Journal of Knee Surgery最新文献

Despite urgent operative management of septic knee arthritis with irrigation and debridement and culture-specific antibiotic therapy, the incidence of additional washouts in knee septic arthritis has been noted to be between 11.4 and 40%. The purpose of this study was to analyze preoperative and postoperative variables associated with failure of primary washout in septic knees. A retrospective review was conducted at a Level I trauma center for all patients with septic arthritis who underwent open irrigation and debridement from 2010 to 2023. Patients were excluded if they were noted to have a knee arthroplasty or additional infection source aside from bacteremia. Demographic information, comorbidities, dates of operative washouts, vitals, and inflammatory markers were noted. Ninety-seven patients met inclusion and exclusion criteria. Forty-two required an additional washout. The average number of days between the primary and secondary washouts was 4.9 days. Decreased age (p = 0.03) and primary Staphylococcus aureus culture (p < 0.01) were found to be significantly associated with failure of the primary washout. Preoperative vitals, inflammatory markers, age, body mass index, intravenous drug use, diabetes, and smoking were not found to be predictors of repeat septic knee washouts. Additional subgroup analysis on bacteremic patients and on C-reactive protein (CRP) trends postoperative day 1 and 2 found no significant predictors of single or repeat septic knee washout. Younger age and presence of S. aureus in aspiration cultures were significantly associated with failure of primary washout. Trending CRP in the immediate postoperative period is not an accurate predictor of repeat septic knee washout.

Arthrofibrosis is a common complication following total knee arthroplasty (TKA), characterized by excessive fibrous tissue formation within the joint, leading to restricted range of motion, pain, and functional limitations. This review focuses on three key areas: (1) dysregulated wound healing processes and molecular risk factors; (2) histopathological and immunohistochemical features; and (3) emerging molecular targets and potential personalized treatment strategies. Dysregulated wound healing after TKA leads to persistent fibroblast and myofibroblast activation, excessive extracellular matrix deposition, and joint capsule contracture. Key molecular mediators, such as transforming growth factor-β 1 (TGF-β1), xylosyltransferase-I (XT-I), and β-catenin (β-catenin), drive these processes, exacerbating fibrosis. Genetic predisposition, inflammatory signaling, and immune cell infiltration further contribute to the progression of arthrofibrosis. Histopathologically, arthrofibrotic tissue shows increased collagen types I and III deposition, along with upregulated markers such as α-smooth muscle actin and TGF-β1 receptor 1, reflecting myofibroblast activation and inflammation. Immunohistochemical analysis reveals abundant CD68+ macrophages and T cell infiltration, supporting the inflammatory microenvironment. Recent advances in molecular profiling have identified potential biomarkers and therapeutic targets, including bromodomain-containing protein 4 and XT-I, offering hope for personalized medicine. Despite promising preclinical findings, clinical translation remains in its early stages. Future research should prioritize the validation of these biomarkers and explore genetic and epigenetic stratification to improve management and outcomes for high-risk patients.

Arthrofibrosis is a debilitating complication following total knee arthroplasty (TKA), resulting in limited knee range of motion (ROM) and functional impairment. This review explores the (1) epidemiology, (2) risk factors, and (3) prevention strategies associated with arthrofibrosis. The incidence of arthrofibrosis ranges from 3 to 10% in primary TKA cases, with up to 13% in some series, and it contributes to up to 10% of revision surgeries within 5 years. Genetic and molecular factors may play a role in predisposition. Other risk factors include younger age, preoperative limited ROM, and surgical factors like prosthetic malpositioning. Prevention strategies focus on patient education, rehabilitation, and pharmacological interventions, with emerging evidence supporting the use of celecoxib, dexamethasone, COX-2 inhibitors, and losartan in reducing the risk of arthrofibrosis. Despite progress, gaps remain, particularly regarding standardized definitions and high-quality randomized controlled trials to assess the optimal treatment methods.

Value in health care is defined as optimized patient-centered outcomes and streamlined costs of care. A patient-level value analysis (PLVA) is a novel value-based health care research method. In a PLVA, the ratio of outcomes to cost is calculated for each individual patient in a cohort, and factors that optimize value are investigated. We performed a PLVA in primary total knee arthroplasty (TKA). We conducted a retrospective analysis of a prospectively maintained multi-institutional arthroplasty registry. A total of 2,789 primary manual TKAs were analyzed. Knee Osteoarthritis Outcome Score-Physical Function Short-Form (KOOS-PS) scores and costs of care using time-driven activity-based costing (TDABC) were collected. All costs were converted from U.S. dollars to arbitrary cost units (CUs) to protect confidential hospital financial data. The primary outcome was the value quotient (Value _KOOS-PS), or the ratio of 1-year improvement in KOOS-PS to the cost of care, which was converted to a scale with a maximum of 100. Multivariable forward linear regression determined factors impacting value in primary TKA. The mean improvement in KOOS-PS was 15.2. The mean cost of care was 859 CUs. The largest contributors to cost were the implant cost (378 CUs, 44.0%) and intraoperative personnel cost (173 CUs, 20.1%). Patient and hospital factors independently correlated with improved TKA Value _KOOS-PS included home discharge (adjusted mean difference: +7.8; p < 0.001), outpatient surgery (adjusted mean difference: +3.6; p < 0.001), lower preoperative KOOS-PS score (adjusted mean difference: +0.6; p < 0.001), lower Charlson Comorbidity Index (adjusted mean difference: +0.6; p = 0.006), and lower body mass index (BMI; adjusted mean difference: +0.2; p = 0.001). Using TDABC and patient-reported outcome measures, we performed a PLVA. We found that the largest contributor to the cost of care was the implant cost. The highest value TKAs occurred in an outpatient setting with home discharges, for patients with more severe preoperative knee symptoms, fewer comorbidities, and lower BMI. Surgeons and hospital administrators can use these findings to inform strategies to optimize value in TKA.

This study describes an arthroscopic technique for popliteal cyst excision and reports preliminary outcomes data. We retrospectively identified patients with symptomatic popliteal cysts who underwent popliteal cyst excision at our institution between 2013 and 2020. Arthroscopic popliteal cyst excision was performed using dual posteromedial portals, expansion of the valvular mechanism, and cyst wall resection. International Knee Documentation Committee (IKDC) scores were collected preoperatively and at follow-up. We calculated the proportions of patients meeting Patient Acceptable Symptomatic State (PASS) cutoffs for the IKDC, compared baseline and follow-up IKDC scores and the proportions of patients meeting PASS cutoffs, and examined the association between demographic and injury variables and outcomes. Forty patients were eligible to be included in this study (mean age = 52.1 years; mean follow-up time = 3.7 years), and baseline IKDC data were available for 30 patients. The mean IKDC score at baseline was 42.6 ± 14.9, compared to 70.4 ± 22.4 at follow-up (p < 0.01). At baseline, 13% of the cohort met the PASS cutoff for the IKDC. The proportion of the cohort meeting the IKDC PASS significantly increased at follow-up to 70% (p < 0.01). Longer postsurgery time was associated with lower IKDC scores at follow-up (R ² = 12.7%; p = 0.02) and with lower odds of meeting IKDC PASS at follow-up (OR = 0.57; p = 0.04). Higher preoperative body mass index was associated with lower IKDC scores at follow-up (R ² = 10.2%; p = 0.04). No patients reported cyst recurrence or need for surgical revision. This arthroscopic technique, utilizing two posteromedial portals, expansion of the valvular mechanism, and cyst wall resection, demonstrates good clinical outcomes at a mean follow-up of 3.7 years in a cohort of 40 patients.The level of evidence is IV (case series).

Manipulation under anesthesia (MUA) is an undesirable outcome after total knee arthroplasty (TKA). Black patients have higher odds of MUA than White patients. Social deprivation is also linked to worse TKA outcomes. We examined the associations between an area- and person-level indicator of social deprivation and odds of MUA within 1 year after TKA. This retrospective cohort study included fee-for-service Medicare beneficiaries 65+ (Medicare Limited Data Set, 5% claims) undergoing unilateral inpatient or outpatient primary elective TKA in 2016 to 2020 with an accompanying diagnosis of knee osteoarthritis. Area-level social deprivation was assessed using the county-level Social Deprivation Index (SDI). Person-level social deprivation was operationalized as dual Medicare/Medicaid eligibility. We assessed the relationship between social deprivation and 1-year MUA in separate mixed effects generalized linear models with a binary distribution and logit link. We report adjusted odds ratios (OR) and 95% confidence intervals (CI). Our cohort included 34,749 TKA patients (median age: 73 [interquartile range (IQR): 69-77]; 63.4% women). Median SDI was 42 (IQR: 20-66); 4.7% were dual-eligible. There were 748 cases of MUA (2.2%). Median time to MUA was 63.5 days (IQR: 49-91). Odds of MUA receipt were significantly lower for the most deprived quintile compared with the second most deprived quintile (OR: 0.77; 95% CI: 0.60-0.98; p = 0.04), the middle quintile (OR: 0.76; 95% CI: 0.59-0.99; p = 0.04), and the second least deprived quintile (OR: 0.70; 95% CI: 0.55-0.91; p = 0.01). Dual eligibility wasn't significantly associated with receipt of MUA (OR: 0.74, 95% CI: 0.50-1.10, p = 0.13). There were no significant differences for the person-level indicator of deprivation. The most socially deprived quintile had lower odds of MUA receipt than patients in less socially deprived quintiles. While this could be viewed as a positive, alternatively, it may reflect a challenge with postoperative care access and should be further examined.

Osteochondral injuries secondary to patella dislocation are common and represent a significant complication of patellar instability. Despite the frequency of this injury, there are no published studies comparing outcomes between patients undergoing isolated medial patellofemoral ligament (MPFL) reconstruction for patellar instability versus patients undergoing MPFL reconstruction combined with procedures to address associated osteochondral defects. To evaluate differences in patient-reported outcome measures (PROMs), complications and revision rates between patients requiring MPFL reconstruction with osteochondral defects versus patients requiring MPFL reconstruction without osteochondral defects. A retrospective review of all patients undergoing MPFL reconstruction for patellar instability between April 2019 and March 2023 was performed. Patients were grouped into those requiring MPFL reconstruction combined with a procedure to address a concomitant osteochondral defect and those who underwent isolated MPFL reconstruction. Preoperative magnetic resonance imaging was used to assess anatomical risk factors for patella instability. At follow-up Lysholm, IKDC, KOOS-PF, satisfaction, and return to sport were evaluated. The study included 44 knees (18 and 26 for the osteochondral defect and isolated MPFL groups, respectively), with a mean age of 21.8 years and a mean follow-up of 23.1 months. The osteochondral defect group had a lower Insall-Salvati ratio (p = 0.03). At follow-up, the osteochondral defect group had lower Lysholm and Kujala scores (p = 0.01 and 0.002). Overall, 66.7% and 88.5% of participants in the osteochondral defect group and isolated MPFL groups, respectively, responded as being very satisfied with the results of surgery (p = 0.13). The return to play rate was 10.0% and 61.9% in the osteochondral defect and isolated MPFL groups, respectively (p = 0.009). Patients with osteochondral defects occurring secondary to patella dislocation had lower Insall-Salvati ratios and lower postoperative PROMs at follow-up. These findings highlight the significant impact of osteochondral injuries on patient outcomes in patients undergoing patellar stabilization surgery. LEVEL OF EVIDENCE:  Cohort study; Level of evidence, 3.

This study developed a classification system for comminuted patella fractures based on anatomic zones of comminution: Type 1 (proximal), Type 2 (central or stellate), and Type 3 (distal). The system's reliability was tested by 30 graders (junior residents, senior residents, fellows, and attendings) who assessed 60 fracture cases twice, one month apart, for a total of 120 assessments. Interobserver reliability, measured by Fleiss' kappa, was 0.67, showing substantial agreement, while intraobserver reliability, measured by Cohen's kappa, was 0.82, indicating excellent agreement. Reliability was consistent across experience levels. This novel classification system for comminuted patella fractures demonstrated substantial interobserver and excellent intraobserver reliability, but clinical validation is needed to confirm its practical utility.

We aimed to evaluate the effect of progressive balance training on lower limb recovery following anterior cruciate ligament (ACL) reconstruction plus meniscus repair. A total of 106 patients undergoing ACL reconstruction plus meniscal repair between March 2022 and March 2024 were recruited and assigned into a control group (n = 53, non-individualized rehabilitation training) and a study group (n = 53, progressive balance training) using a random number table. The indicators related to knee joint proprioception, knee joint function, and lower limb motor function were compared before intervention and after 12 weeks of intervention. After 12 weeks of intervention, the active range of motion and Lysholm scores of the knee joint rose in both groups compared with those before intervention, and they were higher in the study group (p < 0.05). After 8 and 12 weeks of intervention, the anterior, posterolateral, and posteromedial reach distances were longer in the study group than in the control group (p < 0.05). After 12 weeks of intervention, the Fugl-Meyer assessment of lower extremity scores, Holden walking function scores, and 10-m walk test speed all increased in both groups compared with those before intervention, especially in the study group (p < 0.05). Progressive balance training leads to clinically meaningful improvements in knee joint proprioception and lower limb balance function in patients undergoing ACL reconstruction plus meniscal repair. The observed increase in Lysholm scores exceeds the established minimal clinically important difference threshold of 25 points, indicating significant functional gains. The improvements in Y-balance test performance suggest a reduced risk of injury.

Injuries to the posterolateral corner (PLC) of the knee can significantly impair stability and function. In particular, variations in the femoral insertions of the lateral collateral ligament (LCL) and popliteal tendon (PT) may affect surgical planning for PLC injuries. However, these anatomical features are underexplored in the Chilean population. This study seeks to characterize the femoral insertions of the LCL and PT in Chilean patients based on magnetic resonance imaging (MRI) findings. This cross-sectional, observational study was conducted at a single center, including 43 patients aged 18 and older who underwent knee MRI scans. Imaging was performed using a 1.5 Tesla MRI scanner with isotropic voxel dimensions of 0.65 × 0.65 × 0.65 mm. Two musculoskeletal radiologists independently measured the distance between the centroids of the LCL and PT insertion points on the femur. An intraclass correlation coefficient (ICC) was calculated to assess interobserver reliability, and a paired t-test was used to compare the measurements. A p-value < 0.05 was considered statistically significant. Among the 43 patients (51.2% male, 48.8% right knees), the average distance between the LCL and PT insertion centroids was 11.7 mm (standard deviation: 1.61). The measurements by the two radiologists were similar (observer 1: 11.5 mm; observer 2: 11.8 mm), with no significant differences (p = 0.326). The ICC for interobserver agreement was 0.83 (95% confidence interval: 0.69-0.91), indicating high reliability. In this Chilean cohort, the average distance between the LCL and PT femoral insertions was 11.7 mm, a value that differs from previously reported ranges. These findings may help refine surgical approaches to PLC injuries.Level III, cross-sectional observational study.