Journal of Experimental Orthopaedics最新文献

Purpose

Kinesophobia is an important psychosocial construct to consider in rehabilitation of patients with patellar instability, in order to optimise their rehabilitation and ability to return to sport and an active lifestyle. Therefore, it is important to investigate the percentage of patients with kinesophobia before and 6 months after patella stabilising surgery. In addition to how it affects knee function and quality of life 6 months postoperatively.

Methods

A prospective cohort of 76 patients (mean age 22.8 years, 74% female) with patellar instability was included. Patients completed patient reported outcome measures (PROMs), including the Tampa scale of kinesophobia (TSK)-13, International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and Banff Patellofemoral Instability Instrument (BPII), preoperatively and 6 months postoperatively. Those with concomitant knee ligament injuries were excluded. Statistical analyses included paired sample t-tests for score changes and Pearson's correlation for associations between variables.

Results

Preoperative kinesophobia was reported in 47% of patients, decreasing to 18% at 6 months postsurgery. Significant improvements were noted in all PROMs, with the BPII showing the largest increase. Patients with preoperative kinesophobia reported worse knee function postoperatively. A strong negative correlation was found between changes in TSK-13 and BPII scores (r = −0.605), indicating that reductions in kinesophobia were associated with improvements in quality of life. In multiple regression analyse only preoperative TSK scores remained an independent significant 138 predictor of postoperative kinesophobia, with a shared explained variance of 16%.

Conclusion

This study highlights the prevalence of kinesophobia in patients undergoing surgery for patellar instability and its effect on postoperative outcomes. While surgery restored mechanical stability, many patients continued to exhibit kinesophobia after surgery.

Level of Evidence

Level III.

Purpose

To compare the thickness and magnetic resonance imaging (MRI) signal intensity at the patellar attachment of the quadriceps tendon (QT) and patellar tendon (PT) across age groups in order to evaluate age-related degenerative changes relevant to graft selection for anterior cruciate ligament (ACL) reconstruction. It was hypothesised that older groups would show increased signal intensity.

Methods

Patients aged 14–65 years who underwent knee MRI were retrospectively reviewed. Participants were categorised into the senior (50–65 years), middle (30–49 years), young (20–29 years) and teen (14–19 years) groups. After propensity score matching for sex, height and weight, 64 participants were included in each age group. T2* sagittal MR images of the ACL graft harvest area were used to measure the tendon thickness and signal intensity.

Results

QT was significantly thicker and had lower signal intensity than PT across all age groups. Thickness did not significantly differ between QT and PT across age groups. QT signal intensity was significantly higher in seniors than in young adults, whereas PT signal intensity was significantly higher in both middle-aged and senior groups than in the young group.

Conclusions

The QT was thicker than the PT and exhibited a lower signal intensity across all age groups. Compared to the 20–29-year age group, signal intensity was higher in the 50–65-year age group for the QT and in the 30–65-year age group for the PT. These MRI-based findings suggest that the QT may offer advantages as a graft source, particularly in patients aged >30 years.

Level of Evidence

Level III, cross-sectional study.

Purpose

To map the scientific literature on the use of dynamic ultrasound in the assessment of medial knee instability.

Methods

Primary (clinical or experimental) and secondary studies that used dynamic ultrasound to assess medial knee opening were included. There were no restrictions on language or date. Sources of information: The searches were conducted in the PubMed/MEDLINE, Scopus, Web of Science, Embase and CINAHL databases.

Data selection and extraction

The process of data selection and extraction was conducted by two independent reviewers. The information was organised into thematic tables and a conceptual matrix was developed based on the components of population, concept, and context.

Results

Ten studies were included: two biomechanical, six clinical, and two reviews. Ultrasound demonstrated good reliability in measuring medial opening and distinguishing between injured and normal knees. Heterogeneity was observed in the stress protocols, evaluation angles, units of measurement, and anatomical points.

Conclusions

Dynamic ultrasound presents consolidated clinical potential in the assessment of medial knee instability. Standardisation of methods and additional clinical validation are necessary.

Level of Evidence

Not applicable.

Purpose

To investigate the incidence and management of complications associated with all-inside technique (AIT) anterior cruciate ligament reconstruction (ACLR), and to compare postoperative outcomes between patients with successfully managed complications and complication-free controls.

Methods

A retrospective analysis was conducted on patients undergoing AIT-ACLR. AIT-related complications were documented, with a minimum 24-month follow-up. Propensity score matching (PSM, 1:2 ratio) was used to compare the complication and non-complication groups. Knee function was assessed using the Lysholm Knee Score, International Knee Documentation Committee Subjective Score, and Tegner Activity Scale. Stability was measured with the Ligs Digital Arthrometer.

Results

A total of 274 patients were included, with 45 patients (16.4%) experiencing AIT-related complications. Complications comprised tibial lateral subluxation (21 cases, 7.7%; mean displacement: 2.3 mm, range 2.0–2.5 mm), which resolved spontaneously in 4 patients (19.1%) by 1 month postoperatively and in the remaining cases by 3 months. Femoral suspensory button malposition occurred in 12 patients (4.4%), with only one case (8.3%) requiring immediate revision due to a 7.6 mm displacement. The others (mean displacement: 2.5 mm, range 2.1–3.0 mm) were managed conservatively. Cortical breach at the tibial tunnel exit (7 cases, 2.6%) and flip drill bit breakage (5 cases, 1.8%) were addressed intraoperatively. Following PSM (complication group: n = 45 vs. non-complication group: n = 87), baseline demographics demonstrated no significant differences except for operative time (p = 0.035). There were no statistically significant differences in knee function and stability between the matched groups at 3, 6, 12, and 24 months postoperatively (p > 0.05 for all).

Conclusion

Postoperative knee function and stability demonstrated improvement following AIT-ACLR. Although appropriately managed complications did not substantially compromise clinical outcomes, the findings emphasize the importance of technical vigilance, intraoperative complication management, and preventive strategies to optimize surgical outcomes.

Level of Evidence

Level III, case-control study.

Femoral and/or tibial torsional abnormalities are highly prevalent in female patients with anterior knee pain (AKP) who are recalcitrant to appropriate conservative treatment. In this paper, we focus on increased internal femoral torsion, which sometimes is an under-recognised factor contributing to AKP. Two experts in patellofemoral pathology participated in conducting a review on the rationale and outcomes of rotational femoral osteotomy in female AKP patients and femoral maltorsion. Pathological femoral anteversion (FAV) is recognised as a cause of anterior knee pain. FAV is a problem because it changes the direction of the quadriceps and thereby the force acting on the patellofemoral joint. One of the key challenges in planning a rotational osteotomy is determining the precise degree of correction required. Murphy´s CT method is the closest to showing the anatomical reality when FAV is evaluated. Currently, there is no universally accepted cut-off point at which rotational femoral osteotomy should be performed. Moreover, limited evidence exists regarding the optimal level at which the osteotomy must be done. In appropriately selected cases, intertrochanteric rotational femoral osteotomy represents a reliable treatment option for symptomatic excessive FAV, offering favourable outcomes with minimal complications.

Level of Evidence

Level V.

Purpose

To develop and characterise a modification of the preparation protocol of a commercial leucocyte-rich platelet-rich plasma (LR-PRP) preparation device (the GPS® III Platelet Concentration System, Biomet, USA) that allows for consistent leucocyte-poor platelet-rich plasma (LP-PRP) extraction using the same components.

Methods

The study included two stages. In the first, the blood of eight healthy adults was processed using the GPS® III Platelet Concentration System (Biomet, USA). Samples were obtained to characterise platelet and leucocyte distribution in the system during the procedure per the manufacturer′s guidelines. In the second, based on the initial results, the standard preparation protocol that yields LR-PRP was modified to establish a new protocol for obtaining LP-PRP. To conclude, the newly proposed procedure was validated in 20 individuals, using both the traditional and modified protocols simultaneously.

Results

The characterisation of the commercial system suggested a specific distribution of blood components within the device: most leucocytes were found in the plasma collected through side port #3 (red cap) without waving or shaking the tube, whereas platelets in the sediment between the buoys were released when the tube was waved or shaken. When comparing to the standard protocol, the modified technique consistently yielded significantly lower platelet (MD −205 ×10³ platelets/µL, 95% confidence interval [CI], 92.1–317 ×10³ platelets/µL, <0.0001) and leucocyte concentrations (MD −19.0 ×10³ leucocytes/µL, 95% CI, 14.1–23.9 ×10³ leucocytes/µL, p < 0.0001) but the obtained LP-PRP had only 18.1% lower platelet concentration (95% CI, 6.71%–29.4%, p < 0.0001) and a relevant 75.3% lower leucocyte concentration (95% CI, 69.6%–81%, p < 0.0001).

Conclusions

The proposed modified PRP extraction protocol greatly reduced leucocyte concentrations with a minimal reduction in the platelet concentrations, enabling LP-PRP preparation with the same commercial device without the need for additional supplies.

Level of Evidence

Level III.

Purpose

Postoperative pain remains a major obstacle to early mobilisation following total knee arthroplasty (TKA) and is particularly challenging in patients with posttraumatic arthritis due to prior injury, scarring, and complex surgeries. While various analgesic strategies have been evaluated in degenerative TKA, evidence in posttraumatic cases is lacking. This study is the first to compare patient-controlled intravenous analgesia (PCIA), continuous femoral/sciatic nerve block (cFNB/cSNB), and continuous local infiltration analgesia (cLIA) in this specific population.

Methods

In this prospective, monocentric, randomised controlled trial, 92 patients undergoing TKA for posttraumatic arthritis were allocated to PCIA (n = 31), cFNB/cSNB (n = 30) or cLIA (n = 31). Postoperative pain was assessed using the numeric rating scale (NRS) from day 1 (t1) to discharge (t6). Secondary outcomes included range of motion (ROM), rescue analgesic use, Knee Society Score (KSS) and patient satisfaction. Statistical comparisons between groups were performed using adjusted pairwise tests.

Results

At t1, patients in cFNB/cSNB reported significantly lower pain scores compared to cLIA (p = 0.039). cLIA required significantly more rescue analgesics at t1/t2 (both p < 0.05). Active/passive knee flexion was consistently higher in cFNB/cSNB from t1 to t6 (all p < 0.05). No differences were observed in postoperative mobility, KSS or satisfaction. All groups showed significant improvement in pain and ROM over time.

Conclusions

In patients undergoing TKA for posttraumatic arthritis, cFNB/cSNB provided superior early postoperative pain control and functional recovery compared to PCIA and cLIA. The findings suggest that standard fast-track protocols may not be fully applicable in this complex patient population, highlighting the need for individualised analgesic strategies.

Level of Evidence

Level I.

Purpose

Total hip arthroplasty (THA) is a widely performed surgery with growing demand globally. This study aims to evaluate the effectiveness of a fast track (FT) protocol compared to standard care (SC) in patients undergoing THA.

Methods

Ninety patients aged 18–70 years with primary unilateral hip osteoarthritis, American Society of Anesthesiologists (ASA) score <3, body mass index (BMI) ≤ 32 and no cognitive or psychiatric disorders were prospectively enrolled from March 2018 to January 2020. All patients provided informed consent and were randomised to the FT or SC groups. The FT protocol consisted of preoperative education, oral analgesic pain management and early intensive rehabilitation. Functional autonomy was assessed on postoperative Day 3 using the Iowa Level of Assistance (ILOA) scale. Follow-up assessments at 6 weeks, 3, 6, 12 and 60 months included the Harris Hip Score (HHS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results

Forty-six patients were assigned to the FT group. Both groups were comparable in baseline demographics. The FT group showed significantly faster early functional recovery, with lower ILOA scores on postoperative Day 3 (9.60 ± 5.2 vs. 11.7 ± 3.4; p = 0.024), and a shorter hospital stay (3.54 ± 1.25 vs. 6.39 ± 1.59 days; p < 0.0001). WOMAC scores were significantly better in the FT group at 6 weeks (10.38 ± 9.18 vs. 14.21 ± 8.76; p = 0.035) and remained superior at 60 months (0 ± 0 vs. 0.27 ± 0.81; p = 0.027). Although baseline HHS was higher in the FT group, greater improvements from baseline were seen in the SC group at later follow-ups, likely due to a ceiling effect.

Conclusions

The FT protocol enhances early postoperative recovery and significantly reduces hospital stay after THA without compromising safety. Long-term functional outcomes favour the FT approach, supporting its implementation to improve recovery in appropriately selected patients undergoing hip arthroplasty.

Level of Evidence

Level II.

Purpose

Condylar lift-off is the phenomenon in which the femoral component lifts off from the polyethylene insert. In some cases, the mechanical hip–knee–ankle angle (mHKAA) appears more varus than the arithmetic hip–knee–ankle angle (aHKAA) in a standing position, which is thought to be related to lift-off. This study analyzed factors influencing the difference between postoperative aHKAA and mHKAA in bi-cruciate-stabilized total knee arthroplasty (BCS-TKA).

Methods

This study included 100 knees that underwent BCS-TKA. Full-length standing radiographs of both lower extremities were obtained preoperatively and 1-year postoperatively. The mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and mHKAA were measured and aHKAA (mMPTA−mLDFA) was calculated. The difference between postoperative aHKAA (post-aHKAA) and post-mHKAA was defined as post-ΔHKAA (post-mHKAA−post-aHKAA). Correlations between post-ΔHKAA and the measured parameters were analyzed, and multivariable linear regression analyses were performed to identify independent predictors of post-ΔHKAA.

Results

Post-ΔHKAA was significantly correlated with preoperative mLDFA (pre-mLDFA, r = −0.30, p < 0.001), pre-aHKAA (r = 0.22, p = 0.02), pre-mHKAA (r = 0.21, p = 0.03) and post-mMPTA (r = −0.29, p = 0.004). Multivariable linear regression analyses revealed that pre-mLDFA (β = −0.20, p = 0.02) and post-mMPTA (β = −0.32, p = 0.01) were independently associated with post-ΔHKAA. These results indicate that performing TKA in cases with severe femoral varus alignment and placing the tibial implant in valgus relative to the original joint surface leads to increased postoperative coronal varus alignment in the standing position.

Conclusion

In BCS-type TKA, postoperative condylar lift-off in standing positions is more likely to occur in cases with severe preoperative femoral varus alignment or with valgus tibial implant placement.

Level of Evidence

Level Ⅳ.

Purpose

The aim of this study was to investigate the prevalence of the deep lateral femoral notch sign (DLFNS) in skeletally immature patients with anterior cruciate ligament (ACL) injuries and its potential association with trauma-related and clinical factors.

Methods

A total of 87 skeletally immature patients with ACL injuries and a minimum follow-up of 1 year were included and matched based on sex and skeletal age with 44 controls. The presence of the DLFNS, defined as a notch depth of >1.5 mm, was assessed on MRI. Intra- and inter-observer reliability were calculated, and prevalence was determined. Associations between the DLFNS and trauma mechanism, trauma-related bone lesions, concomitant injuries, clinical instability, and treatment at both baseline and follow-up were assessed using Fisher's exact tests.

Results

The prevalence of DLFNS was 11.5% (10/87) among skeletally immature patients with ACL injuries compared to 0% (0/44) in controls (p = 0.02). DLFNS depth demonstrated excellent intra- and inter-observer reliability (ICC > 0.90). Furthermore, a significant positive association was identified between the DLFNS and overall concomitant knee injuries (p = 0.02), including ligamentous, meniscus, and cartilage injuries. Further subgroup analysis did not reveal any statistically significant associations with individual injury types. All patients presenting with a DLFNS ultimately received operative treatment, either during initial management or follow-up. This revealed a significant positive association between the DLFNS and primary operative treatment (p = 0.02).

Conclusion

The prevalence of the DLFNS in skeletally immature patients with ACL injuries was 11.5%. When present, the DLFNS was associated with overall concomitant knee injuries and primary ACL reconstruction. The DLFNS may therefore be an important sign to take into consideration on the primary MRI in skeletally immature patients with ACL injuries.

Level of Evidence

Level III.