Knee Surgery and Related Research最新文献

Background: Implant design in total knee arthroplasty (TKA) has evolved considerably, with recent developments focusing on reproducing native knee kinematics. Some implants now feature anatomically and physiologically accurate articular surface geometries. This study aimed to evaluate the impact of different implant designs on knee kinematics using the same cadaveric specimens to ensure consistent comparison. We hypothesized that implant designs incorporating features intended to replicate native joint anatomy, such as the kinematic retaining (KR) design, would more closely reproduce physiological knee kinematics.

Methods: TKA was performed on nine Thiel-embalmed cadaveric knees with mild medial osteoarthritis, using three implant designs from the Physica system: KR, cruciate retaining (CR), and medial congruent (MC) designs. All procedures were performed using a mechanical alignment technique, with both the posterior tibial slope and femoral rotational angle standardized at 3°. The posterior cruciate ligament was preserved throughout the evaluation of all implant designs. A navigation system was used to collect detailed kinematic data. Evaluations were conducted after trial component placement, focusing on anteroposterior, mediolateral, and compression-distraction positions, as well as rotational angles. From these knee status data, femoral rotational kinematics relative to the tibia and the anteroposterior translation of both femoral condyles during flexion were also calculated.

Results: No significant differences in flexion and extension angles were observed between the groups. The KR group presented the greatest mean femoral external rotation relative to the tibia throughout the range of motion among the groups; however, there were no statistically significant differences. The CR and MC group showed significantly reduced anteroposterior translation of the lateral condyle compared with the native knee (p = 0.021 and 0.003, respectively). Furthermore, the anteroposterior translation of the lateral femoral condyle was significantly greater in the KR group than in MC groups (p = 0.021). In the KR group, six of nine knees exhibited medial pivot motion, compared with three in the CR group and four in the MC group.

Conclusions: Using identical cadaveric specimens and navigation-based analysis, we identified distinct kinematic profiles associated with each implant design. Notably, the KR implant demonstrated kinematics approximating native knee motion; however, these findings remain preliminary and warrant further clinical validation.

Level of evidence: III.

Background: A clear understanding of minimal clinically important difference (MCID) and substantial clinical benefit (SCB) is essential for effectively implementing patient-reported outcome measurements (PROMs) as a performance measure for total knee arthroplasty (TKA). Since not achieving MCID and SCB may reflect suboptimal surgical benefit, the primary aim of this study was to use machine learning to predict patients who may not achieve the threshold-based outcomes (i.e., MCID and SCB) on the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) following TKA.

Methods: Data from 1064 patients who underwent TKA at a single academic medical center between 2016 and 2022 contained 81 preoperative variables, including routinely collected measures and PROMs (KOOS JR and Patient-Reported Outcomes Measurement Information Systems [PROMIS-10]). Several machine-learning models were developed, which include penalized logistic regression as a linear model, support vector machine with polynomial and radial kernels as nonlinear models, and random forest and extreme gradient boosting as nonparametric models. These models predicted both distribution- and anchor-based MCIDs and SCB. In addition, logistic regression models were used to identify relevant risk factors for failing to meet these thresholds.

Results: The random forest models and the penalized logistic regression models achieved acceptable area under the receiver operating characteristic curve (AUC) close to or above 0.7 for all the outcomes. Furthermore, the logistic regression models identified shared risk factors for the three outcomes: preoperative PROMs (i.e., KOOS JR score, PROMIS-10 global physical T-score, and PROMIS-10 general mental health), antidepressant medication history, age, and Kellgren-Lawrence grade.

Conclusions: Machine-learning models were able to identify patients at risk of failure to achieve the threshold-based metrics and relevant preoperative factors. As such, these models may be used to both improve shared decision-making and help create risk-stratification tools to improve quality assessment of surgical outcomes.

Background: Surgical interventions to correct abnormal quadriceps direction are performed in cases of patellofemoral joint disorders, to medialize the patella and reduce lateral stress. However, excessive medialization can lead to increased contact forces and joint instability, underscoring the need for a more detailed understanding of the effects of quadriceps alterations on joint biomechanics. The purpose of this study was to evaluate the impact of variations of the magnitude and direction of the quadriceps force on the kinematics of the patellofemoral joint.

Methods: A total of 12 cadaveric knees were evaluated in flexion-extension applying different loads to the quadriceps tendon. Specifically, we evaluated five different directions of the quadriceps line of action in the frontal plane: neutral, ±6° and ±12°; and two directions in the sagittal plane: neutral and 5° anterior. Three load magnitudes were simulated: 20 N, 160 N, and 280 N. Relative motion between the patella, femur, and tibia was measured using an optoelectronic system.

Results: The comparison under reference loading conditions (neutral direction, 20 N) across all specimens demonstrated consistent patellofemoral motion. Similarly, tibiofemoral kinematics was comparable between specimens and with the literature. Variations of the direction of the quadriceps force in the frontal plane exerted a significant impact on all components of motion in the patellofemoral joint. Compared with the reference condition, at full extension, 12° medialization increased patellar varus rotation (-6.2° ± 3.3°), while at high flexion it increased valgus rotation (4.8° ± 4.8°). Lateralization reversed this pattern, causing valgus at extension (7.7° ± 3.6°) and varus in flexion (-2.8° ± 1.8°). Medial-lateral patellar translation exceeded ±6 mm under 12° deviations. Sagittal-plane changes had minimal impact, mostly in extension when the patella is not yet in the trochlea. Tibiofemoral kinematics was more sensitive to load magnitude, although frontal-plane direction also affected joint rotation.

Conclusions: This study provides essential insights into the biomechanical interplay between quadriceps alignment and patellofemoral kinematics. These findings may inform surgical strategies for optimizing patellar tracking. Level of evidence In vitro biomechanical tests.

Background: Multiligament knee injuries (MLKIs) often result from high-energy trauma in polytrauma patients. They may coincide with other musculoskeletal injuries, especially fractures of the ipsilateral lower extremity (LE) or pelvis. Understanding these fracture patterns can guide surgical planning and improve patient outcomes. The study aim is to describe the ligamentous injury patterns of combined ipsilateral LE or pelvic fractures with surgically treated MLKIs.

Methods: A retrospective cohort study was conducted from April 2008 to August 2024. Patients who sustained tibial plateau (TP), femoral condyle (FC), fibular, tibial shaft, femoral shaft, or pelvic fractures, concurrent with surgically treated MLKIs, were included. Ligament injuries (anterior cruciate [ACL], posterior cruciate [PCL], medial collateral [MCL], and lateral collateral [LCL]) were categorized by number (≥ 2) and pattern (ACL-based, PCL-based, or bicruciate). Comparisons were made between fracture and non-fracture groups.

Results: Among 211 patients (69% male; mean age 28.3 ± 12.9 years), 36% (75/211) had fractures, with 19% (17/75) requiring operative fixation. TP fractures were the most common (57%), followed by FC (47%) and pelvic fractures (16%). ACL-based injuries (65%) were predominant, while PCL-based injuries were less frequent in fracture patients (4% versus 13% in the non-fracture group). ACL/LCL injuries were significantly more common in the fracture group (29% versus 18%, p = 0.049). Two-ligament injuries accounted for 71% (53/75) of fracture cases.

Conclusions: More than one-third of patients with MLKI sustained concomitant LE fractures, with TP fractures occurring most frequently. ACL/LCL and ACL/PCL/LCL patterns showed particularly high fracture rates, whereas PCL-based MLKIs were more common without fractures.

Purpose: The long-term effect of osteochondral autologous transplantation (OAT) on spontaneous osteonecrosis of the knee (SONK) following subchondral insufficiency fracture remains unclear. This study aimed to evaluate the long-term survivorship and clinical outcomes of OAT for SONK, with a focus on factors associated with clinical success.

Methods: Patients who underwent OAT for SONK between 1998 and 2009 were retrospectively reviewed. Survivorship was assessed using Kaplan-Meier analysis, with revision surgery as the endpoint. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) subjective score obtained preoperatively and at final follow-up. Clinical failure was defined as an IKDC score below the patient acceptable symptom state (PASS; 62.1 points). The association between final IKDC score and postoperative femorotibial angle (FTA) was analyzed using linear and quadratic regression.

Results: A total of 33 OATs were included (mean age: 64.6 ± 8.0 years; mean lesion size: 3.9 ± 1.7 cm²). High tibial osteotomy was performed in 15 patients with FTA > 180°, and 24 patients were followed for ≥ 10 years (mean: 13.7 ± 3.4 years). One arthroplasty was performed at 14.2 years, yielding a 15-year survival rate of 88%. The IKDC score improved significantly (35.0 ± 12.6 to 70.6 ± 14.1, p < 0.001), with a clinical success rate of 79.2%. Quadratic regression showed optimal postoperative FTA between 163.1° and 178.3° for achieving PASS.

Conclusions: OAT may provide favorable long-term survivorship and clinical outcomes in SONK, particularly when postoperative alignment is appropriately corrected.

Introduction: Chloroprocaine is a rapid, short-acting spinal anesthetic that may facilitate quicker postoperative recovery in total knee arthroplasty (TKA). However, limited literature exists regarding its use in patients undergoing same-day discharge (SDD) TKA. This study evaluated the clinical outcomes and safety of chloroprocaine compared with those of mepivacaine.

Methods: This retrospective study of 178 patients who underwent primary TKA at a single ambulatory surgery center from March 2022 to June 2023 compared chloroprocaine (n = 114) and mepivacaine (n = 64) spinal anesthesia. Surgical outcomes, including estimated blood loss (EBL), operative time, discharge time, 90-day emergency department visits, and 90-day readmissions, were evaluated. In addition, anesthesia-related complications such as hypotension, bradycardia, urinary retention, and postanesthesia care unit (PACU) outcomes were recorded. Continuous variables between the chloroprocaine and mepivacaine groups were compared via independent sample t-tests, whereas categorical variables were analyzed via chi-squared tests. A p-value of less than 0.05 was considered statistically significant.

Results: There were no differences in the baseline characteristics between the two groups. The chloroprocaine group had a significantly shorter operative time (73.1 versus 84.9 min, p < 0.001) and faster discharge (3.7 versus 4.2 h, p < 0.001), with no difference in EBL. Patients in the chloroprocaine group had a lower incidence of urinary retention (2.5 versus 15.6%, p = 0.004), a lower proportion of patients who needed a urinary catheter (2.6 versus 14.1%, p = 0.004), and fewer postoperative complaints of numbness (19.3 versus 39.1%, p = 0.004). There were no differences in surgical complications.

Conclusions: Compared with mepivacaine, chloroprocaine spinal anesthesia for SDD TKA was associated with lower rates of urinary retention, a reduced need for urinary catheterization, fewer neurological complaints in the PACU, and faster discharge times. No differences were observed in surgical outcomes between the groups, and there were no instances of unplanned direct admissions. These results suggest that chloroprocaine can be safely used as a reliable alternative to mepivacaine in outpatient TKA.

Purpose: The aim of this study was to compare total perioperative blood loss in patients undergoing total knee arthroplasty (TKA) in different ABO blood types.

Methods: This study was approved by the Institutional Review Board of our hospital (IRB No. 1510) on 2 February 2015. A total of 260 knees undergoing unilateral primary cemented cruciate-retaining TKA for knee osteoarthritis were retrospectively registered. Perioperative total blood loss was calculated for each blood types based on the change in hematocrit from pre- to postoperative day 7, preoperative height and weight. Differences in blood loss among the four ABO blood types were assessed. The association between blood type (O versus others) and total blood loss was further evaluated after adjusting for baseline characteristics through inverse probability of treatment weighting (IPTW).

Results: The study population was divided based on the ABO blood type: type O, 87; type A, 82; type B, 54; and type AB, 37. The mean total blood loss was 829 ± 370 ml for type O, 702 ± 384 ml for type A, 574 ± 361 ml for type B, and 528 ± 282 ml for type AB. Patients with blood Type O had significantly higher blood loss than all other blood types. After IPTW adjustment, mean total blood loss remained higher in type O (790 ± 370 ml) compared to other blood types (613 ± 364 ml).

Conclusion: These findings suggest that blood type O may be associated with increased perioperative blood loss in TKA.

Background: Mobile-bearing (MB) and medial-pivot (MP) prostheses are the two popular designs used in total knee arthroplasty (TKA), yet their long-term outcomes remain controversial. This meta-analysis was conducted to determine whether there are any differences in outcomes between patients who receive these two prostheses in TKA.

Method: We comprehensively searched electronic databases up to November 2024. Observational studies or randomized controlled trials reported postoperative outcomes, including radiographic results, functional score through the Knee Society Score (KSS), Western Ontario and McMaster Universities (WOMAC) score, and patient satisfaction. The results are presented in odd ratios (ORs) or mean differences with corresponding 95% confidence intervals (CIs).

Results: In total, four studies were included, with 1069 patients and 1251 operated knees (632 MB TKAs and 619 MP TKAs). The mean age was 68.21 years old and the mean follow-up duration was from 5 to 11 years. Regarding patient satisfaction, the MB prostheses brought greater comfort to patients in the last follow-up than the MP group (OR = 3.19; 95%CI 1.92-5.30; p < 0.001). Additionally, there were no differences in the outcomes of functional scores, including the KSS (p = 0.34), WOMAC score (p = 0.16), and range of motion (ROM) (p = 0.36) between patients receiving the MB and MP prostheses.

Conclusions: Our meta-analysis of four studies highlighted the long-term outcomes of TKA between MB and MP designs. While KSS, WOMAC scores, and knee ROM showed no significant differences, patients with MB designs reported higher satisfaction levels compared with those with MP designs.

Background: Tibial eminence fractures are common injuries that can cause significant functional limitations and require timely and effective treatment. Arthroscopic screw fixation and suture fixation are the primary methods used for managing displaced fractures. This study aimed to compare the functional and clinical outcomes between the two groups.

Methods: An associated systematic review was carried out with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines utilizing the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Sage Journals, Science Direct, and Core Journals databases. Any language publication that assessed the results following the fixation of tibial eminence fractures by screw and suture fixation from 2000 to 2024 was included. Clinical, functional outcomes, subsequent surgeries, complications, operation time, and union time were evaluated. All data were assessed using SPSS version 25 and RevMan version 5.4.

Results: A total of 9 studies involving 412 patients were analyzed out of 3365 papers. There were no significant differences (p > 0.05) between the two methods in the Lysholm score, Tegner Activity Scale, International Knee Documentation Committee (IKDC) score, range of motion, Lachman test, pivot-shift test, KT-1000, and union time. However, screw fixation had a significantly higher rate of subsequent surgeries (planned removal implant excluded) (29.75% versus 11.6%; p < 0.00001), complications (p = 0.0003), and shorter operation times (67 min versus 85 min; p = 0.0003).

Conclusions: The findings revealed that suture fixation carried a significantly lower risk of subsequent surgery and complications but required a longer operation time. Each technique presents advantages and challenges, making the decision a crucial aspect of patient care.

Introduction: Patella fractures account for about 1% of all bone fractures, predominantly affecting males at a 2:1 ratio and exhibiting distinctive age-related patterns. In younger individuals, these injuries typically result from high-velocity impacts, while in the elderly, they usually arise from lower-energy impacts. Consequently, the types of fractures differ; horizontal fractures are more common in younger individuals, whereas comminuted fractures are more prevalent in older adults. Owing to the knee's biomechanics, surgical intervention is often necessary. Preserving the articular surface is crucial to prevent retropatellar osteoarthritis, making thorough planning of surgical treatment essential. How can the osteosynthesis of this fracture entity be simulated as realistically as possible?

Materials and methods: This study focused on the feasibility of inducing realistic patella fractures with an intact soft tissue envelope on human cadaveric specimens for surgical training purposes. A total of seven fresh-frozen human cadaveric knee joints were used, and fractures were created using a custom-designed drop-test bench. The induced fractures were then classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Speck and Regazzoni classifications using radiographic and computed tomography (CT) evaluations. In addition, intra-rater and inter-rater reliability were further examined.

Results: All specimens were successfully fractured. The results demonstrated high intra-rater and inter-rater reliability in both fracture classification systems, indicating that the method can reliably replicate realistic fractures for training purposes.

Conclusions: The study highlights the significance of using specimens with realistically induced fracture patterns in surgical education. Given that patella fractures are relatively rare and limit direct clinical exposure, realistic fracture models are invaluable for understanding these conditions. These models enhance surgical training, enabling both novice and experienced surgeons to refine their skills and effectively adapt to new surgical techniques.