Journal of Knee Surgery最新文献

The removal of osteophytes during total knee arthroplasty (TKA) results in reduced soft tissue tension, which may result in joint laxity. Thus, for gap balancing, a surgeon may try to predict the effect of osteophyte removal on the resulting flexion and extension gap before any bone cuts are made and before those osteophytes are removed. Posterior osteophytes, however, are relatively inaccessible, since their removal can be done only after posterior bone cuts are made on the femur. Any laxity created by posterior osteophyte removal cannot be corrected by adjusting bone cuts because they have already been made. The authors have developed a predictive algorithm for use in robotic TKA, which anticipates the effect of osteophyte removal, allowing adjustment in bony resection before any bone cuts are made. The cross-sectional area of the posterior femoral osteophytes is measured on the sagittal plane of the preoperative computed axial tomography (CAT) scan. The authors' method of osteophyte correction is to make changes to the tibial cut based on the size and shape of the posterior osteophytes, as they believe the laxity created by osteophyte removal effects both extension and flexion. The amount and specific location of bony resection are then determined based on the size and location (posteromedial vs. posterolateral) of the osteophytes. Through the described technique, the authors have found that the amount of laxity created by osteophyte removal correlates directly to the dimension of the osteophyte over which the soft tissue extends. The size and shape of initially inaccessible posterior osteophytes, determined using CAT scan-based imaging, were used to create a predictive bony balancing algorithm, designed to be incorporated with the surgeon's preferred bony balancing technique. Our predictive algorithm anticipates the laxity created by osteophyte removal prior to their removal and can be used to alter bone resection parameters and/or implant parameters (e.g., thickness of a tibial liner) to accommodate the increased laxity, allowing for the conservation of bone and correction of deformity.

The peroneus longus tendon (PLT) is an increasingly used autograft for anterior cruciate ligament reconstruction (ACLR). Several studies have reported donor site morbidity, gait, muscle strength, and long-term safety. This study provides additional 5-year outcome data, including pedorthist-led gait and foot posture assessment. This study aimed to evaluate 5-year gait symmetry, foot posture, and patient-reported outcomes following ACLR using a PLT autograft. Seventeen patients underwent assessment 5 years after ACLR with PLT autograft. Pedorthist-led gait analysis using pressure-mapping technology measured stance time, midfoot force, center-of-pressure (COP) excursion, and gait force differential. Foot posture was classified as planus, cavus, or neutral. Patient-reported outcomes included the Foot and Ankle Disability Index (FADI) and Tegner Activity Scale. The pedorthist, blinded to the operative side, attempted to identify the reconstructed limb. Statistical analysis used paired t-tests, Spearman correlation, and chi-square testing. At 5 years, no significant differences were detected in stance time, midfoot force, or COP excursion between operated and non-operated limbs. Gait force differentials were similar (p = 0.75). Foot posture was not associated with the operated side (p = 0.183), and FADI scores did not differ by foot type. The pedorthist correctly identified the operative limb in 23.5% of cases. PLT harvest was not associated with detectable differences in gait symmetry or arch morphology at 5 years. Findings are consistent with a favorable biomechanical profile; however, the small sample size, lack of preoperative baseline data, and the absence of a control group limit the strength of these inferences. Larger, controlled studies are needed to confirm long-term safety. The level of evidence was IV-retrospective case series with prospective biomechanical follow-up.

The Coronal Plane Alignment of the Knee (CPAK) classification system categorizes nine phenotypes based on constitutional limb alignment and joint line obliquity (JLO). Understanding relationships between CPAK phenotypes and tibial slope (TS) could streamline total knee arthroplasty planning. This study investigated the correlations between CPAK classification and medial TS in patients with osteoarthritis. A retrospective analysis of 622 cases in 535 patients with osteoarthritis undergoing primary total knee arthroplasty was conducted. Three-dimensional computed tomography imaging with MyPlanner software determined mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, and medial TS. Statistical analysis included multiple linear regression, Pearson correlation, and one-way analysis of variance (ANOVA) with Tukey post hoc testing. Outliers were removed using interquartile range criteria, resulting in 581 knees for final analysis. Multiple linear regression revealed minimal correlation between coronal alignment and TS (TS = 26.35 - 0.1045 arithmetic hip-knee-ankle [aHKA] - 0.1004 JLO; r ² = 0.0233). aHKA angle and JLO explained only 2.33% of TS variance. Contour mapping demonstrated no discernible patterns in data distribution. Despite weak correlations, ANOVA identified statistically significant differences between CPAK groups for TS (F = 2.97; p = 0.003). Tukey post hoc analysis revealed significant differences between CPAK group I and groups V and VII, with mean differences ranging 1.39 to 2.06 degrees. No clinically meaningful relationship exists between CPAK classification and TS in osteoarthritic knees. While statistical significance differences were observed between certain CPAK groups, the extremely low correlation coefficient and small effect sizes indicate these differences fall within measurement variability and are substantially smaller than TS variations that influence total knee arthroplasty outcomes. CPAK classification cannot reliably predict sagittal plane morphology, necessitating an independent, comprehensive three-dimensional assessment of coronal and sagittal characteristics during surgical planning.Level III-Retrospective Comparative Study.

Patellar dislocations often result in damage to the medial patellofemoral ligament (MPFL), a key stabilizer preventing lateral patellar translation. Various reconstruction techniques, including semitendinosus (ST) and quadriceps tendon (QT) autografts, have been developed to restore stability, with QT emerging as a promising option due to lower risk of complications. We aimed to compare the functional outcomes of patients who underwent MPFL reconstruction using double bundle ST autograft and those who underwent reconstruction using partial QT autograft. Patients who underwent MPFL reconstruction at our institution between January 2018 and January 2023 were retrospectively reviewed. The inclusion criteria were patients with a history of at least two patellar dislocations, a follow-up period of more than 24 months, positive preoperative patellar apprehension, traumatic dislocations, and no prior surgical history on the same knee. Two groups were formed based on the used graft type for reconstruction: a partial QT and ST groups. At the final follow-up, visual analog scale (VAS), Kujala patellofemoral pain score, Lysholm knee score, Tegner activity index, IKDC score, and Crosby-Insall grading system parameters were evaluated. A total of 40 patients (23 QT, 17 ST) were included. Based on the Crosby-Insall grading system, the QT group had 17 excellent, 5 good, and 1 poor result, while the ST group had 8 excellent, 7 good, and 2 poor results (p = 0.215). Mean scores for QT versus ST were as follows: Kujala 91.4 ± 7.1 versus 88.4 ± 10.0 (p = 0.401), Lysholm 92.8 ± 7.5 versus 90.2 ± 10.4 (p = 0.464), IKDC 91.3 ± 6.1 versus 87.5 ± 12.1 (p = 0.725), Tegner 6.8 ± 1.2 versus 6.4 ± 1.5 (p = 0.516), and VAS 0.2 ± 0.5 versus 0.4 ± 1.0 (p = 0.935). The functional outcomes of reconstruction techniques using double bundle ST and partial QT autografts were both successful. Given the potential complications of ST technique, we believe partial QT could be a good alternative in MPFL reconstruction. LEVEL OF EVIDENCE: was retrospective cohort study, level 3.

Computed tomography-based robotic-arm-assisted total knee arthroplasty (RATKA) enables three-dimensional surgical planning and intraoperative adjustment of implant positioning based on ligament laxity. Stability and kinematic assessments may offer enhanced insight into multiplanar knee laxity, but their reproducibility remains underexplored. This study evaluated the reliability of intraoperative knee kinematic (dynamic), sagittal and transverse stability assessments in a cadaver setting under different support conditions. Cruciate-retaining RATKA was performed on five fresh-frozen cadaver knees by three experienced surgeons. Medial and lateral anteroposterior translation (MAP, LAP) and internal-external rotation (IE) were measured at 10, 45, and 90 degrees of flexion before and after component implantation. Dynamic assessments across the full range of motion were used to calculate the average medial contact position (AMCP) and medial pivot ratio (MPR). Inter- and intra-rater reliability were determined using intraclass correlation coefficients (ICC: poor < 0.4, good 0.4 to 0.74, and excellent ≥ 0.75). Analyses compared a leg-holder-only condition with all surgeons, including manual support. Intra- and inter-rater reliability across all surgeons was generally good to excellent. For intact knees, reliability ranged from ICC 0.52 to 0.84 for MAP, 0.44 to 0.57 for LAP, and 0.48 to 0.62 for IE. With components, reliability remained good to excellent for MAP, LAP, and IE (ICC 0.47 to 0.80). Dynamic AMCP assessments demonstrated excellent inter-rater reliability (ICC 0.84 to 0.93), while MPR showed good reliability (ICC 0.57). The leg holder reduced variance for MAP/LAP and IE, maintaining error within two mm or 5 degrees, respectively. Intra-rater reliability was consistently excellent across nearly all measures (ICC 0.69 to 0.99). Intraoperative stability and kinematic assessments during RATKA are reproducible, particularly for AMCP. The leg holder generally improved consistently across observers and reduced variance. These findings support the reliability of robotic-assisted intraoperative stability and kinematic measures for evaluating knee function and guiding surgical planning.

Achieving proper skin closure after total knee arthroplasty (TKA) is crucial for minimizing complications, as the surrounding skin is under significant tension during the early postoperative period. Cyanoacrylate, or skin adhesive, supplements subcuticular suture closure, providing a secure, watertight seal while lowering infection risk. This study compared wound healing, complications, and patient-reported outcomes between suture closure and suture plus adhesive. A total of 167 patients undergoing primary TKA were enrolled in a prospective single-blinded protocol change study at a single institution from August 2023 to September 2024. Patients had their wound closed with subcuticular 3-0 Monocryl suture (n = 69) or suture plus cyanoacrylate adhesive (S + C) (n = 98), alternating techniques every 3 months. Scar healing was assessed through photographic review at 1 month, evaluating scabbing and scar length. Wound complications, stiffness, and readmission rates were recorded. Patient satisfaction was measured at 6 months using the Patient and Observer Scar Assessment Scale (POSAS) score. Bivariate analyses evaluated differences between groups. Wound complications occurred at a similar rate between suture (11.6%) and S + C (14.3%; p = 0.784). Stiffness was reported in 6.6% of patients (8.7% suture vs. 5.1% S + C; p = 0.365). A 90-day readmission occurred in 3.6% (4.4% suture vs. 3.1% S + C; p = 0.692). Scar healing assessments showed 19.1% of patients had more than two scabs, with a higher frequency in S + C (24.2%) than sutures (12.5%; p = 0.193). The mean scar length was slightly longer in S + C (15.0 vs. 14.5 cm; p = 0.148). No cosmetic differences were noted between groups according to the mean POSAS score (5.0 ± 4.18 sutures vs. 5.1 ± 5.57 S + C; p = 0.641). Both sutures and cyanoacrylate adhesive demonstrated comparable clinical and patient-reported outcomes following TKA. The cyanoacrylate adhesive group had a slightly higher rate of minor wound healing concerns. Both closure methods are viable options, and the choice of technique can be left to the surgeon.

The medial patellofemoral ligament (MPFL) is of critical importance for patellar stability and is universally incompetent in patients with patella dislocations. However, radiological (magnetic resonance imaging [MRI]) assessment of the MPFLs' integrity following dislocation is variable, adding confusion to patients and providers during treatment decision-making. We aimed to assess the reliability of MRI to evaluate MPFL integrity by measuring inter- and intraobserver agreement between a musculoskeletal radiologist and an orthopaedic surgeon, specializing in sports medicine using a novel standardized MRI-based scoring system. We anticipated higher intraobserver than interobserver reliability of MPFL integrity. We retrospectively reviewed 100 consecutive knee MRIs: 50 from patients with a clinical history of recent acute patellofemoral dislocation and 50 controls drawn from an anterior cruciate ligament (ACL) injury cohort who had no history or clinical symptoms of patellar instability. Two blinded reviewers, an orthopaedic surgeon with fellowship training in sports medicine and subspecialty expertise in patellofemoral pathology, and a fellowship-trained musculoskeletal radiologist, independently evaluated the MPFL on axial MRIs. Demographic characteristics (age, body mass index, sex) did not differ significantly between the instability and control groups. Eight percent of patellar instability patients had their MPFL graded as "intact" in our first review. Twenty-six percent of ACL control patients had their MPFL graded as at least attenuated. Intraobserver reliability was substantial to excellent and interobserver reliability was fair to moderate. Our findings demonstrate that MRI-based evaluation of MPFL integrity lacks the consistency and accuracy required for confident clinical decision-making and that MRI findings do not universally correlate with clinical history. These findings support a growing consensus that current imaging analyses alone are insufficient for surgical decision-making in patellofemoral instability, particularly in the assessment of the MPFL.Level III.

Infection is a leading cause of primary total knee arthroplasty failure. Numerous strategies for infection prevention have been devised; however, the vast number of variables has made it difficult to isolate impactful factors. This study aims to narrow the scope by parsing the surgical procedure into stages to determine when the contamination risk is elevated. Twenty-six primary knee arthroplasties were divided into six stages: draping, skin incision, bone cuts, trial placement/balancing, implanting of components, and wound closure. Samples were taken at the end of each stage by swabbing surgical instruments and blotting the surgeon's fingertips. An active particle counter was also in operation during the procedure. A viable contaminant was detected during at least one surgical stage in 54% of the cases. The balancing (19%) and implanting (23%) stages tended to have the most occurrences. Of the contaminated cases, 42% had positive cultures transferred from the surgeon's gloves and 12% from the overhead light handle. A positive correlation was seen between the number of staff present and the occurrence of contamination (p = 0.008). The level of airborne particles 10 μm and larger also correlated with the number of staff present (p = 0.025). Limiting the number of personnel being trained per case and changing the surgical team's gloves after balancing may help to reduce the risk of contamination.

This retrospective study investigates whether the degree of infrapatellar fat pad (IFP) fibrosis influences postoperative pain 6 months following patellofemoral arthroplasty (PFA). Furthermore, this study explores whether sex and patellar height are impacted by the degree of IFP fibrosis. A total of 64 patients who underwent PFA from 2010 to 2023 were included, all of whom had a preoperative knee MRI and at least 1 year of follow-up. Patients were categorized into low (grades 0-1) and increased (grades 2-5) IFP fibrosis groups based on defined MRI findings. Pain outcome was assessed via a numeric rating scale. Demographic data, imaging parameters (e.g., preoperative Insall-Salvati index (IS), pre- and postoperative Caton-Deschamps index (CD), and patella morphology), and implant survivorship were analyzed. Contrary to the hypothesis, no significant association was found between IFP fibrosis degree and postoperative pain levels 6 months following PFA. Notably, the low IFP fibrosis group had a significantly higher prevalence of females (p = 0.02) and a higher preoperative IS index (p < 0.05), suggesting a connection among IFP fibrosis status, sex, and patellar height. No differences between groups were observed in age, body mass index, delta CD index, patella type, or implant survivorship. The lack of association between IFP fibrosis and postoperative pain suggests that IFP fibrosis may not be a determinant of PFA outcomes, potentially guiding surgeons to focus on other factors for optimizing postoperative pain management and implant success. Further studies are needed to elucidate the roles of sex and patellar height in the development of IFP fibrosis. The study provides level III evidence.

This preclinical ex vivo study was conducted to evaluate the effects of submersion in saline or the Missouri Osteochondral Preservation System (MOPS®) solution during reaming on viable chondrocyte density (VCD) of osteochondral allografts (OCAs). Distal femoral OCAs preserved with MOPS were reamed to create cylindrical "plug" grafts using one of three techniques: Submersion in MOPS (SG-MOPS), submersion in saline (SG-Saline), or reamer saturated with MOPS without OCA submersion (SR-MOPS). All plug reaming was performed using standardized instrumentation and technique to harvest 18-mm-diameter plugs. Pre-reaming cartilage samples were collected to confirm baseline VCD. Post-reaming plugs were bisected and stained for live/dead analysis using fluorescent microscopy. VCD was quantified via image analysis, and %Day-0 VCD was calculated. Group comparisons were made using one-way analysis of variance (ANOVA; α = 0.05). A total of 21 plugs from 9 donors were analyzed: SG-MOPS (n = 8), SG-Saline (n = 6), SR-MOPS (n = 7). Mean %Day-0 VCD was highest in SG-MOPS (92.6 ± 7.8%), followed by SG-Saline (83.3 ± 10.2%), and SR-MOPS (80.2 ± 9.1%), though differences were not statistically significant (p = 0.68). A higher proportion of SG-MOPS plugs (7/8, 88%) exceeded the minimum essential VCD threshold (70%) compared with SG-Saline (4/6, 67%) and SR-MOPS (3/7, 43%). Submerging distal femur OCAs in MOPS during 18-mm-diameter femoral condyle plug reaming had clinically meaningful beneficial effects on viable donor chondrocyte density when compared with saline-submerged or non-submerged grafts. Based on the use of this submerged reaming technique that is standardized, repeatable, readily available, cost-effective, and safe, this methodology can be considered "best practice" for OCA plug reaming protocols, motivating implementation of this evidence-based shift in practice at our institution.