Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine最新文献

Introduction/objectives: Patella alta is implicated in numerous disorders of the patellofemoral joint, including patellofemoral instability (PFI). Caton-Deschamps Index (CDI) is a validated index for assessing patellar height in pediatric patients on knee radiographs. In adults, Magnetic Resonance Imaging (MRI)-derived CDI demonstrates variable agreement with radiograph-derived CDI, though no study to date has investigated the applicability of this index in pediatric patients. The study objective is to compare MRI- and radiograph-derived CDI in pediatric patients with PFI and healthy controls.

Methods: 252 knees of patients ages ≤18 years were included in this study. 126 knees from 112 patients with PFI undergoing medial patellofemoral ligament reconstruction with preoperative MRI and XR were included as well as 126 knees from 119 healthy controls. Caton-Deschamps Index (CDI) was measured on both MRI and XR. CDI values were compared using two-way random, single measures, absolute agreement intraclass correlation coefficient (ICC[2, 1]) and Bland-Altman analysis.

Results: The mean age of the patient cohort was 14.5±2.07, with 154 females (66.7%). The mean CDI as measured on XR was 1.21±0.22 and on MRI was 1.21±0.19, ICC[2, 1] was 0.67 (95% CI: 0.5 -0.73, p<0.001). Bland-Altman analysis revealed a mean difference of -0.0034±0.17 between XR and MRI (Limits of Agreement: 0.33 to -0.33). Agreement between XR and MRI patella alta classification was fair (kappa=0.50, p<0.001) with disagreement occurring in 54 patients (21%). When stratifying patients by the presence of PFI, ICC additionally demonstrated fair agreement between XR and MRI CDI. Multivariable logistic regression demonstrated younger age (OR=0.82, 95% CI: 0.71-0.95, p=0.009) and higher CDI (OR=8.28, 95% CI: 2.24-30.57, p=0.002) were independently associated with high disagreement.

Conclusions: In pediatric patients with and without PFI, Caton-Deschamps Index demonstrates good agreement when measured on radiographs and MRI, though fair agreement in classifying patella alta. Caution should be taken when utilizing this index to assess patellar height in pediatric patients, particularly in younger patients.

Level of evidence: III.

Introduction/objectives: Periprosthetic joint infection (PJI) remains one of the most serious complications following total knee arthroplasty (TKA). This study evaluated the hospital-based incidence rate, risk factors and early functional outcomes of PJI after primary TKA in two regional orthopaedic hospitals in Southern Nigeria.

Methods: This was a retrospective-prospective two-centre cohort study on primary TKA procedures conducted between January 2022 and August 2025. Data from the arthroplasty registry of two regional hospitals were analysed for demographic characteristics, perioperative details, postoperative complications, and functional outcomes measured using the Visual Analogue Scale (VAS) and Knee Society Score (KSS). PJI was diagnosed using the Musculoskeletal Infection Society criteria.

Results: There were 392 primary TKAs from which 10 cases of PJI were identified over the period, giving an incidence rate of 2.6% (CI 1.0, 4.2. p = 0.307). Most infections were early PJIs. Staphylococcus aureus was the commonest organism isolated. Diabetes mellitus, obesity, surgical duration greater than 120 minutes, and drain use beyond 48 hours were not statistically significantly associated with the development of PJI. Patients without PJI recorded statistically significant improvement in VAS (p= 0.000), and KSS (p= 0.000), at three months, while those treated for PJI also demonstrated postoperative functional gains(p=0.023) CONCLUSION: The incidence of PJI in this setting is not statistically significantly higher than rates reported in high-income countries. Modifiable perioperative factors such as blood glucose control, reduced operative duration, and judicious use of drains will help reduce the risk.

Level of evidence: III.

Introduction/objectives: The Coronal Plane Alignment of the Knee (CPAK) classification, derived from the arithmetic Hip-Knee-Ankle angle (aHKA) and Joint Line Obliquity (JLO), is scarcely studied in Indian populations. This study evaluated CPAK phenotype distribution in Indian osteoarthritic (OA) knees and its association with demographics and early outcomes following robotic-assisted total knee arthroplasty (RATKA) using a functional alignment (FA) approach.

Methods: All RATKA done consecutively between January 2022 and September 2023 were included for this retrospective study. Patient's preoperative long-leg radiographs were analyzed to measure the Medial Proximal Tibial Angle (MPTA), Lateral Distal Femoral Angle (LDFA), aHKA, and JLO. Knees were classified into nine CPAK phenotypes (Types I-IX) according to alignment category (varus ≤ -3°, neutral -3° to 3°, valgus ≥ 3°) and JLO orientation (apex-distal-AD, neutral, apex-proximal-AP). Chi-square/Fisher's exact tests assessed associations with age, gender, and operative side. Postoperative alignment restoration and early functional outcomes were evaluated at six months.

Results: Finally, the sample was based on 947 end-stage OA (Kellgren-Lawrence grade 4) knees from 604 Indian patients with a mean age of 61.7 ± 9.7 years; 65% were women. Varus alignment: 88.2% of knees, valgus: 11.8%, and none were neutral. CPAK Type I (varus with AD joint line) predominated (78.7%), followed by Types III (9.5%), VII (6.8%), and IX (5.0%). No statistically significant differences were found between genders (p = 0.088) or sides. Postoperatively, 60% of Type I knees retained their native alignment with correction with ±3° aHKA, while 18% were moderated toward Type II alignment. After 6 months Knee injury and Osteoarthritis Outcome Score (KOOS) increased from 50.7±2.1 to 89.1±1.2, KOOS- Activities of Daily Living subscale from 41.6±3.2 to 85.9±1.3, and Forgotten Joint Score from 29.8±1.2 to 77.9±1.3 (all p < 0.05).

Conclusion: In this large-scale radiographic study of Indian OA knees, varus alignment with an apex-distal joint line (CPAK Type I) was the most prevalent phenotype. Postoperative radiographic assessment showed alignment restoration within a physiologic range in most cases, accompanied by marked improvement in early functional outcomes.

Level of evidence: Level IV - Retrospective observational study.

Introduction/objectives: Residual rotational laxity remains a relevant clinical concern after anterior cruciate ligament (ACL) reconstruction. Combined ACL and anterolateral ligament (ALL) reconstruction has been proposed to improve control of rotational laxity; however, clinical outcome data supporting techniques using adjustable-loop femoral fixation for combined reconstruction remain limited. This study aimed to compare short-term clinical outcomes and knee laxity between combined ACL+ALL reconstruction and isolated ACL reconstruction. We hypothesized that combined reconstruction would demonstrate a lower frequency of residual postoperative pivot shift.

Methods: A retrospective, non-randomized comparative study evaluated patients undergoing primary ACL reconstruction at a single institution. Of 48 eligible patients, 42 were included after exclusion criteria and loss to follow-up: 21 treated with combined ACL+ALL reconstruction and 21 with isolated ACL reconstruction. All procedures used hamstring tendon autografts and adjustable-loop femoral fixation. Overall follow-up ranged from 18 to 30 months. Functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scores, and knee laxity was evaluated clinically. Multivariable linear regression was performed to adjust for baseline differences.

Results: Both groups demonstrated statistically significant improvement in IKDC and Lysholm scores from preoperative to postoperative evaluation (all p< 0.001). Postoperative functional scores were slightly higher in the combined ACL+ALL group; however, these differences were small and not clinically meaningful. Residual pivot shift was observed in 1 patient (4.8%) in the combined group and 6 patients (28.6%) in the isolated ACL group (RR= 6.0; 95%CI, 0.79-45.63); this difference did not reach statistical significance. In multivariable analysis, surgical technique was not identified as an independent predictor of postoperative functional outcomes. Lower preoperative IKDC scores were independently associated with greater postoperative functional improvement (ΔIKDC) (β=-0.99, p<0.001). No patients required reintervention or experienced graft re-rupture during follow-up.

Conclusions: At short-term follow-up, combined ACL+ALL reconstruction using an adjustable-loop device resulted in functional outcomes comparable to isolated ACL reconstruction. Functional improvement (ΔIKDC) was primarily associated with baseline functional status rather than surgical technique. Residual postoperative pivot shift was less frequent in the combined group but did not reach statistical significance, and the small differences in patient-reported outcomes are unlikely to be clinically meaningful.

Level of evidence: Level III.

Avulsion fractures of the anterior cruciate ligament (ACL) are rare in adults and typically involve the tibial insertion. Femoral-sided avulsion or proximal detachment is exceedingly uncommon, particularly in skeletally mature individuals. To date, simultaneous disruption of both the tibial and femoral attachment sites-whether via ligamentous rupture or bony avulsion-has not been systematically described in the literature. We present a rare case of a 23-year-old female who sustained acute knee trauma resulting in a dual-site ACL injury. Initial radiographs demonstrated a displaced tibial spine fracture consistent with a Type III avulsion. Preoperative MRI revealed hyperintense signal changes at the femoral origin of the ACL, suggestive of a proximal tear. Arthroscopic evaluation confirmed a bipolar pattern of injury: an avulsed tibial eminence fragment and a proximal detachment of the ACL from its femoral origin. Due to the non-viability of the remnant ACL tissue and the complexity of anatomical repair, the avulsed tibial fragment was excised, and a primary single-bundle ACL reconstruction was performed using a semitendinosus tendon autograft. The patient achieved excellent clinical outcomes, with restoration of knee stability, full range of motion, and negative Lachman and pivot-shift tests at follow-up. We propose the term "Bipolar ACL Injury" to describe this unique pattern of simultaneous disruption at both the femoral and tibial insertion sites. This terminology may also encompass previously reported cases involving combined failure of the ACL's origin and insertion. Early recognition of this injury pattern is critical for surgical decision-making, as tibial fixation alone may be insufficient. MRI plays a pivotal role in preoperative diagnosis. In cases where anatomical repair is not feasible, primary ACL reconstruction provides a reliable and definitive treatment approach. LEVEL OF EVIDENCE: V.

In this report a rare case of isolated dorsal dislocation of the intermediate cuneiform in a 32-year-old woman following a low-energy injury is presented. The patient sustained a direct medial-to-lateral midfoot crush injury. Imaging revealed dorsal dislocation of the intermediate cuneiform with associated plantar avulsion fractures, indicating ligamentous instability. Closed reduction under general anaesthesia was unsuccessful due to soft tissue interpositioning. Open reduction and internal fixation was performed using two lag screws, achieving a stable anatomical alignment. The patient underwent staged immobilization and a structured rehabilitation program. At 9 months follow-up the patient demonstrated minimal pain and satisfactory return to function. This case underscores the challenges of closed reduction due to the unique anatomy of the cuneiform complex and possibility of soft-tissue interpositioning, reinforcing the need for early consideration of open reduction and internal fixation. LEVEL OF EVIDENCE: V, case report.

Introduction/objectives: Biomechanical studies suggest that persistent posterior cruciate ligament (PCL) deficiency may lead to abnormal joint contact mechanics and subsequent secondary intraarticular injury. However, clinical evidence that delayed PCL reconstruction (PCL-R) directly impacts the prevalence of intraarticular injury remains limited. The aim of the study was to determine the impact of time from injury to surgery on the prevalence of intraarticular injury in patients with primary isolated PCL-R.

Methods: Patients with PCL-R registered in the Scandinavian Knee Ligament Registries between 2004-2020 were considered for eligibility. Patients with primary isolated PCL-R and complete preoperative baseline Knee injury and Osteoarthritis Outcome Score (KOOS) were selected for the final study population. The primary outcome was the prevalence of intraarticular injury at the time of PCL-R, defined as meniscal tear or articular cartilage injury of any grade determined during diagnostic arthroscopic examination. Univariable logistic regression was used to determine the association between time from injury to primary isolated PCL-R and intraarticular injury prevalence, overall and by knee compartment.

Results: A total of 210 patients were included (mean age 29.7 ± 11.8 years, 61% male). The median time from injury to surgery was 14.2 months (range 0.4-128.8 months). The mean baseline KOOS knee-related quality of life (QoL) subscale was 31.2 (95% confidence interval [CI] = 28.9 - 33.6). Overall, 105 (50%) patients had intraarticular injuries at the time of PCL-R. Univariable logistic regression showed no statistically significant association between time from injury to PCL-R and overall intraarticular injury prevalence (odds ratio = 1.01; 95% CI, 1.01-1.02; p = 0.19). Similarly, no significant associations were found between surgical timing and injury across specific knee compartments.

Conclusion: Delayed surgical timing is not associated with an increased prevalence of intraarticular knee injury in patients with primary isolated PCL-R. Consequently, registry data does not corroborate the hypothesized relationship between persistent knee instability and intraarticular injury burden in patients with PCL deficiency.

Level of evidence: Retrospective cohort study, level III.

Introduction/objectives: This study aimed to evaluate whether intraoperative injury to the anterior root of the lateral meniscus (lateral meniscus anterior root [LMAR]) is associated with postoperative lateral meniscal extrusion (LME) during primary anterior cruciate ligament reconstruction (ACLR) surgery. Other potentially postoperative LME causal factors were also evaluated such as concomitant lateral meniscal (LM) tear and the surgical method used (single- vs double-bundle technique).

Methods: Retrospective study of all consecutive primary ACLR performed between 2015 and 2021 at a single hospital was conducted in patients without a prior history of knee lesions. Surgical methods were categorized as single- or double-bundle techniques. Preoperative and 12-month postoperative magnetic resonance imaging were used to assess LMAR injury (absolute attachment-width and baseline-referenced injury rate) and absolute LME on the corresponding coronal slice. The association between LMAR injury and LME was evaluated. Factors associated with LME, including the surgical technique and the presence of a concomitant LM tear, were evaluated using multiple linear regression.

Results: A total of 102 patients met the inclusion criteria. LMAR injury did not significantly correlate with LME. The single-bundle ACLR was associated with a significantly higher LMAR injury rate than the double-bundle technique (27.3% vs. 5.7%, P<0.001) and lateral deviation of the bone tunnel position correlated positively with the LMAR injury rate; however, neither factor resulted in greater LME. In multiple linear regression, however, the single-bundle technique (β=0.70, P<0.001) and concomitant LM tear (β=0.99, P<0.001) were independently associated with greater postoperative LME.

Conclusion: LMAR injury alone may not contribute significantly to LME postoperatively. Lateral tibial tunnel creation during ACLR correlated with increased LMAR injury; however, it did not directly increase LME. Concomitant LM tears were a statistically significant predictor of postoperative LME. Although these findings are based on short-term imaging assessments rather than structural osteoarthritis outcomes, they may help refine surgical strategies to minimize the risk of LME.

Evidence level: Level Ⅲ, Retrospective comparative study.