Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: To perform a systematic review and meta-analysis of the existing literature on meniscal centralisation procedures, analysing its impact on meniscal extrusion, joint biomechanics and clinical and radiological outcome measures.

Methods: The Cochrane Controlled Register of Trials, PubMed (MEDLINE) and Embase were used to perform a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Biomechanical studies on healthy animal or human cadaveric knee joints that assessed meniscal extrusion or tibiofemoral contact mechanics (contact area and pressure) following centralization for meniscal pathologies were included. For clinical studies, those that prospectively or retrospectively assessed patient-reported outcome measures (PROMs), postoperative knee motion, complications and radiological extrusion following centralization for meniscal pathologies were included.

Results: Fifteen studies were included in the analysis, comprising eight biomechanical, six clinical and one both. There were 92 knee specimens for biomechanical testing, of which 40 were human cadaveric and 52 porcine models. Biomechanical data revealed centralization to be commonly performed for posterior meniscal root tears and significantly reduced extrusion and contact pressure whilst improving contact area following a tear (p < 0.00001). Centralization restored extrusion to that of the native knee at all flexion angles described (0-90°, p = 0.25) and, compared to the torn state, brought tibiofemoral contact mechanics 3.2-5.0 times closer to the native state. Clinical data showed that 158 patients underwent centralization for extrusion. It improved postoperative Knee Injury and Osteoarthritis Outcome score (KOOS) (p = 0.006) and Lysholm scores (p < 0.00001) at 25.0 months, maintained extrusion reduction at 17.1 months (p < 0.00001) and preserved knee motion.

Conclusion: Centralisation for various meniscal injuries associated with extrusion can reduce meniscal extrusion and improve joint biomechanics, along with clinical and radiological outcomes. Existing evidence is still scarce and exhibits a notable amount of methodological heterogeneity.

Level of evidence: Systematic review of Level IV evidence.

Purpose: This study aimed to identify the risk factors for anterior knee pain (AKP) after medial patellofemoral ligament reconstruction (MPFLR).

Methods: Patients aged 15-35 years who underwent isolated MPFLR between 2012 and 2022 were included in the study. These patients were divided into two groups (AKP and control group). Patient demographics and preoperative and postoperative clinical outcomes between the two groups were assessed and compared. Univariate logistic regression analysis was performed to explore the potential risk factors associated with postoperative AKP. Subgroup analysis stratified the results based on the time to return to sports (RTS) (>9 and ≤9 months). Furthermore, Spearman correlation analysis was performed to investigate the association between Kujala score and time to RTS.

Results: A total of 206 patients were included (AKP, n = 59; control, n = 147). At the 2-year follow-up, patients with AKP demonstrated a shorter duration in returning to their pre-injury activity level compared to those without AKP (9.0 ± 3.6 vs. 10.3 ± 2.7 months, p < 0.05). RTS earlier than 9 months after MPFLR was the only significant risk factor associated with postoperative AKP (odds ratio, 2.13, 95% confidence interval, 1.03-4.39; p < 0.05). Further subgroup analysis revealed that patient RTS earlier than 9 months exhibited worse patient-reported outcomes in both the total cohort and control group (p < 0.05). Furthermore, among patient RTS within 9 months, a longer recovery duration before RTS strongly correlated with a higher Kujala score (R = 0.670, p < 0.001).

Conclusions: Young patients who RTS at their pre-injury levels before 9 months after MPFLR have a higher incidence of postoperative AKP and poorer functional outcomes compared to those who delay their return. Specifically, within the first 9 months after MPFLR, the earlier the RTS, the more severe the AKP symptoms. Careful consideration of the timing for RTS may help reduce the incidence of postoperative AKP.

Level of evidence: Level III.

Purpose: This study compared the radiological characteristics between habitual and recurrent patellar dislocation in skeletally mature patients.

Methods: From 2017 to 2019, 77 skeletally mature patients with habitual patellar dislocation were surgically treated at a single institution and reviewed retrospectively. A total of 55 knees from these patients were included in the habitual patellar dislocation group. During the same period, 55 knees with recurrent patellar dislocation were randomly selected from 242 patients and included in the recurrent patellar dislocation group. Various bony deformities were measured and compared between the two groups. Additionally, a subgroup analysis was conducted among patients with habitual patellar dislocation, comparing those with and without an 'invisible patella' observed on true lateral views with 30° of knee flexion.

Results: The femoral anteversion angle (21.8° vs. 26.3°, p = 0.041), tibiofemoral rotation angle (9.7° vs. 12.4°, p = 0.042) and external tibial rotation angle (24.3° vs. 29.6°, p = 0.001) in the habitual patellar dislocation group were significantly lower than those in the recurrent patellar dislocation group. 54% of knees in the habitual patellar dislocation group had a patella baja, and this was in sharp contrast to the recurrent patellar dislocation group in which none of the knees had a patella baja. 49.1% of knees in the habitual patellar dislocation group showed 'invisible patella' at 30° of knee flexion, and knees with 'invisible patella' had significantly higher tibial tubercle-trochlear groove (TT-TG) distance (30.4 vs. 19.8, p < 0.001) and tibiofemoral rotation angle (13.2° vs. 6.4°, p < 0.001) than knees with a visible patella.

Conclusions: A distinct difference in bony anatomical features was observed between habitual and recurrent patellar dislocation in skeletally mature patients. Habitual patellar dislocation exhibited less severe rotational deformities of the lower extremity but showed poorer trochlear and patellar development, a larger TT-TG distance and a higher incidence of patella baja compared with recurrent patellar dislocation.

Level of evidence: Level III.

Purpose: Robotic-assisted technology in medial unicompartmental knee arthroplasty (mUKA) allows for customized adjustments of joint laxity through virtual preoperative component positioning before bone preparation. Nevertheless, the optimal balancing curve has yet to be delineated. This study sought to investigate if varying intraoperative knee laxity patterns had any impact on postoperative patient outcomes.

Materials and methods: A retrospective analysis was conducted on prospectively collected data from 326 fixed-bearing RAUKA procedures performed between 2018 and 2022 with a minimum 2-year follow-up. Patients were categorized into three cohorts based on intraoperative joint laxity patterns (millimetres of joint gap during valgus stress) imparted at 20°, 60°, 90° and 120° of knee flexion: cohort 1 < +0.5 mm (tight); cohort 2 between 0.6 and 1.9 mm (physiologic); cohort 3 > 2 mm (loose). Wilcoxon and Kruskal-Wallis tests were conducted to assess patient-reported outcome measure (PROM) improvements and preoperative and postoperative differences across the cohorts. A Spearman's test evaluated the correlation between knee balance at all degrees of flexion and preoperative and postoperative HKA.

Results: No differences in preoperative and postoperative PROMs were identified across the cohorts (p > 0.05). All three cohorts with different joint laxity patterns showed a significant improvement in the postoperative PROMS (p < 0.05). The preoperative or postoperative limb alignment did not significantly affect clinical outcomes relative to different laxity patterns.

Conclusion: No differences were found in the outcomes across different joint laxity patterns in robotic-assisted medial UKA using fixed-bearing mUKAs. There was no evident advantage for maintaining a closer to physiologic laxity compared to tighter or looser balancing.

Level of evidence: Level III therapeutic study.

Purpose: The purpose of this study was to determine the incidence and hospitalization trends of meniscectomy in Italy from 2001 to 2016. A secondary aim was to investigate the economic burden of the disease on the national healthcare system.

Methods: Data were extracted from the Italian Ministry of Health's National Hospital Discharge Reports. Diagnoses are coded according to the ICD-9-CM. Meniscectomy was defined by the following main procedure codes: 806, 8026 and 8145. By dividing the number of annual cases by the size of the adult population reported annually by ISTAT, incidence rates were computed.

Results: Overall, 1,454,891 meniscectomies were performed in the study period between 2001 and 2016. The incidence was 178 procedures for every 100,000 Italian inhabitants. The incidence declined from 202 in 2001 to 106 in 2016. Males were the largest portion of patients undergoing surgery (68.2%). The average age of patients was 46.59 ± 15.07. A decreasing trend in length of hospital stay was observed over the study period. The annual average cost per 100,000 inhabitants was EUR 491.219 ± 122.148 with a range from EUR 291,500 ± 79.500 in 2016 to EUR 610,500 ± 166.500 in 2004.

Conclusion: In Italy, the number of meniscectomies performed in the adult population has almost halved over the study period. Results of the present study in the Italian population seem to reflect how the clinical evidence basis affects surgical technique selection. The economic burden of meniscectomy is relevant in Italy with an estimated expenditure from EUR 181.861.375 to 318.257.406 between 2001 and 2016.

Level of evidence: Level III.

Purpose: The aim of this study was to analyse clinical, functional and shoulder kinematics results using subacromial balloon spacer in nonreparable massive rotator cuff tears. Subacromial balloon spacer was hypothesised to improve shoulder kinematics and increases clinical and functional outcomes scores in nonreparable massive rotator cuff tears.

Methods: This is a prospective study in massive rotator cuff tears. From October 2021 to October 2022, a total of 127 shoulders suffering massive rotator cuff tears were initially evaluated. All patients were evaluated preoperatively, at 6 and 12 months. Patients' patient-reported outcome measures (PROM) subjective values using visual analogue scale (VAS) and the Spanish Western Ontario Rotator Cuff Index (WORC) version were analysed. We also evaluated objective outcomes: constant score, range of movement and kinematic shoulder analysis (isokinetic test to evaluate internal and external rotation forces). Statistical analysis was conducted using SPSS software; continuous variables were presented as means and standard deviations (SDs).

Results: Seventeen nonrepairable massive rotator cuff tears were finally included. Three patients required reverse shoulder arthroplasty before 6 months postoperative. After 1-year follow-up, objective and subjective (PROM) outcome scores and isokinetic measurements improved in 13 patients. Preoperative VAS improved from 6.5 ± 2.1 to 2 ± 1.9 points on average at 1-year follow-up and WORC index from 1603 ± 217.3 to 699 ± 361.6. Constant score from 42.1 ± 13.1 on average and at 1-year follow-up increased to 60.8 ± 14.7. Range of movement also improved in elevation 122.2 ± 39.3 to 166.9 ± 25.8, abduction 120.3 ± 38.6 to 134.6 ± 21.1, external rotation 30.3 ± 19.7 to 86.1 ± 13.8 and internal rotation L4-T12 on average at 1-year follow-up. Isokinetic evaluation showed functional improvement 1 year after implantation. Both internal and external rotation improved compared with their healthy shoulder. External rotation improved from 30.3° ± 19.7° preoperatively to 86.1° ± 13.8° (43.7% in the isokinetic study) and internal rotation from L4 preoperatively to L1 (49.8% in isokinetic study) on average.

Conclusion: Among the different alternatives for irreparable rotator cuff injuries surgical treatment, subacromial balloon spacer is an effective alternative in selected patients, both in terms of clinical-functional improvement and short-term isokinetic results.

Level of evidence: Level II.

Purpose: Anterior cruciate ligament (ACL) rupture is increasingly common in paediatric and adolescent populations, typically requiring surgical ACL reconstruction (ACLR) to restore knee stability. However, ACLR substantially alters knee biomechanics (e.g., motion and tissue mechanics) placing the patient at elevated risk of early-onset knee osteoarthritis.

Methods: This study employed a linked neuromusculoskeletal (NMSK)-finite element (FE) model to determine effects of four critical ACLR surgical parameters (graft type, size, location and pre-tension) on tibial articular cartilage stresses in three paediatric knees of different sizes during walking. Optimal surgical combinations were defined by minimal kinematic and tibial cartilage stress deviations in comparison to a corresponding intact healthy knee, with substantial deviations defined by normalized root mean square error (nRMSE) > 10%.

Results: Results showed unique trends of principal stress deviations across knee sizes with small knee showing least deviation from intact knee, followed by large- and medium-sized knees. The nRMSE values for cartilage stresses displayed notable variability across different knees. Surgical combination yielding the highest nRMSE in comparison to the one with lowest nRMSE resulted in an increase of maximum principal stress on the medial tibial cartilage by 18.0%, 6.0% and 1.2% for small, medium and large knees, respectively. Similarly, there was an increase of maximum principal stress on lateral tibial cartilage by 11.2%, 4.1% and 12.7% for small, medium and large knees, respectively. Knee phenotype and NMSK factors contributed to deviations in knee kinematics and tibial cartilage stresses. Although optimal surgical configurations were found for each knee size, no generalizable trends emerged emphasizing the subject-specific nature of the knee and neuromuscular system.

Conclusion: Study findings underscore subject-specific complexities in ACLR biomechanics, necessitating personalized surgical planning for effective restoration of native motion and tissue mechanics. Future research should expand investigations to include a broader spectrum of subject-specific factors to advance personalized surgical planning.

Level of evidence: Level III.

Purpose: The objective is to evaluate the orientation of the trochlear groove in patients with objective patellar instability (OPI) compared to a control group. The hypothesis is that the trochlear groove angle (TGA) is correlated with the severity of the trochlear dysplasia.

Methods: From 2019 to 2023, magnetic resonance imaging of 82 knees with OPI were compared with 82 control knees. TGA quantified the angle between the femoral anatomical axis and the trochlear groove. The intraclass correlation coefficient for TGA was evaluated. Central spur in the sagittal plane (CSSP) and cranial trochlear orientation (CTO) angle were also measured. TGA, CSSP and CTO were compared between the two groups. A TGA subgroup analysis separating the OPI group into low-grade (CSSP < 5 mm or negative CTO) and high-grade dysplasia (CSSP ≥ 5 mm or positive CTO) was also performed.

Results: A significant difference (p < 0.001) was found between the TGA of the OPI group (mean [SD], 11.3 [3.7]°) and the control group (4.2 [2.5]°). TGA for patients with high-grade dysplasia (11.9 [3.8]°) was significantly higher than patients with low-grade dysplasia (9.6 [3.9]°).

Conclusion: Patients with OPI have a TGA of 11°, compared to the control group, which exhibits a TGA of 4°. The femoral mechanical axis can be considered an appropriate threshold for separating these two groups. Furthermore, TGA is correlated with the severity of dysplasia.

Study design: Case-control study.

Level of evidence: Level III.

Purpose: This study aimed (1) to determine complications and survival rates of lateral opening wedge distal femoral osteotomy (LOW-DFO) in the long term, (2) to assess their clinical outcomes in the long term and (3) to identify risk factors of failure.

Methods: Between 1991 and 2011, 62 LOW-DFOs were performed in the same department. Inclusion criteria were all isolated LOW-DFO performed for isolated lateral tibiofemoral osteoarthritis and valgus malalignment, with a minimum 10-year follow-up. Thirty-eight patients were included, with a mean age of 48 ± 9 years. All patients had clinical and radiological assessments. The survival curves were calculated based on the following endpoints: unicompartmental or total knee arthroplasty.

Results: The mean follow-up was 15.2 ± 4.4 [10-29] years. The mean preoperative mechanical FemoroTibial Axis (mFTA) was 188.8° ± 3.2° [184°-197°], primarily due to femur deformity (mean lateral distal femoral axis [LDFA] 83.2° ± 2.8°). Bone union was achieved in 89.5% of patients (n = 34) at a mean delay of 6.5 ± 6.7 months. The complication rate was 26% (five stiffness, one nonunion, three secondary displacements and one deep vein thrombosis). Nine revision surgeries (24%) were recorded. Survival rates at 5 and 10 years were 92.1% and 78.9%, respectively. The mean delay between DFO and total knee arthroplasty (TKA) was 11.6 ± 5.7 [1-27] years. Nineteen patients (50%) were free of TKA at the last follow-up. KSS scores were improved significantly. Return to sports was obtained in 92% of cases (n = 35), with a mean delay of 11 ± 8 months. Seventy-four per cent of patients were satisfied or very satisfied with the surgery. Eighty-four per cent would be willing to undergo the surgery again. Older age (p = 0.032) was a significant risk factor for TKA conversion.

Conclusion: LOW-DFO is an efficient procedure to manage lateral knee osteoarthritis in young patients with valgus deformity, with a good survival rate at 10 years and high patient satisfaction.

Level of evidence: Level III.

Purpose: This study aimed to clarify the characteristics of delaminated rotator cuff tears (RCTs) and evaluate the clinical outcomes of a modified arthroscopic en masse suture bridge repair for delaminated RCTs.

Methods: Patients with full-thickness RCTs, who underwent arthroscopic suture bridge repair with a minimum 2-year follow-up, were retrospectively reviewed. Patients were categorized into two groups based on the presence of delamination. Delaminated RCTs were treated using a modified en masse suture bridge technique, while nondelaminated RCTs received a conventional suture bridge technique. Preoperative and postoperative Constant scores and American Shoulder and Elbow Surgeons (ASES) scores were determined to evaluate clinical outcomes. Postoperative magnetic resonance imaging (MRI) was carried out to identify the integrity and retear of the repaired rotator cuff.

Results: A total of 172 patients were included in our study cohort, in which 67 (39%) delaminated RCTs were confirmed intraoperatively. The prevalence of delamination was significantly higher in large tears (53/102, 52%) compared to medium tears (14/70, 20%) (p < 0.001). No significant differences in age (n.s.) or gender (n.s.) were observed between the two groups. Both groups showed significant improvements in Constant and ASES scores postoperatively (both p < 0.001), with no significant differences between the groups (n.s.). The retear rates were 2/67 (3.0%) in the delamination group and 3/105 (2.9%) in the nondelamination group, showing no significant difference (n.s.).

Conclusions: The modified arthroscopic en masse suture bridge technique was effective for repairing delaminated RCTs, yielding favourable clinical outcomes comparable to those of nondelaminated tears.

Level of evidence: Level IV.