Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: To identify risk factors associated with increased postoperative opioid consumption and inferior pain outcomes following knee and shoulder arthroscopy.

Methods: Using the data set from the NonOpioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) trial, eight prognostic factors were chosen a priori to evaluate their effect on opioid consumption and patient-reported pain following arthroscopic knee and shoulder surgery. The primary outcome was the number of oral morphine equivalents (OMEs) consumed at 2 and 6 weeks postoperatively. The secondary outcome was patient-reported postoperative pain using the Visual Analogue Scale (VAS) at 2 and 6 weeks postoperatively. A multivariable linear regression was used to analyse these outcomes with eight prognostic factors as independent variables.

Results: Tobacco usage was significantly associated with higher opioid usage at 2 (p < 0.001) and 6 weeks (p = 0.02) postoperatively. Former tobacco users had a higher 2-week (p = 0.002) and cumulative OME (p = 0.002) consumption compared to current and nonsmokers. Patients with a higher number of comorbidities (p = 0.006) and those who were employed (p = 0.006) reported higher pain scores at 6 weeks. Patients in the 'not employed/other' category had significantly lower pain scores at 6 weeks postoperatively (p = 0.046).

Conclusion: Former smoking status was significantly associated with increased post-operative opioid consumption following knee and shoulder arthroscopy at 2 and 6 weeks postoperatively. Increased pain was found to be significantly associated with employment status and an increasing number of comorbidities at 6 weeks postoperatively. These findings can aid clinicians in identifying and mitigating increased opioid utilization as well as worse pain outcomes in high-risk patient populations.

Level of evidence: Level III, cohort study.

Purpose: The optimal management of degenerative meniscal tears remains controversial. Extracorporeal shockwave therapy (ESWT) has been shown to promote tissue repair in both preclinical and clinical studies; however, its effect on degenerative meniscal tears remains unknown. This study aimed to examine whether ESWT improves meniscal degeneration.

Methods: This randomized trial was conducted between 2020 and 2022 and involved patients with degenerative medial meniscal tears. Patients were allocated to receive either focused ESWT (0.25 mJ/mm², 2000 impulses, 3 sessions with a 1-week interval) or sham treatment. Patients were evaluated using magnetic resonance imaging (MRI) before treatment and at 12 months after treatment. The primary endpoint was improvement in meniscal degeneration, as assessed by the change in T2 relaxation time from baseline on MRI T2 mapping. Knee pain and clinical outcomes were also examined at the same time.

Results: Of 29 randomized patients, 27 patients (mean age 63.9 ± 8.7 years; females 37%; ESWT group 14 patients; control group 13 patients) were included in the final analysis. At 12 months postintervention, patients in the ESWT group showed a greater decrease in the T2 relaxation time (ESWT group -2.9 ± 1.7 ms vs. control group 1.0 ± 1.9 ms; p < 0.001) and had less knee pain (p = 0.04). The clinical outcomes at 12 months post-treatment were not statistically significant. No adverse events were reported.

Conclusion: ESWT decreased the T2 relaxation time in the meniscus at 12 months post-treatment. ESWT also provided pain relief, but no differences were observed in clinical outcomes.

Level of evidence: Level II.

Purpose: This study investigates the clinical and activity-based outcomes after anterior cruciate ligament reconstruction (ACLR) versus multiligamentous knee reconstruction (MLKR) following a pivoting sports injury.

Methods: Fifty MLKR patients were included, of which 20 (40%) were injured during pivoting sports. A further 50 patients undergoing ACLR following an injury during pivoting sports were consecutively recruited for comparison. Patients were assessed before the surgery and at 6-, 12- and 24 months with patient-reported outcome measures (PROMs) including the International Knee Documentation Committee (IKDC) form, Tegner activity scale (TAS) and anterior cruciate ligament return to sport after injury (ACL-RSI) score. Knee movement, the single (SHD) and triple (THD) hop tests for distance, and peak isokinetic knee extensor and flexor strength were assessed, with Limb Symmetry Indices (LSIs) calculated. Outcomes were compared across groups: (1) ACLR (n = 50), (2) MLKR (n = 50) and (3) MLKR due to pivoting sport injury (n = 20).

Results: IKDC, TAS and ACL-RSI scores remained lower (p < 0.05) in the full MLKR versus ACLR cohort at all timepoints. Comparing the ACLR and MLKR cohort that had injuries specifically during pivoting sports, the IKDC (p < 0.001) and TAS (p = 0.009) were higher in the ACLR group at 6 months, and the ACL-RSI was higher at 6 (p < 0.001) and 12 (p = 0.007) months, there were no further differences. Hop and knee extensor strength LSIs were lower (p < 0.05) in the full MLKR (versus ACLR) cohort at all timepoints (apart from the 24-month SHD LSI). However, the ACLR group only demonstrated greater LSIs than the pivoting sport MLKR for the SHD at 6 months (p < 0.001), and knee extensor strength at 6 (p < 0.001) and 12 (p < 0.001) months.

Conclusions: While the recovery of patients undergoing MLKR due to a pivoting sports injury is delayed compared with their ACLR counterparts, the clinical outcome and activity profile are similar by 24 months.

Level of evidence: Level IV.

Purpose: To determine arthroscopic Bankart repair outcomes and recurrence risk factors at a minimum 5-year follow-up.

Methods: Retrospective assessment of prospectively collected data, single-cohort study of patients who underwent arthroscopic Bankart repair with a minimum 5-year follow-up. Demographical and preoperative instability features were collected. Primary outcome was recurrent instability set as dislocation or subluxation. Secondary outcomes were revision surgery, postoperative instability degree according to Manta criteria, objective and subjective clinical and functional status, assessed by the Rowe, Western Ontario Shoulder Index (WOSI) and Subjective Shoulder Value (SSV) scores. Return to sport and postoperative sports activity at the final follow-up were also recorded.

Results: One-hundred and seventy-two patients, 82% men, average age at surgery 29.5 ± 9.2 years, were included. At a mean follow-up of 8.3 ± 2.6 years, recurrent instability occurred in 53 of 172 patients (30.8%). Revision surgery was required in 23/53 (43.4%) of shoulder with recurrent instability. Recurrence occurred within the first 2 years postoperative in 49% of the shoulders, whereas 51% of recurrences occurred after this period. Recurrence took place after a traumatic event in 25% and 56%, respectively. Recurrence rates were higher in patients who underwent surgery after two or more dislocations (p = 0.029). Patients younger at the time of first dislocation, younger at surgery and those with a higher preoperative degree of instability also showed significantly higher rates of recurrence (p = 0.04, p = 0.02, p = 0.03). Postoperative ROWE, WOSI and SSV scores were significantly worse in patients with recurrent instability (p < 0.001). Return-to-sports rate was also lower in patients with postoperative recurrence (p < 0.001).

Conclusion: The arthroscopic Bankart repair was associated with a high long-term recurrence rate, and its effectiveness decreased over time. The lowest recurrence rates in arthroscopic Bankart repair were achieved in older patients with only one prior instability episode and a lower instability degree.

Level of evidence: Level IV.

Purpose: A cell-free biomimetic osteochondral scaffold was developed to treat cartilage knee lesions, with positive clinical results documented in small case series. However, clear evidence on patient and lesion characteristics that might affect the outcome is still lacking. The aim of this study is to analyse a large cohort of patients treated with this scaffold to investigate factors that could influence the clinical outcome.

Methods: Two hundred and three patients (mean age 30.7 ± 10.9 years) treated with this scaffold were prospectively evaluated at baseline, 6-, 12- and 24-month follow-up. The clinical outcome was analysed using the International Knee Documentation Committee (IKDC) score, and the activity level was assessed with the Tegner score. The influence of patient and lesion characteristics on clinical outcomes was analysed.

Results: Mild and severe adverse reactions were found in 39.0% and 1.5% of patients, respectively. The failure rate was 2.0%, increasing to 12.3% when including also clinical failures. The IKDC subjective score increased from 43.3 ± 15.9 to 61.0 ± 16.2 at 6 months, 68.3 ± 18.5 at 12 months and 73.8 ± 18.3 at 24 months (p < 0.0005). The Tegner improved from 2.5 ± 1.7 to 4.2 ± 1.7 at 24 months (p < 0.0005), without reaching the pre-injury level (6.0 ± 2.2) (p < 0.0005). The IKDC objective score changed from 68.5% normal and nearly normal knees before the treatment to 90.1% at 24 months. At 24 months, age showed a correlation with the IKDC subjective score (ρ = -0.247; p < 0.0005), women had a lower score (p < 0.0005), as well as patients with patellar lesions (p = 0.002). Previous surgery correlated with lower results (p = 0.003), while better results were found in osteochondritis dissecans (OCD) compared to degenerative lesions (p = 0.001).

Conclusion: This cell-free biomimetic scaffold is a safe and effective treatment for cartilage knee lesions, offering positive clinical results at 2 years with a low failure rate. Better outcomes were observed in younger patients, in lesions of the femoral condyles and in OCD, while joints affected by patellar lesions, patients who underwent previous knee surgery, and women may expect lower results.

Level of evidence: III, Cohort study.

Purpose: The existing knee-specific pediatric patient-reported outcome measures (PROMs) lack content and construct validity for children with anterior cruciate ligament (ACL) injury. This impairs their accuracy which can lead to false interpretations of data and inaccurate clinical guidelines. The purpose of this study was to develop a content-valid PROM for children with an ACL injury.

Methods: The process adhered to the COnsensus-based Standards for the selection of health Measurement INstruments guidelines for PROM development. Informants were children with ACL deficiency and sampled based on age, sex, and treatment. Semistructured interviews were conducted exploring themes within the International Classification of Functioning, Disability and Health model. Interviews continued beyond data saturation. By thematic analysis and by probing items from the adult PROM 'KNEES-ACL', new themes and items emerged. Content coverage, relevance and understandability were continuously evaluated. All interviews were recorded and transcribed verbatim. The NVivo 12 software was used for data analysis and coding of items.

Results: A PROM of 60 items across nine subscales was formed. From cognitive interviews, 19 new items emerged. Forty-one of 55 items from KNEES-ACL were endorsed as relevant; however, all required rewording to ensure understandability. Substantial differences in the psychosocial impact between adults and children were observed. The children experienced a more considerable negative psychosocial impact caused by a loss of participation in sports, lower self-confidence and loss of social networks. This resulted in four new domains. The physical issues were similar to adults, with few exceptions.

Conclusion: The 'KIDS-KNEES-ACL' 1.0 (qualitative version) was developed. This version will be subjected to psychometric analysis, resulting in adequate measurement properties of the final KIDS-KNEES-ACL 2.0. As the only adequate pediatric ACL-specific PROM, its use in clinical trials and databases will enhance PROM data quality, and strengthen clinical guidelines and thus the treatment of children with ACL injury.

Level of evidence: Not applicable.

Purpose: This study aimed to compare in vivo kinematics during weight-bearing daily activities and determine the relationship with clinical outcomes in patients undergoing total knee arthroplasty (TKA) with a medial-pivot (MP, Evolution™) versus a posterior-stabilized (PS, Persona®) design under constant conditions of intraoperative soft tissue balance.

Methods: Forty patients undergoing MP or PS-TKA under similar conditions of soft tissue balance were enrolled in this prospective randomized controlled trial. Outcome measures included clinical knee society scores (KSS) and knee injury and osteoarthritis outcome scores (KOOS). A kinematic assessment was conducted while the participants performed lunge and step-up activities under fluoroscopic guidance.

Results: Eighteen patients in each arm completed 1-year follow-up and were included in the analysis. All patients experienced pain relief and satisfactory knee function postoperatively. In kinematics, in the MP arm, the medial femoral condyle remained consistent, whereas the lateral femoral condyle gradually shifted posteriorly with increasing knee flexion. Conversely, in the PS arm, paradoxical anterior movement of the medial femoral condyle accompanied the lateral pivot motion. During lunge and step-up activities, a medial-pivot motion was observed in 83% and 72% of knees in the MP arm, respectively, compared with 22% and 11% in the PS arm. Despite these differences in kinematics, there were no statistically significant differences in the KSS and KOOS between the two groups.

Conclusion: Under weight-bearing conditions during flexion, knees that underwent Evolution™ MP-TKA did not show superior clinical results compared to Persona® PS-TKA, despite exhibiting in vivo kinematics closely resembling the normal in vivo pattern.

Level of evidence: Therapeutic studies-Level I.

Purpose: Patellofemoral pain, maltracking and instability remain common and challenging complications after total knee arthroplasty. Controversy exists regarding the effect of kinematic alignment on the patellofemoral joint, as it generally leads to more femoral component valgus and internal rotation compared to mechanical alignment. The aim of this systematic review is to thoroughly examine the influence of kinematic alignment on the third space.

Methods: A systematic search of the Pubmed, Cochrane and Web of Science databases was performed to screen for relevant articles published before 7 April 2024. This led to the final inclusion of 42 articles: 2 cadaveric, 9 radiographic, 12 computer simulation and 19 clinical studies. The risk of bias was evaluated with the risk of bias in non-randomised studies - of interventions tool as the lowest level of evidence of the included clinical studies was IV. The effects of kinematic alignment on patellar kinematics and kinetics, trochlear anatomy reconstruction and patellofemoral complication rate were investigated.

Results: Kinematic alignment closely restores native patellar kinematics and kinetics, better reproduces native trochlear anatomy than mechanical alignment and leads to a 0%-11.4% incidence of patellofemoral complications. A more valgus joint line of the distal femur can cause lateral trochlear undercoverage and a trochlear angle orientation medial to the quadriceps vector when applying kinematic alignment, both of which can be solved by using an adjusted design with a 20.5° valgus trochlea.

Conclusion: Kinematic alignment appears to be a safe strategy for the patellofemoral joint in most knees, provided that certain precautions are taken to minimize the risk of complications.

Level of evidence: Level IV clinical studies, in vitro research.

Purpose: To compare clinical outcomes of autologous osteoperiosteal transplantation versus bone marrow stimulation (BMS) for medium-sized (100-150 mm²) cystic osteochondral lesions of the talus (OLTs) and assess the correlation between patient demographics and outcomes. It was hypothesised that autologous osteoperiosteal transplantation would provide better clinical outcomes than BMS for medium-sized cystic OLTs.

Methods: Patients who underwent autologous osteoperiosteal transplantation or BMS for medium-sized cystic OLTs between 2014 and 2019 were retrospectively evaluated. According to their characteristics, a 1:1 propensity-score matching was performed and 33 pairs of patients were matched. The visual analogue scale, American Orthopaedic Foot and Ankle Society (AOFAS) score, Foot Ankle Outcome Score (FAOS) and Ankle Activity Score were collected preoperatively and at the last follow-up. In addition, a general linear model analysis was performed between patient demographics and clinical outcomes in two groups separately to detect potential risk factors.

Results: Finally, 28 patients in the grafted group and 27 patients in the BMS group completed the follow-up and were enrolled with a mean follow-up period of 63.5 ± 13.9 months. Both groups showed significant improvement in all patient-reported outcomes (p < 0.01). At the final follow-up, no significant differences between groups were found in all postoperative scores except FAOS Pain (p = 0.02). Correlation analysis showed a moderate correlation between cyst depth and the postoperative AOFAS score in the BMS group (r = -0.48, p = 0.01). Based on the regression line, the patients in the BMS group with a cyst deeper than 6 mm showed a lower AOFAS score than the mean score (88.7 ± 9.5) of the grafted group.

Conclusion: Autologous osteoperiosteal transplantation and BMS are both safe and effective for medium-sized cystic OLTs. However, autologous osteoperiosteal transplantation is expected to provide better clinical outcomes than BMS when the cysts are deeper than 6 mm.

Level of evidence: Level III.