across different patient groups highlight these techniques as effective, safe and attractive options for managing these challenging cases. LEVEL OF EVIDENCE: Level IV.

Purpose: Rupture of the anterior cruciate ligament (ACL) is a prevalent and debilitating injury typically arising from aberrant biomechanics during landing or deceleration tasks. Pain-related fear, a component of kinesiophobia, has been associated with poor functional outcomes and altered movement patterns in individuals with ACL reconstruction (ACLr), however, the influence of pain-related fear on landing mechanics remains unclear. The purpose of this investigation was to examine the effects of pain-related fear on landing movement patterns in a population of ACLr and healthy females.

Methods: Thirty-two females (15 recreationally active with a history of ACLr and 17 recreationally active with no history of ACLr) took part. Participants performed five trials of a drop jump (DJ) task (Baseline), underwent a pain stimulus (PS) familiarization task utilizing an electrical stimulus to induce pain-related fear, and performed a subsequent round of DJs while under threat of PS (PS-threat). Lower extremity and trunk kinematics, ground reaction force (GRF) data and muscle activation were analyzed.

Results: At baseline, ACLr participants scored higher (21 ± 5.5) on the TSK-11 compared to healthy participants (17 ± 3.4) (p = 0.007). For both groups, the PS intervention significantly increased pain-related fear (ACLr p < 0.001; Healthy p < 0.001). When comparing baseline to PS-threat trials, ACLr participants experienced a significant increase in peak GRF (p = 0.005), decreases in hip (p = 0.003) and knee (p = 0.005) flexion, decreased contact time (p = 0.006) and decreased muscle preactivation for all muscles tested (p < 0.05). Healthy participants experienced significant increases in peak GRF (p = 0.014) and decreased hip (p = 0.005) and trunk peak (p = 0.004) flexion.

Conclusions: Pain-related fear alters landing biomechanics in healthy and ACLr females. This may implicate pain-related fear as a contributor to movement alterations commonly associated with ACL injury risk.

Level of evidence: Level III.

Purpose: Alignment strategies in knee arthroplasty have a profound influence not only on knee biomechanics but also on the biomechanics of adjacent joints, particularly the ankle. Functional alignment (FA) represents a flexible alignment strategy aimed at achieving patient-specific balance. However, predefined boundaries are often applied to ensure mechanical stability, leading to adjustments in the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) while still respecting the patient's native alignment as much as possible. FA is a patient-specific strategy that seeks to respect the patient's preoperative phenotype or constitutional alignment while achieving a balanced and stable knee. The hypothesis is that FA strategies can protect the ankle from excessive biomechanical stress.

Methods: A retrospective cohort analysis was conducted on 300 consecutive patients who underwent robotic-assisted knee arthroplasty. Preoperative and 6-month post-operative radiographic evaluations measured key ankle parameters, tibial plafond inclination (TPI), talar inclination (TI) and Talar Tilt (TT). Statistical analyses evaluated the influence of alignment strategies on these parameters, with particular focus on whether MPTA and LDFA crossed the 90° threshold, indicating a shift from varus to valgus or vice versa.

Results: FA demonstrated smaller changes in ankle parameters compared to mechanical alignment (MA). In the FA group, mean changes were 1.8° for KTPA (standard deviation [SD] = 1.1°, p = 0.03), 2.4° for TPI (SD = 1.0°, p = 0.04), 2.1° for TI (SD = 1.3°, p = 0.05) and 1.7° for TT (SD = 0.9°, p = 0.04). The MA group showed greater deviations: 3.9° for KTPA (SD = 1.5°, p = 0.01), 5.2° for TPI (SD = 1.2°, p = 0.02), 4.8° for TI (SD = 1.4°, p = 0.03) and 3.6° for TT (SD = 1.1°, p = 0.04). Alterations in LDFA and MPTA exceeding 2° were significantly associated with worsening ankle alignment. Furthermore, FA, with its goal of maintaining Coronal Plane Alignment of the Knee (CPAK) classification, was associated with minimal modifications to ankle angles, suggesting potential biomechanical benefits as reported in the literature.

Conclusions: FA was associated with smaller changes in ankle alignment parameters, indicating its ability to better preserve native joint positioning. Future research should focus on longitudinal studies to confirm these benefits and further establish the FA strategy as a standard in knee arthroplasty, particularly its capacity to maintain CPAK classification alignment.

Level of evidence: Level III.

Purpose: Our primary goal was to deepen the understanding of the mechanisms leading to anterior cruciate ligament (ACL) injuries by reconstructing the three-dimensional (3D) joint kinematics of ACL injuries that occurred in professional male football matches. In particular, we aimed to compare the time courses of trunk and injured limb joint angles between noncontact and indirect contact injury mechanisms.

Methods: In this cross-sectional observational study, we analysed a total of 27 cases (18 noncontact, 9 indirect contact). Whole-body 3D kinematics preceding and during ACL injuries was reconstructed using the Model-Based Image-Matching technique, implemented in Blender. For each injury, television footage from multiple perspectives (≥2, nine frames per view) were used, and Euler's joint angles across all the anatomical planes were extracted. The joint angle time courses of both the trunk and the injured limb, comprising 12 waveforms in total, were compared between injury mechanisms and Statistical Parametric Mapping was used to detect significant clusters.

Results: Compared to noncontact injuries, indirect contact cases showed a lower hip abduction (-16°, p = 0.003), knee internal rotation (~3°, p < 0.001) at the initial contact with the ground, and ankle dorsiflexion (~7°, p = 0.035) at instants before the initial ground contact. These differences resulted from the player's adaptation to the sudden (yet variable) mechanical perturbation due to the contact with the opponent.

Conclusion: Mechanical interactions with other players impact segmental kinematics before and during ACL injuries in professional male football. These findings reinforce the importance of considering the sport-specificity of mechanisms in injury prevention.

Level of evidence: Level IV.

Purpose: Joint line obliquity is crucial for the long-term success of a high tibial osteotomy (HTO), particularly when large corrections are made. The relationship between the size of correction and changes in joint line obliquity (KJLO) is complex, often leading to the preference for a double-level osteotomy to manage significant post-operative obliquity. We aim to improve the prediction of knee joint line orientation changes and correction size by examining the influence of foot position. The goal is to develop a linear model to predict post-operative KJLO, which could assist in determining whether a single- or double-level osteotomy is necessary to prevent excessive post-operative joint line obliquity.

Methods: A retrospective radiographic analysis was conducted on patients who underwent HTO surgery between April 2016 and April 2017. Ninety-one patients were randomly selected for radiographic measurements on long-leg radiographs pre- and 3-month post-operative. A novel radiographic parameter was introduced to realign the foot of the operated side to the midline. The foot position relative to the midline was assessed by determining the angle formed when rotating the natural foot position onto the midline using the centre of the hip as a rotation point. The angle obtained by subtracting this from the KJLO results in a corrected KJLO for midline foot position (aKJLO).

Results: Predictive model of differences between pre- and post-operative values of MPTA (ΔMPTA [medial proximal tibial angle]) and KJLO (ΔKJLO) was less predictive (0.185 [p < 0.001]) than ΔMPTA and ΔKJLO corrected for foot position, namely ΔaKJLO (0.688 [p < 0.001]). Adding more parameters did not significantly improve the linear model's predictions.

Conclusion: Predictability of aKJLO could be significantly enhanced. With this new parameter, inter- and intra-variability of foot position is bypassed. A safe MPTA position of 91° can be presumed; however, inter-individual variability in limb adaptation following correction remains uncertain.

Level of evidence: Level IV.