Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: To compare the load distributed to the medial tibial articular cartilage after refixation of posterior medial meniscus root tears between the suture anchor and transtibial pullout techniques in posterior medial meniscus root tears.

Methods: Twelve Thiel's embalmed human cadaveric knees are used and divided into three groups (four knees in each group): (1) intact meniscus (IM), (2) fixation with suture anchor technique (SA) and (3) fixation with transtibial pullout technique (TP). Each group applies an axial compression load up to 1500 N by Instron E 10000 at two knee flexion angles (0° and 60°). A Tekscan 4000 pressure sensor is used to record the contact pressure and the contact area for each testing condition.

Results: The contact pressure and the contact area between the three conditions are not significantly different at 0° and 60° knee flexion angles. The peak contact pressure and contact area are 3734.8 ± 2642.2 kPa, 288.2 ± 115.0 mm², 4510 ± 2930.5 kPa, 204.4 ± 36.8 mm² and 5328.8 ± 2607.7 kPa, 219.2 ± 84.7 mm² in IM, SA and TP, respectively.

Conclusion: Both suture anchor and transtibial pullout refixation of PMMRT can restore contact pressure and contact area similar to the intact meniscus. This finding suggests that either technique can be reliably used in clinical practice to preserve joint function and potentially reduce the risk of osteoarthritis progression following posterior medial meniscus root tear repairs.

Level of evidence: Level III.

Purpose: To identify, synthesise and critically appraise findings of systematic reviews and meta-analyses on pre- and post-operative radiographic angles (lateral distal femoral angle [LDFA], medial proximal tibial angle [MPTA] and hip-knee-ankle [HKA] angle) of unrestricted kinematic alignment versus mechanical alignment in total knee arthroplasty (TKA).

Methods: Two authors searched MEDLINE, EMBASE and Epistemonikos for systematic reviews, with or without meta-analyses, that reported on TKA outcomes using unrestricted kinematic alignment. The methodological quality of the included systematic reviews and meta-analyses was independently assessed using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). The effect size with its 95% confidence interval (CI) for radiographic angles was extracted from the systematic reviews and meta-analyses. The characteristics of clinical studies included in systematic reviews were listed and tabulated. Pre- and post-operative MPTA, LDFA and HKA angles were summarised using meta-analytic random-effects models.

Results: Nineteen records were eligible for data extraction. Systematic reviews and meta-analyses included 44 clinical studies, of which 31 were on unrestricted kinematic alignment and 13 were on restricted versions of kinematic alignment. None of the included systematic reviews or meta-analyses fulfiled all seven critical AMSTAR-2 domains. Few comparative studies reported both pre- and post-operative angles (LDFA, n = 3; MPTA, n = 4; and HKA angle, n = 10). Mean pre- and post-operative LDFAs were 88.0° (range, 83-94°) and 88.0° (range, 80-96°) for the kinematic alignment group, and 88.2° (range, 83-95°) and 90.2° (range, 84-97°) for the mechanical alignment group. Mean pre- and post-operative MPTAs were 86.0° (range, 78-93°) and 87.1° (range, 78-94°) for the kinematic alignment group and 86.4° (range, 77-94°) and 89.6° (range, 84-95°) for the mechanical alignment group. Mean pre- and post-operative HKA angles were -3.3° (range, -24° to 24°) and -0.3° (range, -10° to 8°) for the kinematic alignment group and -6.9° (range, -25° to 7°) and -0.9° (range, -8° to 7°) for the mechanical alignment group.

Conclusion: Most systematic reviews and meta-analyses that report outcomes of TKA using kinematic alignment do not distinguish between the different versions of kinematic alignment. The clinical studies included in systematic reviews are limited and inconsistent in their reporting of radiographic angles. Different alignment strategies are often grouped under the umbrella term of kinematic alignment, which contributes to conflicting reports, confusion and unresolved questions regarding the efficacy of true unrestricted kinematic alignment.

Level of evidence: Level IV.

Purpose: Knee joint dislocations, though rare, present significant challenges due to potential complications like vascular and nerve damage, and are known to be often linked to sports injuries, accidents and obesity. This study aims to analyse the epidemiology, incidence and treatment approaches for knee dislocations in Germany from 2019 to 2022.

Methods: This retrospective cohort study utilized data from the German Institute for the Hospital Remuneration System to examine knee dislocation cases across German medical institutions. Patient data coded under International Statistical Classification of Diseases and Related Health Problems 10 for 'knee dislocation' enabled detailed analysis by age, sex and surgical procedures categorized by operation and procedure codes. The Patient Clinical Complexity Level (PCCL) assessed complication severity.

Results: Analysis of 1643 knee dislocation cases revealed an incidence rate of 0.44-0.54 per 100,000 inhabitants annually. During the years 2020 and 2021, there were fewer cases of knee dislocations. Male patients comprised 50%-56% of cases, with an average hospital stay of 11 days. Most cases were PCCL 0 (62%-72%) and predominantly affected patients aged 18-29 years. Anterior tibial dislocations were common among classified cases. Injuries included ligament ruptures, meniscus lesions and grade I soft-tissue injuries. Patients with pre-existing knee prostheses constituted 0%-16% annually. Treatment involved closed reduction, external fixation and surgeries like capsuloligamentous reconstructions and arthroscopic procedures. Revision knee arthroplasty was required in 2%-9% of cases, with obesity rates up to 7%.

Conclusions: This study provides valuable insights into the epidemiology, incidence and treatment of knee dislocations in Germany, with a focus on demographic risk factors, treatment complexities and the impact of obesity and knee prostheses. The findings emphasize the importance of specialized care in larger hospitals, comprehensive management of concomitant injuries and the need for improved coding accuracy. Future research should aim to refine treatment protocols.

Level of evidence: Level III.

Purpose: To (1) investigate the hypothesis that there is high variability in the reported methods to derive axes and joint orientations from three-dimensional (3D) bone models to (a) perform 3D knee-related leg alignment analysis and (b) define coordinate systems for the femur, tibia and leg and (2) identify underlying principles that might lead to agreement on a universal 3D leg alignment analysis framework.

Methods: A systematic review of the literature between January 2006 and June 2024 was performed. Articles explicitly reporting methods to derive axes and joint orientations from CT-based 3D bone models for alignment parameters and/or coordinate systems of the femur, tibia and leg were included. Study characteristics and reported methods were extracted and presented as a qualitative synthesis.

Results: A total of 93 studies were included. There was high variability in the reported methods to derive axes and joint orientations from 3D bone models. Nevertheless, the reported methods could be categorized into four groups, and several underlying principles of the four groups could be identified. Furthermore, the definitions of femoral and tibial coordinate systems were most frequently based on the mechanical axis (femoral, 13/19 [68%]; tibial, 13/26 [50%]) and a central medial-lateral axis (femoral, 16/19 [84%]; tibial, 12/26 [46%]); no leg coordinate system was reported. Interestingly, of the included studies that reported on leg alignment parameters (76/93, 82%), only a minority reported expressing these in a complete coordinate system (25/76, 33%).

Conclusion: There is high variability in 3D knee-related leg alignment analysis. Therefore, universal 3D reference values for alignment parameters cannot yet be defined, and comparison of alignment parameter values between different studies is impossible. However, several underlying principles to the reported methods were identified, which could serve to reach more agreement on a future universal 3D framework for leg alignment analysis.

Level of evidence: Level I (1).

Purpose: Posterior elongation of the physiological terminal sulcus (TS) due to lateral femoral condyle impaction fracture (LFC-IF) after an anterior cruciate ligament (ACL) tear could potentially decrease the weight-bearing area of the tibiofemoral joint, decrease the tension on lateral meniscus and cause flattening of the LFC which would influence rotational knee motion and cause anisometry of the lateral and anterolateral stabilizers. Therefore, the purpose of the study was to assess if the LFC-IF elongates the physiological TS posteriorly.

Methods: One hundred patients magnetic resonance images (MRIs) (75 males, 25 females, mean age 32.2 years, SD = 8.2) were included with a 1:1 ratio between the full-thickness ACL tear group and the control group (patients with knee MRI performed due to other reasons, with no tear of ACL on MRI and negative clinical tests). Two independent raters evaluated the sagittal T1-weighted preselected MRI scans. The principal measurement of interest was the distance from the intersection of the Blumensaat line with subchondral bone to the posterior border of the TS/LFC-IF.

Results: The median distance from the Blumensaat line to the posterior border of the TS/LFC-IF was significantly higher in the ACL tear group: 14.3 mm, interquartile range (IQR) = 11.6-16.4 mm versus control group: 12.8 mm, IQR = 9.0-15.0 mm, p = 0.038. Intrarater and inter-rater reliabilities were >0.90.

Conclusion: LFC-IF after full-thickness ACL tear significantly elongates the physiological TS in the posterior direction.

Level of evidence: Level III.

Purpose: The prevalence and appreciation of meniscal tears in children have increased in both number and complexity. There is currently a paucity of high-quality evidence that can guide surgeons in treating skeletally immature patients with meniscal injuries. The aim of this study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children.

Methods: An international, two-round, modified Delphi consensus was completed. Included 'experts' were identified as having an established adult knee practice, including children and either: (1) Faculty at an international paediatric knee conference, (2) Active members of complex national paediatric multi-disciplinary groups or (3) Members of faculty on recognised national/international instructional courses aimed at teaching the management of meniscal lesions to knee surgeons. The currently available literature was reviewed, and areas of poor quality, inconclusive or absent evidence were examined and formed the focus of the study. A threshold of 70% was used to define consensus for our study based on other similar Delphi consensus studies in the literature.

Results: A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study, including surgeons from Europe, the United States of America and South America. 34 statements were identified exploring three main domains-clinical assessment, management and complex tears (bucket handle, discoid and radial). Following Round 1, consensus was reached on 17 (50%) statements; subsequently, after completion of Round 2, consensus was reached on 28 (82%) statements, leaving six (18%) with no consensus. The areas of no consensus included investigation of painless clicking, the most sensitive clinical test for meniscal pathology, treatment of small radial tears (less than 1/3 width), ability to reduce chronic bucket handle tears and timing of surgery.

Conclusions: This is the first modified Delphi consensus that provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. A valuable level of consensus was reached on the assessment and management of simple and specialist meniscal tears. These consensus statements can both inform clinical practice and be used in the development of further high-quality research studies.

Level of evidence: Level V.

Purpose: This work developed a novel preclinical test of total knee replacements (TKRs) in order to explain TKR instability linked to patient dissatisfaction. It was hypothesized that stability tests on the isolated moving prostheses would provide novel comparative data on the stability and kinematics among TKR designs.

Methods: Three TKR designs, DePuy Synthes Attune MS, Stryker Triathlon and Zimmer Biomet Persona MC, were assessed using a robotic arm while flexing-extending 0-140°. Tests imposed 710 N body weight combined with three tibial loads: no anterior-posterior (AP) force, 90 N anterior or 90 N posterior force. Other load effects were minimized and the kinematics was recorded. Each implant was tested six times to investigate the repeatability of the method. Data were analysed using statistical parametric mapping with one-way analysis of variance (ANOVA). If significance was found (p < 0.05), post hoc t tests with Bonferroni correction were used to contrast groups.

Results: Significant differences were found throughout flexion-extension. Femoral rollback, AP stability, coupled internal-external rotation and AP position (roll-back) were all influenced by implant design. AP stability of the TKRs reduced with flexion reaching Attune 15 mm, Persona 13 mm and Triathlon 21 mm at 140° flexion. Tractive rolling significantly affected kinematics in the less congruent Triathlon design, with 6 mm different paths between flexion and extension motion (p < 0.05 across 5-100°). Paradoxical anterior femoral sliding in early flexion (0-40°) occurred in Persona and Triathlon designs.

Conclusions: The novel testing technique provides, for the first time, comparative data on the inherent stability and kinematics of the TKR implants themselves across the arc of flexion-extension, independent of variables including soft tissue behaviour and surgical technique. The data show how much each prosthesis can contribute to the stability and motion of the implanted knee. Similar data from a wider range of designs will enable more informed decisions regarding implant design choice, aiming to reduce the prevalence of TKR instability in patients.

Level of evidence: Controlled laboratory study.

Purpose: To investigate the impact of orthopaedic surgeons' arthroplasty distributions on patient-reported outcome measures (PROMs) following knee arthroplasty, thus addressing the gap in knowledge regarding the optimal distribution of arthroplasties.

Methods: 2256 knee arthroplasties were included (total knee arthroplasty [TKA] or unicompartmental knee arthroplasty [UKA]). All were conducted at a single centre between August 2016 and August 2022 with a minimum of 1-year follow-up. The Oxford Knee Score (OKS), the Forgotten Joint Score (FJS) and the Activity and Participation Questionnaire (APQ) were assessed preoperatively, and at 3 and 12 months postoperatively. Patients were categorized based on the surgeons' yearly surgeries: (1) TKA only, (2) TKA+ <20% medial UKA, (3) TKA+ ≥20% medial UKA and (4) TKA+ ≥20% medial UKA + lateral UKA + patellofemoral UKA. Linear regression models adjusted for demographic variables and preoperative PROM scores were used to estimate changes in mean PROM scores.

Results: Group 4 showed significantly higher improvements in PROM scores at 3 and 12 months compared to Group 1. In the 12-month adjusted analysis, Group 4 had 1.9 points (95% confidence interval [CI]: 1.0-2.8) higher OKS-, 7.0 points (95% CI: 3.9-10.2) higher FJS- and 8.3 points (95% CI: 4.8-11.8) higher APQ-change than Group 1. There were no significant differences between Groups 1 and 2, nor any clinically relevant differences between Groups 3 and 4. Additionally, the percentage of patients who achieved excellent OKS (>41) was significantly higher in Groups 3 + 4 compared to Groups 1 + 2 (p < 0.001).

Conclusion: Despite limitations, the findings of this study suggest that utilizing ≥20% medial UKA leads to greater postoperative improvements in PROM across all treated knee arthroplasty patients.

Level of evidence: Level III.

Purpose: To compare the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) preoperatively and at minimum 10-year follow-up using patient-reported outcome measures (PROMs).

Methods: A total of 128 patients with FAIS were prospectively included. The patients underwent arthroscopic surgery for FAIS between 2011 and 2013 and had a minimum of 10-year follow-up. The International Hip Outcome Tool short version (iHOT-12) was the primary outcome. Secondary outcomes were the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the European Quality visual analogue scale (EQ VAS), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analogue Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery. The Wilcoxon signed rank test was used to compare pre- and postoperative PROMs.

Results: There was a significant improvement (p < 0.001) of iHOT-12, HAGOS subscales, EQ-5D, EQ VAS and VAS for overall hip function. A total of 83% of the patients were satisfied with their surgery. The survivorship of hip arthroscopy, defined as nonconversion to total hip arthroplasty (THA), at the end of the follow-up period was 77%.

Conclusion: Patients undergoing arthroscopic treatment for FAIS reported statistically significant and clinically relevant improved outcomes at 10-year follow-up.

Level of evidence: Case series, level IV.