Journal of Experimental Orthopaedics最新文献

Purpose

Despite advances in surgical techniques and rehabilitation protocols, arthrofibrosis following total knee arthroplasty (TKA) still has poor outcomes. In the last decade, attention has been focused on the pathogenesis and cascade of events leading to the development of fibrosis. Currently, one of the most promising approaches consists in the indirect antagonisation of transforming growth factor beta 1 (TGF-beta 1) through the downregulation of the renin–angiotensin–aldosterone system (RAAS). This systematic review aims to analyse the available evidence regarding the use of angiotensin receptor blockers (ARBs)/angiotensin-converting-enzyme inhibitors (ACEi) in order to prevent post-operative knee arthrofibrosis following TKA.

Methods

Extensive research on the PubMed, Cochrane, and Google Scholar databases was performed on 8 July 2024, using keywords related to ARBs, ACE inhibitors and arthrofibrosis. Inclusion criteria included: (1) clinical trials of any level of evidence; (2) written in English; (3) studies conducted on humans; and (4) evaluating the antifibrotic effects of ACE inhibitors or ARBs administered for TKA surgeries. Exclusion criteria were articles written in other languages; preclinical studies; expert opinions; reviews and trials evaluating the effects of ACEi/ARBs not related to their antifibrotic effect after TKA.

Results

A total of six studies met the inclusion criteria and were analysed. All studies were retrospective and involved a total of 158,310 patients. Time of administration varied among the studies as well as the dosage, which fell within the range for cardiological use. Four out of six studies focused exclusively on losartan. Three studies reported a clear, significant correlation between the use of ARBs and/or ACEi and a reduced likelihood of developing arthrofibrosis.

Conclusions

The RAAS antagonism could have potential for stiffness prevention after TKA. However, given the side effects and the limited evidence available, the use of ACEi/sartans for the sole purpose of avoiding arthrofibrosis after TKA is not currently recommended.

Level of Evidence

Level III.

Purpose

To compare different measurement techniques of the posterior tibial slope (PTS) on lateral radiographs with the actual in situ PTS and evaluate the effect of tibial malrotation and image section length.

Methods

Actual PTS was measured on eight fresh-frozen tibiae using a portable 6-axis measuring arm with an accuracy of ±0.01°. True lateral radiographs were taken in the neutral position and after applying 10/20/30° internal/external rotation (IR/ER) and 5/10/15° varus/valgus rotation. The PTS was measured radiographically using five different reference axes: anterior tibial cortex (ATC), anatomical tibial axis, proximal tibial anatomical axis (PTAA), posterior tibial cortex (PTC) and fibular shaft axis (FSA).

Results

The ATC and PTAA methods showed the lowest deviation from the actual PTS, while the PTC method showed the highest difference of 5.5 ± 1.5° (medial) and 7.1 ± 1.8° (lateral) among all tested methods (p < .001). The PTAA technique showed a 1.9 ± 1.4° (medial) and 2.9 ± 1.8° (lateral) difference from the actual slope (n.s.). ER caused the PTS to increase 0.7 ± 2.0° (10° ER, n.s.) to 3.4 ± 2.1° (30° ER, p < .05), whereas IR caused the PTS to decrease 1.6 ± 1.3° (n.s) to 4.1 ± 1.7° (p < .05) when comparing to the PTAA method for the neutral position. Varus and valgus rotation showed the highest deviation from the neutral rotation at 15° valgus (3.1 ± 2.1°, n.s.).

Conclusion

Tibial slope measurements have a high degree of variability between different measurement methods, while the ATC and PTAA methods showed the least deviation from the actual PTS measured in this in vitro model. Malrotation resulted in a severe distortion of the PTS values, which may alter preoperative planning and intraoperative results. Therefore, radiographic PTS measurements may be contrasted with more objective, reproducible and reliable measuring methods.

Level of Evidence

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

Purpose

To evaluate the impact of delaying reconstruction following anterior cruciate ligament (ACL) injury on the risk of meniscal injury and subsequent meniscectomy, the study was carried out. This constitutes the first study of its kind to be conducted in China.

Methods

This study collected data on patients who had undergone ACL reconstruction surgery at Peking University First Hospital between 2010 and 2022. Patient's injury details, including the time and cause of ACL injury, surgery date and meniscal injury details, were recorded. Patients were stratified into distinct cohorts based on the duration between injury and reconstruction. Logistic regression analysis was used to evaluate the impact of a delayed reconstruction time on the risk of meniscal injury and meniscectomy.

Results

The study involved patients with an average age of 34.1 ± 11.3 years. Nearly half of the patients (49.74%) had meniscal injuries. Univariate logistic regression analysis showed that gender and the time from ACL trauma to surgery were significantly associated with meniscus injury (p < 0.01). Men have a higher risk of meniscus damage than women (p < 0.01, odds ratio: 1.94, 95% confidence interval: 1.23–3.05). Patients who had surgery 12 months after injury had a significantly increased risk of meniscus injury compared to those who had surgery within 3 months after injury (p < 0.01). The time from ACL injury to operation was significantly correlated with medial meniscus injury (p < 0.001). There was no significant correlation between time to ACL reconstruction and lateral meniscus injury (p > 0.05). Age was significantly associated with the risk of medial meniscectomy (p > 0.05). Time from injury to surgery was not significantly associated with the risk of lateral meniscectomy (p > 0.05).

Conclusions

Delayed reconstruction beyond 12 months after ACL rupture increases the risk of medial meniscus injury. The risk of meniscus injury after ACL injury is higher in men than in women, and the risk of medial meniscectomy increases with age.

Level of Evidence

Level III.

Purpose

Many treatment options are available for the revision of large acetabular defects. Debate continues as to which technique is most effective. This meta-analysis aimed to determine the rates of failure of acetabular bone defects Paprosky type III or American Academy of Orthopaedic types III–IV treated with morselized allograft in association with cemented cup or cementless cup or reinforcement devices.

Methods

The US National Library of Medicine (PubMed/MEDLINE), EMBASE and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to 1 April 2024 utilizing keywords pertinent to total hip arthroplasty (THA), acetabular impaction bone grafting and revision THA. The main outcome measure was the 9-year implant failure rate.

Results

Thirty-nine articles were eligible for inclusion in the current study. We found 41 treatment approaches that we grouped into three different treatment options: 1 = morselized allograft and cemented cup (10 studies); 2 =morselized allograft and cementless cup (nine studies); 3 = morselized allograft and device (22 studies). The overall implant failure rate was 2.1% (95% confidence interval [CI], 1.6%–2.8%) at a mean of 9.2 years. There was no significant difference in failure rates between different treatment options (1.6% [95% CI, 0.9%–2.6%]) for morselized allograft and cemented cup; 2.1% (95% CI, 1.4%–3.2%) for morselized allograft and cementless cup; 2.5% (95% CI, 1.7%–3.7%) for morselized allograft and device) between the three different types of treatment (heterogeneity between groups p = 0.351).

It was determined that the number one cause of failure was aseptic loosening (80.5%), followed by infection (13.1%) and dislocation (6.4%). THA with reinforcement devices has a higher incidence of infection (3.6 vs. 0.7%, p = 0.001) and dislocation (1.4 vs. 0.6%, p = 0.010) than THA with a cemented cup.

Conclusions

The use of morselized allograft in hip revision of large acetabular defects has low implant failure rates, independently of the associated type of implant. Reinforcement devices increase the risk of re-revision for infection and dislocation.

Level of Evidence

Level III.

Purpose

Younger age and steep posterior tibial slope (PTS) have been reported as risk factors for graft failure after anterior cruciate ligament reconstruction (ACLR). Few studies have evaluated these risk factors simultaneously in a large cohort of patients undergoing double-bundle ACLR (DB-ACLR). Therefore, this retrospective study aimed to simultaneously investigate known risk factors such as PTS and age in DB-ACLR, determine their thresholds and calculate odds ratios (ORs).

Methods

We investigated 482 knees that underwent DB-ACLR with a follow-up period of at least 2 years. Receiver operating characteristic analysis determined cut-off values for age and PTS for graft failure. Subsequently, logistic regression analysis was conducted to evaluate the effects of age, sex, height, weight, laterality, surgical waiting period, pre-operative sport type and level, meniscal injury, hyperextension, general joint laxity and PTS on graft failure.

Results

Graft failure was observed in 33 out of 482 knees (6.8%). Notably, the graft failure group was significantly younger (18.0 ± 5.0 years [standard deviation] vs. 30.4 ± 13.1 years, p < 0.01) and had a steeper PTS (11.9 ± 2.3° [standard deviation] vs. 9.6 ± 2.9°, p < 0.01) than the group with no graft failure. The cut-off values were 20.0 years for age (specificity, 64.6%; sensitivity, 87.9% and area under the curve, 0.808) and 12.0° for PTS (specificity, 70.9%; sensitivity, 69.7% and area under the curve, 0.734). Logistic regression analysis identified an age of <20 years (OR = 10.1; p < 0.01), PTS of ≥12° (OR = 5.6; p < 0.01) and pre-operative participation in pivoting sports (OR = 6.0; p < 0.01) as significant risk factors for graft failure.

Conclusion

We identified an age of <20 years, PTS of ≥12° and pre-operative participation in pivoting sports as significant risk factors for graft failure after DB-ACLR.

Level of Evidence

Level III.

Purpose

In this study, we aimed to characterize the elution profile of the ligament augmentation and reconstruction system (LARS) immersed in different concentrations of vancomycin using different immersion methods and determine whether the amount of vancomycin released was lower than the toxic concentrations for osteoblasts and chondroblasts.

Methods

The LARS was presoaked with 5, 2.5 or 1.25 mg/mL vancomycin solutions or wrapped in presoaked sterile gauze. After 10 min, the rinsed and unrinsed LARS samples were eluted in 100 mL agitated 37°C phosphate-buffered saline. An ultraviolet spectrophotometer was used to analyze 1 mL samples taken after 10 min and 0.5, 1, 6, 12, 24h.

Results

Initially, no hysteresis was observed with vancomycin release into the solution at the tested conditions. The LARS elution profiles for different concentrations of the vancomycin solutions varied significantly. The amount of vancomycin released after 24 h was 9.10 ± 1.21, 5.29 ± 0.63 and 2.28 ± 0.59 mg for the 5, 2.5 and 1.25 mg/mL solutions, respectively. The amount of vancomycin released in the soaked group was significantly higher than in the rinsed and wrapped groups. The released amounts of vancomycin were below the toxic concentrations for osteoblasts and chondrocytes.

Conclusion

Soaked LARS can act as a reservoir for vancomycin, with the amount released and the elution profile dependent on rinsing, soaking solution concentration and soaking method. The eluted concentrations of vancomycin were lower than those previously reported for osteoblast and chondrocyte toxicity and higher than the minimal inhibitory concentrations for Staphylococci.

Level of Evidence

N/A.

Purpose

This retrospective comparative study aimed to compare the native patellar alignment and clinical outcomes of the Rotating Concave–Convex (ROCC) knee, which features a saddle-shaped rotating platform (RP) insert and a deep trochlea, versus the low contact stress (LCS) knee, which has favourable long-term outcomes and features an anatomically shaped trochlea and a cruciate-sacrificing RP insert. We hypothesized that the deeper trochlea of the ROCC would further stabilize the native patella, resulting in superior clinical outcomes compared to LCS-RP.

Methods

Consecutive patients who underwent patellar-nonresurfacing primary total knee arthroplasty (TKA) using ROCC or LCS-RP were retrospectively reviewed. Patients with over 1-year post-TKA follow-up were included. Patients with neurologic disorders affecting knee function or additional ipsilateral knee surgery before evaluation were excluded. Patellar alignment was evaluated using the patella tilting angle (PTA), patella shift (PS), and the ratio of patella fitting depth into the trochlea (F) on axial radiographs. Primary and secondary outcomes were evaluated using the patellar score assessing patellofemoral function and Knee Injury and Osteoarthritis Outcome Score. Multiple regression analyses were performed with primary and secondary outcomes as dependent variables.

Results

The analysis included 113 ROCC knees and 94 LCS-RP knees (median follow-up: 25 months, follow-up rate: 92.3%). For ROCC and LCS-RP, respectively, the mean PTA was 0.3 (3.2)° and 4.3 (2.9)°; PS was 0.5 (1.8) and 2.0 (2.5) mm; and F was 29.6 (8.1)% and 21.4 (6.5)% (all p < 0.001). On multivariate analysis, ROCC positively affected both primary and secondary outcomes (p = 0.004 and 0.0003–0.02, respectively).

Conclusion

At short-term follow-up, ROCC stabilized the patella further horizontally, centrally, and deeply into the trochlea, thus outperforming LCS-RP clinically. Orthopaedic surgeons should consider these potential advantages when selecting TKA models, especially those featuring cruciate-sacrificing RP mechanisms in patellar-nonresurfacing procedures.

Level of Evidence

III. Retrospective comparative study.

Purpose

To compare the clinical outcomes between opening wedge high tibial osteotomy (OWHTO) and unicompartmental knee arthroplasty (UKA) in patients with Ahlbäck Grade 3 medial compartmental knee osteoarthritis (OA) using a propensity score matching (PSM) analysis.

Methods

This retrospective study included all OWHTO and UKA procedures performed between 2016 and 2021 at a single institution. Inclusion criteria were patients diagnosed with medial knee OA, specifically Ahlbäck Grade 3 arthritis. Clinical outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Radiographic parameters included hip–knee–ankle (HKA), medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA) and joint line convergence angle (JLCA). Primary outcomes included improvement in clinical scores at 3, 12 and 24 months post-operatively. Secondary outcomes included radiographic parameters, complication rates and re-intervention rates. One-to-one PSM was conducted based on gender, age and preoperative KOOS pain scores.

Results

After evaluating eligibility using PSM, a total of 50 knees in the UKA group and 50 knees in the OWHTO group were included. There was no significant difference between groups in preoperative overall KOOS, but the UKA group had better overall KOOS at 3 months (p < 0.001). However, the overall KOOS at 12 and 24 months were superior in the OWHTO group compared to the UKA group (12 months; 84.6 ± 4.9 vs. 86.4 ± 2.9, p = 0.022, 24 months; 84.9 ± 5.3 vs. 87.0 ± 3.7, p = 0.022). As for post-operative radiological parameters, HKA, MPTA, LDFA and JLCA were higher in the OWHTO group at 24 months post-operatively. No significant differences were noted in the rates of complication or re-intervention between groups.

Conclusions

OWHTO can provide outcomes equal to or better than UKA at 24 months post-operatively in patients with advanced knee OA.

Level of Evidence

Level Ⅲ, Prospective designed retrospective comparative study.

Purpose

Various assistive techniques, such as conventional cutting instruments (CON), computer-assisted navigation systems (CAS), patient-specific instruments (PSI) and robot-assisted systems (RAS), have been developed and applied in primary total knee arthroplasty (TKA). In this study, we aimed to assess the relative accuracy and efficacy of several assistive techniques for TKA through a network meta-analysis (NMA) based on multiple published randomized controlled trials (RCTs).

Methods

The PubMed, EMBASE and Cochrane databases were searched for RCTs to conduct this NMA from inception to 1 January 2024. We combined direct and indirect comparisons using a Bayesian NMA framework to assess and compare the effects of different assistive techniques on radiological and clinical outcomes. An NMA was conducted, and the study protocol was published online at PROSPERO (CRD42023402882).

Results

One hundred and twelve RCTs involving 14,968 TKAs with four different assistive techniques (CON, CAS, PSI and RAS) were evaluated. Inconsistency and heterogeneity were acceptable for most outcomes. Based on the surface under the cumulative ranking curve, RAS could be the best technique for accurate mechanical axis alignment and component position, followed by CAS, PSI and CON. We observed no difference in clinical outcome scores. Additionally, CAS was the best intervention for visual analogue scale scores, and PSI had the shortest operative time. No significant differences were observed in postoperative complications, range of motion or total blood loss.

Conclusion

RAS was most likely to achieve an accurate alignment, followed by CAS, PSI and CON. No differences were observed in clinical outcome scores and postoperative complications among the four assistive techniques.

Level of Evidence

Level I (systematic review of Level-I randomized controlled studies).

Introduction

Axial malalignment in the coronal plane has been identified as a significant risk factor for knee cartilage damage, leading to osteoarthritis progression. However, the impact of sagittal axial deviation on cartilage damage remains underexplored. Biomechanical studies have suggested that an increased tibial slope leads to altered pressure distribution in the articular cartilage, potentially contributing to cartilage damage. Despite these biomechanical insights, clinical evidence linking increased tibial slope to cartilage damage is lacking.

Methods

This retrospective study focuses on patients who underwent surgical cartilage transplantation between January 2016 and July 2023. A total of 108 patients were divided into two groups based on the presence or absence of other pathologies contributing to cartilage damage. Clinical data, including tibial slope measurements from lateral radiographs, were collected. A further subgroup-matched pair analysis was conducted comparing cases with patellar lesions and healthy knees. Statistical analysis compared tibial slope values between groups and assessed correlations between tibial slope and cartilage lesion grade.

Results

Patients without other identifiable pathologies exhibited a significantly higher medial tibial slope compared to those with known causative factors for cartilage damage (p < 0.05). Cartilage damage, particularly in the patellar region, was more prevalent in patients with an increased tibial slope. Patients with patellar lesions had a significant increased slope than healthy controls (p < 0.05). However, there was no significant correlation between cartilage lesion grade and tibial slope.

Conclusion

The study identified increased medial tibial slope as a possible independent risk factor for cartilage damage in the knee, especially in the patellar region.

Level of Evidence

Level IV.