Journal of Knee Surgery最新文献

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.

A naturally occurring step-off (SO) between the lateral femoral condyle and the lateral tibial plateau creates a zone where the middle part of the lateral meniscus (LM) is not covered by the femoral condyle. We assessed the effects of this SO on the development of meniscal damage and osteoarthritis (OA). A total of 82 patients who underwent meniscectomy of the LM were retrospectively reviewed. The patients were divided into two groups based on findings of OA on radiography. The control group consisted of patients without OA who were matched to those who had acute isolated anterior cruciate ligament injuries. The size of the SO and extrusion of the LM were obtained by preoperative magnetic resonance imaging. The mean size of the SO in the LM group was significantly larger than that in the control group (4.0 ± 0.92 mm vs. 1.6 ± 1.11 mm, p < 0.0001). Extrusion of LM was not significantly different between the two groups. Extrusion of the tibial side in patients with OA was significantly larger than that in the non-OA group (1.9 ± 1.2 vs. 0.50 ± 0.95, p < 0.001). However, the size of the SO was not significantly different (4.2 ± 1.28 vs. 4.0 ± 0.92, p = 0.53). A large SO was identified as an anatomical risk factor for degenerative LM tears, leading to extrusion of LM and development of lateral knee OA.

As value-based care reshapes the landscape of orthopedic surgery, understanding how insurance type influences patient-reported outcomes (PROMs) after total knee arthroplasty (TKA) is increasingly important. While Traditional Medicare (TM) and Medicare Advantage (MA) differ significantly in structure and access, limited data exist comparing functional outcomes between these groups. This retrospective cohort study used a prospectively collected institutional registry to evaluate 6,010 Medicare beneficiaries who underwent primary TKA between 2016 and 2023. Patients were categorized by insurance type (TM or MA) at the time of surgery. Primary PROMs included the KOOS pain, physical function shortform (PS), and Joint Replacement (JR) subscales. Clinically meaningful improvement was assessed using minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) thresholds. Multivariable logistic regression was performed to evaluate the independent association between insurance type and each outcome, adjusting for demographic, clinical, and socioeconomic covariates. At baseline, MA patients had significantly lower KOOS pain, PS, and JR (p < 0.001). However, by 1-year follow-up, both groups achieved similar KOOS pain and PS scores, and comparable PROM improvements from baseline. MA patients had slightly lower KOOS JR scores (p = 0.006) at 1-year, but equivalent odds of achieving MCID, PASS, and SCB thresholds across all KOOS domains after multivariable adjustment. Patient satisfaction at 1 year also did not differ by Medicare plan type (p = 0.729). Despite presenting with worse baseline functional status, MA patients achieved similar postoperative outcomes, PROM gains, and satisfaction as their TM counterparts. These findings suggest that MA enrollment does not negatively impact patient-perceived benefit after TKA and may not warrant differential risk-adjustment in PROM-based value assessments.

Unicompartmental knee arthroplasty (UKA), encompassing both medial and lateral approaches, facilitates accelerated rehabilitation and enhances patient satisfaction in comparison to total knee arthroplasty (TKA). However, the optimal surgical techniques and implant positioning continue to be topics of ongoing debate. This study compares the clinical efficacy and implant survival rates of medial and lateral UKA to inform clinical decision-making and optimize patient outcomes. A comprehensive literature search was performed across four major electronic databases (PubMed, EMBASE, Scopus, and Cochrane Library), yielding peer-reviewed journal articles that met the inclusion criteria. Statistical analysis involved calculating standardized mean differences (SMDs) and odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Heterogeneity was evaluated using the Cochrane Q test and I ² statistic, with p-values reported accordingly. Data analysis was facilitated using Review Manager (RevMan) version 5.4. This meta-analysis of 15 studies (n = 36,006 UKA patients) found no significant differences in survival rates, postoperative pain, and function scores between medial and lateral UKA. Specifically, the long-term subgroup (>10 years) showed a non-significant higher survival rate for lateral UKA (OR: 0.99, 95% CI: 0.73-1.32, p = 0.92, I ² = 51%), while the short- and mid-term subgroup (<10 years) showed a non-significant higher survival rate for medial UKA (OR: 1.20, 95% CI: 0.96-1.50, p = 0.12, I ² = 73%). Additionally, the pooled SMD revealed no significant differences in postoperative pain (SMD: 0.08, 95% CI: -0.27 to 0.44) and functional scores (SMD: 0.23, 95% CI: -0.05 to 0.51) between the two groups. In conclusion, this systematic review and meta-analysis found no substantial disparities in clinical outcomes, survival rates, functional improvement, or pain alleviation between medial and lateral UKAs, confirming both as viable options.