Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: Recently, blood flow restriction (BFR) and cross education (CE) trainings are the options for quadriceps strength recovery after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to investigate the effects of CE combined with BFR on quadriceps strength and thickness after ACLR.

Methods: Twenty-four male patients [(Age: 24.9 ± 6.3 years, body mass index: 24 ± 2.3 kg/m²) who had undergone ACLR with hamstring autograft were included. At 4 weeks after surgery, the patients were randomly divided into two groups (Group-1: CE + BFR, n = 13, Group-2: CE, n = 11). All patients had standardized rehabilitation for their reconstructed limb until 12 weeks postsurgery, and they all received CE training for uninjured limb at isokinetic system (quadriceps eccentric contraction, 60°/s 3-set 12-rep, 2-days in a week) during 8 weeks. Group 2 performed the same CE procedure with BFR. Quadriceps isometric strength was measured using an isokinetic dynamometer, while the thickness of quadriceps (rectus femoris, vastus lateralis, vastus medialis obliquus) and cross-sectional area of rectus femoris were evaluated using ultrasound pretraining (4th-week postsurgery) and posttraining (12th-week postsurgery). Analysis of variance was used for statistical analysis.

Results: Group-by-time interaction and the group main effect were not significant for any measured variables in both limbs (p > 0.05). There was a significant main effect of time observed for quadriceps strength and thickness in involved and uninvolved limbs (p < 0.001, p < 0.05, respectively). In Group 1, the limb symmetry index for quadriceps strength increased from 49.3% to 71.7%, while in Group 2, it increased from 50.9% to 75.2%.

Conclusion: BFR training, adapted to CE eccentric strengthening, may not be effective for quadriceps muscle strength recovery after ACLR. Further investigations with varied training protocols are needed to research the impact of BFR on CE.

Level of evidence: Level II randomized controlled trial.

Purpose: To identify values of reported quadriceps tendon (QT) autograft diameter and length in anterior cruciate ligament reconstruction (ACLR), and to identify methods to predict these parameters.

Methods: A search was conducted across three databases from inception to 30 March 2024. Data on study characteristics, demographics, anthropometric data, imaging techniques, and QT autograft or harvested QT tendon parameters were extracted. Values quantifying the statistical strength of associations between imaging or anthropometric characteristics and graft or tendon parameters as well as for associations between these parameters and postoperative outcomes were recorded.

Results: A total of 3633 patients were included. The weighted mean QT autograft diameter and length were 8.9 (standard deviation [SD]: 0.7, range: 7.8-10.4) mm and 8.1 (SD: 1.3, range: 5.6-9.3) cm, respectively. A total of 93.8% of studies that reported mean QT autograft diameter found a value of 8 mm or greater. The QT groups had similar or significantly greater mean autograft diameter compared to the hamstring tendon (HT) groups in 91.7% of studies that reported significance. Regarding MRI measurements, 71.4% of the correlation coefficients reported showed a moderate positive correlation, 28.6% showed a low positive correlation and 14.3% showed a high positive correlation. Regarding anthropometric characteristics, 33.3% and 16.7%, 16.7% and 14.3% of studies that reported on the relationship between QT autograft diameter and height, weight, body mass index or age, respectively, found a low positive statistically significant correlation. Only statistically nonsignificant associations were reported between QT autograft parameters and post-operative outcomes and complications.

Conclusions: QT autografts used in ACLR have a mean diameter of 8 mm or greater and are consistently larger than HT autografts. Preoperative MRI measurements are better than anthropometric characteristics at predicting QT autograft parameters; however, preoperative prediction may not be necessary for this graft type. QT autograft parameters were not found to be significantly associated with any post-operative complication or outcome.

Level of evidence: Level IV.

Purpose: To evaluate clinical, functional and radiological mid-term outcomes following posterior open-wedge glenoid osteotomy (POWGO) for the treatment of posterior shoulder instability (PSI) associated with increased glenoid retroversion.

Methods: Patients who underwent POWGO for the treatment of symptomatic PSI with glenoid retroversion >10° and participated in a previous study assessing short-term outcomes were included after a minimum follow-up of 5 years. Clinical (Rowe score and physical examination) and functional outcomes (Oxford Shoulder Instability Score [OSIS] and visual analogue scale [VAS] for pain) were assessed. Preoperative versus follow-up magnetic resonance imaging (MRI) assessments were compared for changes in posterior humeral head subluxation (PHHS) and progression of osteoarthritis (shoulder osteoarthritis severity [SOAS] score).

Results: Eight patients (nine shoulders) were included 92.0 months (88.0-109.5 months) post-operatively, of which seven patients (eight shoulders) underwent MRI. Shoulder function was good (Rowe score: 80.0 [76.3-91.3], OSIS: 41.0 [31.0-41.5]) and pain levels were low (VAS for pain: 3.0 [1.0-3.0]) at follow-up. Overall, the degree of PHHS did not change between preoperatively and follow-up (p > 0.05). Four shoulders demonstrated PHHS preoperatively, of which two had a centred humeral head at follow-up. Shoulder osteoarthritis progressed significantly (SOAS score: 17.0 [11.0-24.5] to 33.0 [31.0-45.0], p = 0.018). Residual PSI was evident in 75.0% of shoulders.

Conclusion: At mid-term follow-up, POWGO for PSI associated with increased glenoid retroversion led to good functional outcomes but failed to reliably restore posterior shoulder stability and prevent osteoarthritis progression.

Level of evidence: Level IV.

Purpose: To investigate the biomechanical consequences of osteosynthesis of lateral hinge fractures (LHFs) in medial open wedge high tibial osteotomy (MOWHTO).

Methods: Sixteen fresh-frozen human cadaveric proximal tibiae underwent MOWHTO fixed with an ipsilateral locking compression plate. The specimens were assigned to two clusters simulating LHFs according to the Takeuchi classification: (1) Type II fracture; and (2) Type III fracture. The following conditions were serially tested: (1) intact hinge; (2) fractured hinge; (3) screw fixation of the LHF; (4) staple fixation of the LHF; and (5) locking T-plate fixation of the LHF. Each specimen was subjected to 10 cycles of axial compression load (720 N; 36 N/s), and internal and external rotational loads (10 N m; 1 N m/s), while capturing the interfragmentary movements via motion tracking.

Results: In Takeuchi Type II fractures, osteosynthesis of the fractured hinge with staples or a plate significantly reduced fracture site displacement (p < 0.05) and significantly increased construct stiffness (p < 0.05) under axial and torsional loading, while only the plate restored intact torsional displacement (n.s.). For Takeuchi Type III fractures, both screw and plate fixation significantly reduced fracture site displacement (p < 0.05) and significantly increased construct stiffness (p < 0.05) under axial and torsional loading. Both techniques restored torsional stiffness in each rotational direction and torsional displacement in internal rotation (n.s.).

Conclusion: Additional plate fixation of Takeuchi Type II fractures was the construct with the highest stiffness, restoring the axial and torsional stability to a MOWHTO with an intact hinge. Screw and plate fixation of Takeuchi Type III fractures provided equivalent stability and restored the torsional and axial stability of the MOWHTO. In case of a Takeuchi Type II or III fracture, surgeons should consider additional plate or screw osteosynthesis of the fractured hinge to best restore the stability of the MOWHTO, which may potentially reduce the risk of loss of correction and impaired bone healing.

Level of evidence: There is no level of evidence as this study was an experimental laboratory study.

Purpose: Different techniques of slope-decreasing anterior closed-wedge proximal tibial osteotomy (ACW-PTO) have been described. To determine the peri- and post-operative complication rate and obtain data on bone healing in ACW-PTO with an infratuberositary approach.

Methods: A total of 170 consecutive ACW-PTO of two sports-orthopaedic centres were retrospectively evaluated (97 and 73, respectively). Routine follow-up was performed after 6 weeks and was available in 166 cases (97.7%). Medical charts and x-rays of these cases were reviewed with regard to technique-specific complications. Lateral x-rays (n = 155) at 6 weeks post-operatively were evaluated with regard to bone healing (completely healed, partially healed or with no or delayed signs of bone healing). A multivariate binary logistic regression was performed to detect factors that influence bone healing.

Results: There was one case with haematoma and superficial wound-healing problems after 5 weeks with progression to a deep wound infection and revision surgery (plate exchange) at 11 weeks after the index surgery. One case with delayed bone healing was treated with plate exchange combined with revision anterior cruciate ligament reconstruction after 4 months. The further course of both cases was uneventful. No other complications were observed. Therefore, the overall complication rate was 1.2% (2 out of 166). Radiologic evaluation at 6 weeks showed complete healing in 104 cases (67.1%), partial healing in 50 cases (32.3%) and delayed healing only in the aforementioned case (0.6%), respectively. All cases of partial healing showed complete healing at 12 weeks. In regression analysis, a completely closed osteotomy (odds ratio [OR] = 3.5, p = 0.003) and compression of the osteotomy (OR = 2.5, p = 0.026) were significantly associated with complete bone healing at 6 weeks.

Conclusions: ACW-PTO using an infratuberositary approach is very safe with regard to complication rate and shows rapid bone healing. The osteotomy should be completely closed and compression should be applied for optimal bone healing.

Study design: Case series with pooled data of two centres.

Level of evidence: Level 4.

Purpose: In modern anterior cruciate ligament (ACL) surgery, the focus is usually on anatomical reconstruction to restore the natural kinematics of the knee. The individual optimal positioning of the ACL footprints (FPs) in primary surgery is still controversial and, especially in revision surgery, difficult to realize surgically. In this regard, a new MRI-based sequence, the Compressed Lateral and anteroposterior Anatomic Systematic Sequence (CLASS) with marked femoral and tibial FPs as a template, could help. The purpose of this study was to (1) validate the reliability and reproducibility of the localization of femoral and tibial FPs of ACL in the generation of CLASS and (2) compare the identification of ACL FPs by CLASS with previously described methods.

Methods: Magnetic resonance imaging (MRI) of uninjured knees from a predominantly young cohort is used to apply the CLASS algorithm. ACL FPs were subsequently identified by a board-certified radiologist and an orthopaedic knee surgeon. Intraobserver reliability and interobserver reproducibility were assessed. Measurements of the ACL FPs according to established methods were performed and compared with the results from the literature.

Results: Identification of ACL FPs and generation of CLASS images resulted in 'almost perfect' reliability and reproducibility. Most measurements also showed 'almost perfect' consistency. Statistical analysis showed significant variations between the deep-shallow and high-low positions when compared to the published literature.

Conclusions: The CLASS MRI sequence is a reliable and reproducible method for identifying ACL FPs. The observed variability in the location of the ACL FP underlines the importance of a patient-specific surgical approach.

Level of evidence: Level II.

Purpose: The purpose of this study was to assess the impact of post-operative coronal plane alignment of the knee (CPAK) class change on functional outcomes and determine the rate and type of CPAK class change after image-based robotic arm-assisted (RA)-total knee arthroplasty (TKA) performed with functional alignment (FA) at two different centres.

Methods: The present retrospective, observational, multicentre study included 201 patients treated with RA-TKA between October 2020 and April 2022 at two different centres. The radiographic CPAK classification was adapted using CT images to achieve pre- and post-operative knee categorization into CPAK classes. At a minimum of 1 year post-operatively, patients were administered the Forgotten Joint Score-12 (FJS-12) and surveyed about their post-operative satisfaction level using a 5-level Likert scale (5-LLS).

Results: The most common preoperative overall CPAK classes were: Types II, I, III, IV and V. Implant positioning after RA-TKA with FA within the alignment boundaries, determined distribution in the CPAK classification, predominantly maintaining classes I, II, IV, and V. No statistically significant FJS-12 differences were detected between subjects who maintained and changed their preoperative CPAK class. The mean 5-LLS for satisfaction in patients where the preoperative CPAK class was maintained intraoperatively was 4.4 ± 1.1 (range = 1-5), while subjects having the CPAK class changed had a mean 5-LLS of 4.4 ± SD 1.0 (range 1-5).

Conclusion: In the setting of image-based RA-TKA with FA, CPAK can be changed within a 'functional safe-zone', without compromising functional outcomes. Good functional outcomes are the result of a stable and balanced knee with soft-tissue preservation, regardless of the maintenance of the preoperative CPAK class.

Level of evidence: Level III.

Purpose: This study aims to summarize the graft dimensions, failure rates, return-to-sport rates and patient-reported outcome measures (PROMs) following anterior cruciate ligament reconstruction (ACLR) with six or eight-strand hamstring tendon autografts (6SHG or 8SHG).

Methods: Three databases were searched from inception to 12 February 2024. The authors adhered to PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. All clinical studies reporting patient demographics, objective clinical outcomes and PROMs following ACLR with 6SHG or 8SHG were included for data synthesis. PROMs included the International Knee Documentation Committee (IKDC), Lysholm and Tegner scores.

Results: Thirteen studies comprising 1103 patients were included (mean age: 30.6 years). The transtibial technique was used in all studies, except one study using anatomic ACLR (n = 38), and one study using transtibial and all-inside ACLR (n = 41). Eight studies comprising 512 patients used 6SHG, four studies comprising 507 patients 8SHG and two studies comprising 97 patients used either. Mean graft diameters ranged from 8.0 to 9.2 mm (6SHG) and 9.1 to 9.9 mm (8SHG). Mean graft lengths for 49 6SHG patients ranged from 60.0 to 83.3 mm. The failure rate for 817 patients (6SHG or 8SHG) was 4.8% (0.0%-20.0%). The return-to-sport rate for 112 patients (6SHG or 8SHG) was 75.9% (69.7%-100.0%). Mean IKDC, Lysholm and Tegner scores for 6SHG or 8SHG were 88.4 (86.1-96.3), 91.7 (90.4-96.5) and 6.9 (6.5-7.3), respectively.

Conclusions: Both 6SHG and 8SHG produced graft diameters <8 mm. Data regarding PROMs suggested good patient satisfaction based on established criteria. Re-rupture and return-to-sport rates were 4.8% and 75.9%, respectively.

Level of evidence: Level IV.

Purpose: Lateralisation of the proximal apex of the quadriceps tendon relative to the mechanical axis or external rotation relative to the femoral shaft can be accurately measured and is strongly associated with patella maltracking. The aim of this study was to first assess the association between preoperative quadriceps tendon alignment (QTA) and the patient-reported outcomes (PROMs) of total knee replacement, and second, determine the influence of component position on outcomes in patients with preoperative quadriceps tendon malalignment (QTM).

Methods: A retrospective analysis of prospectively collected data was performed. All patients had preoperative and postoperative CT scans performed. PROMs were collected preoperatively and at 1 year postoperatively. QTA was measured by the quadriceps tendon axial angle (QTAx). The preoperative and postoperative coronal and axial alignment were measured. Femoral component rotation was measured relative to the preoperative posterior condyles.

Results: Analysis was conducted on 388 cases and the mean preoperative QTAx was 6.2° externally rotated (standard deviation 12.0°). QTM (QTAx > 14°) was identified in 76 (19.8%) patients. The diagnosis of QTM was associated with reduced patient outcomes including Forgotten Joint Score (60.2 vs. 51.2, p = 0.008), EuroQol Visual Analogue Scale (81.3 vs. 75.7, p = 0.009), KOOS-12 (80.3 vs. 73.3, p = 0.001) and reduced PASS percentages for all KOOS subscales. In patients with preoperative QTM, femoral component external rotation >2° was associated with improved PROMs when compared to patients with <2° of femoral rotation. This included a clinically significant difference in the improvement of KOOS-12 (11.7 points, p = 0.013) and improved PASS percentages in all KOOS subscales. There was no association between coronal alignment or tibial axial alignment and outcomes.

Conclusions: Quadriceps malalignment is a common cause for poorer patient outcomes following total knee replacement. This can be avoided by externally rotating the femoral component to accommodate the deformity in the extensor mechanism.

Level of evidence: Level III, case-control study.

Purpose: This study aims to perform a systematic review to determine whether ultra-high molecular weight polyethylene (UHMWPE) tapes have superior biomechanical properties compared to conventional sutures in posterior meniscal root tear (PMRT) repairs, and whether this translates into superior clinical outcomes.

Methods: The Cochrane Controlled Register of Trials, PubMed and Embase were used to perform a systematic review using the following search terms: (meniscus OR meniscal) AND (root OR posterior horn) AND (suture OR tape OR wire OR cord). Data pertaining to certain biomechanical properties (load to failure, stiffness, displacement during cyclical loading and at failure), meniscal healing and patient-reported outcome measures (PROMs) were extracted.

Results: Seven biomechanical and two clinical studies were included. There were 232 knees for biomechanical testing: 81 with UHMWPE tapes and 151 with conventional sutures (133 with UHMWPE sutures and 18 with Ethibond [Ethicon]). Testing set-up was similar across studies, but there were differences in repair techniques, including suture configuration, location and method of fixation. In general, the consensus was that tapes had a higher load to failure and stiffness, with similar displacement at failure to that of UHMWPE sutures. A similar trend was also observed when tapes were compared to Ethibond, except for FiberTape (Arthrex). This particular UHMWPE tape showed greater displacement during cyclical loading, resulting from knot slippage. Clinically, there were 73 patients, 41 with UHMWPE tapes and 32 with either UHMWPE sutures (n = 18) or braided polyester sutures (n = 14). Tapes led to greater meniscal healing 1 year postoperatively, with PROMs similar across groups.

Conclusions: UHMWPE tapes generally demonstrated superior biomechanical properties compared to conventional sutures in PMRT repairs with a simple stitch configuration. However, further biomechanical studies are required to determine the extent to which tapes contribute to the repaired construct, especially with more complex repair configurations, as the existing evidence displayed a notable amount of methodological heterogeneity.

Level of evidence: Level IV systematic review of level IV evidence.