Journal of Knee Surgery最新文献

Arthrofibrosis is a common issue that can occur after a primary total knee arthroplasty (TKA) and is a significant cause of patient dissatisfaction. As the annual incidence of TKA in the United States rises, the prevalence of arthrofibrosis will rise. The prevalence of this outcome has been reported between 1.3 and 5.3%. The range of values is attributed to the varying quantitative thresholds of flexion and/or extension loss used to define arthrofibrosis. This causes a significant burden on the healthcare system, with a reported 27.5% of the 90-day readmissions after TKA due to arthrofibrosis. This can lead to debilitating results for the affected patients with pain, abnormal gait, fatigue, and difficulty rising from the seated position. The definition of stiffness has changed over the years. This underscores the increasing expectations that both surgeons and patients have for total knee replacements. Management of arthrofibrosis includes both nonoperative and operative modalities. The treatment algorithm includes physical therapy and manipulation under anesthesia (MUA). Physical therapy is most used, while revision arthroplasty is typically reserved as a last resort.

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 (ROM), pain, and functional impairment. Accurate diagnosis is essential for distinguishing arthrofibrosis from other causes of postoperative knee stiffness, such as infection, mechanical block, or malalignment. This review aims to explore current diagnostic methods and evolving standards for arthrofibrosis after TKA, focusing on (1) clinical differentiation from other causes of knee stiffness; (2) assessment and diagnostic criteria; (3) imaging, laboratory, and histopathological techniques; and (4) an integrated diagnostic algorithm and future directions. Diagnosis is primarily based on persistent ROM limitation (flexion <90 degrees or extension >5 degrees) for more than 12 weeks, after excluding infection and mechanical causes. Advanced magnetic resonance imaging (MRI) with metal artifact reduction techniques can be used to visualize intra-articular fibrosis, with an MRI-based synovial classification correlating with ROM deficits and severity. Synovial fluid analysis helps rule out infection, and histopathology is employed when the diagnosis remains unclear. The study proposes a stepwise diagnostic algorithm that integrates clinical, imaging, and laboratory findings and discusses future directions for optimizing diagnosis and treatment pathways to improve patient outcomes.

Title: Comparable Outcome Scores for Medial Collateral Ligament Reconstruction and Repair in Grade III Injuries, with Lower Rates of Complication Following Repair at Two-Year Follow-Up: A Systematic Review Purpose: To compare patient-reported outcomes and complications of MCL repair versus reconstruction in patients with grade III medial collateral ligament (MCL) injuries, and to report whether these were isolated or associated lesions, with minimum 2-year follow-up.

Methods: A comprehensive search of PubMed, Scopus, and Embase was conducted from database inception to August 2024 according to PRISMA 2020 guidelines. Studies reporting outcomes and complications following repair or reconstruction of grade III MCL injuries with ≥2-year follow-up were included. Data on concomitant procedures were extracted to determine the frequency of isolated versus combined lesions.

Results: Twelve studies met criteria, comprising 388 patients: 277 underwent MCL reconstruction and 111 underwent MCL repair. Mean follow-up was 37.6 months for reconstruction and 56.2 months for repair. The majority of injuries were combined lesions, with concomitant ACL reconstruction performed in 70.8% of reconstruction and 58.6% of repair cohorts. Postoperative IKDC scores ranged 54.3-89 for reconstruction and 79.1-88.8 for repair; Lysholm scores ranged 59.4-94.8 and 83.8-98.5, respectively. Complications occurred in 14.4% of reconstruction and 4.5% of repair patients, most commonly range of motion deficits. Reoperation rates were comparable (6.1% vs 7.2%).

Conclusion: Both reconstruction and repair for grade III MCL injuries yielded favorable outcomes at ≥2-year follow-up. MCL repair demonstrated slightly higher IKDC and Lysholm scores with fewer complications overall. Most cases involved combined MCL and ACL injuries, highlighting the rarity of isolated grade III MCL lesions.

Arthrofibrosis after total knee arthroplasty (TKA) is the result of excessive scar formation because of the inflammatory insult of surgery. This formation can lead to significant loss of range of motion, pain, and functional deficits requiring further treatment. Although much has been researched on arthrofibrosis, it continues to lack definitive diagnostic testing. This has led to an array of approaches and treatments to relieve patients of this complication. In response to the inflammatory insult caused by TKA, arthrofibrosis occurs because of an overactivation and proliferation of myofibroblasts. This leads to an abundant deposition of type I collagen and scar tissue formation. This general cascade has been found to be associated with multiple signaling pathways involving primarily transforming growth factor-beta. Additionally, there is a multifactorial component of risk factors and comorbidities, which contribute to the formation of arthrofibrosis. Arthrofibrosis is diagnosed as both a clinical diagnosis and a diagnosis of exclusion. Using the patient's history, clinical examination, and diagnostic testing to rule out other etiologies, one can obtain the diagnosis of arthrofibrosis. While stiffness is an umbrella term that is commonly used interchangeably with arthrofibrosis, it is imperative to use the diagnostic testing to systematically rule out other causes of stiffness. There is no definitive imaging, biopsy, or biomarker test specific for arthrofibrosis currently, which makes obtaining a definitive diagnosis difficult. Nonoperative and operative treatment options are available for the treatment of arthrofibrosis. Most conservative approaches begin with physical therapy, appropriate pain management, and oral anti-inflammatory medication. Treatment options rise in invasiveness with manipulation under anesthesia, arthroscopic lysis of adhesions, open lysis of adhesions, and ultimately revision TKA. This review will focus on the role of manipulation under anesthesia in the setting of arthrofibrosis.

Anterior cruciate ligament (ACL) injuries are among the most common sports-related knee injuries, affecting athletes across varying levels of competition. ACL repair procedures have become a popular treatment option to repair these lesions. There is a need for a comprehensive analysis of recent studies among a growing body of literature to better understand return to sport (RTS), return to previous level (RPL), and timing of RTS following these procedures. A systematic review was performed using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A literature search of PubMed, Embase, Scopus, and SPORTDiscus databases was performed on October 11, 2024. Two independent reviewers screened 2,098 articles. The inclusion criteria included studies from 2000 to the present, a minimum of 12-month follow-up, level of evidence (LOE) I to IV, English language, and reported outcomes after ACL repair procedures with RTS data. Data were stratified by ACL repair technique for subgroup analysis. RTS, RPL, and RTS timing were reported as ranges to reflect study variability. The 16 studies included 614 athletes with RTS rates ranging from 36% to 100%. Seven studies report RPL encompassing 342 athletes with RPL rates ranging from 60% to 81%. The average time for athletes to RTS ranged from 5.9 to 11.9 months. ACL repair with bone marrow stimulation achieved RTS rates ranging from 78% to 92%. Primary repair techniques demonstrated RTS rates from 67% to 100%, while primary repair with internal brace techniques demonstrated RTS rates ranging from 36% to 100%. RTS rates following the Bridge-Enhanced ACL Repair (BEAR) technique were only reported in one study, and reported an RTS rate at 88%. The majority of patients undergoing ACL repair RTS, with a majority also returning to preinjury levels between 4 and 11.9 months postsurgery. ACL repair techniques are a viable treatment option in the correct patient population.LOE is IV; systematic review of level IV studies.

This cohort study aimed to identify whether time greater than 3 months between the onset of new symptoms of instability after primary anterior cruciate ligament (ACL) reconstruction (ACLR) and subsequent revision ACLR influences outcomes of revision surgery. We hypothesized greater than 3 months from onset of symptoms to revision ACLR is associated with increased intra-articular damage and poorer outcomes following revision ACLR. A retrospective chart review was conducted to identify patients who underwent revision ACLR at a large tertiary referral institution between 2008 and 2019. Demographic, surgical, and postsurgical data were collected. Patients who underwent revision ACLR within 3 months of documented graft symptomology were defined as the Early Revision group, and patients who underwent revision ACLR at or greater than 3 months after onset of graft symptomology were defined as the Late Revision group. Demographic data, intraoperative findings, subsequent graft failure, and patient-reported outcomes were compared between the groups. A total of 74 patients met inclusion criteria. Patients in the Late Revision group were more likely to have cartilage damage in the patella, trochlea, medial tibial plateau, lateral femoral condyle, and lateral tibial plateau. Patients in the Late Revision group were also more likely to have concomitant lateral meniscus tears. Medial meniscus tears identified at time of surgery in this group were also less likely to be deemed repairable. No significant differences were noted in postoperative Knee Injury and Osteoarthritis Outcome Scores, Marx Activity scores, or ACL graft retear risk based on the time from injury to surgery. Undergoing revision ACLR more than 3 months after graft tear is associated with more severe articular cartilage damage, more frequent lateral meniscus pathology, and a greater incidence of irreparable medial meniscus tears. No significant differences in patient-reported outcomes or revision graft failure risk were observed. LEVEL OF EVIDENCE:  III.

Arthrofibrosis is a common and debilitating complication after total knee arthroplasty (TKA), with an incidence ranging from 1.3 to 19.8%. It is associated with pain, restricted range of motion, and elevated revision rates, yet diagnostic definitions and management strategies remain inconsistent. This review examines surgical options for arthrofibrosis after TKA, focusing on open lysis of adhesions (LOA) and tibial component exchange, and summarizes evidence on indications, patient selection, techniques, outcomes, complications, and predictors of success. A narrative review of the literature was performed, including studies on nonoperative strategies, manipulation under anesthesia (MUA), arthroscopic LOA, open LOA, and revision TKA. Nonoperative treatment and MUA are most effective in the early postoperative period (<12 weeks). Arthroscopic LOA benefits localized adhesions but is limited in diffuse or posterior fibrosis. Open LOA allows broader release and produces average range-of-motion gains, although outcomes vary. Tibial component or polyethylene exchange can be successful in select patients with moderate stiffness, whereas full component revision is more effective in severe cases or when mechanical errors are present. Complications include persistent stiffness, infection, fracture, and extensor mechanism compromise. Predictors of favorable outcomes include early intervention, correctable technical factors, and adherence to rehabilitation. Arthrofibrosis remains a multifactorial complication without a universally effective treatment. Management should be individualized and stepwise, beginning conservatively and escalating to surgical intervention when appropriate. Open LOA and tibial component exchange are valuable tools in select patients, but recurrence and complications remain common. Further prospective studies with standardized definitions and outcomes are needed to improve care.

Arthrofibrosis remains a challenging complication to manage following total knee arthroplasty (TKA). Early arthrofibrosis, occurring within 12 weeks of TKA, is more responsive to manipulation under anesthesia, whereas late presentations often require surgical intervention. Arthroscopic lysis of adhesions (aLOA) has emerged as a reliable treatment when non-operative measures fail. The procedure involves thorough arthroscopic debridement followed by gentle manipulation and immediate rehabilitation. Published literature has demonstrated that aLOA consistently improves knee ROM by approximately 20 to 60 degrees, with corresponding gains in Knee Society Scores and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) indices, and reductions in pain. Although overall complication rates are rare, large database analyses warn of non-trivial risks, including recurrent stiffness, surgical site infection, and periprosthetic joint infection, with outcomes influenced by factors such as younger age, higher comorbidity burden, poor baseline ROM, and elevated body mass index. Careful patient selection, preoperative exclusion of mechanical or infectious causes of stiffness, and intensive postoperative rehabilitation are critical to the success of this procedure. When applied in appropriately selected patients, aLOA offers meaningful improvement in motion and function and represents a key therapeutic option in the management of arthrofibrosis.

The ongoing opioid epidemic has prompted a reexamination of perioperative pain management, especially in total knee arthroplasty (TKA)-a procedure known for its high amount of postoperative pain and historical reliance on opioids. Among strategies for opioid-naïve patients, three broad approaches have emerged: Quantity limitation, dynamic reassessment-based prescribing, and tiered, multimodal pain regimens. While limiting prescription size and scheduling timely follow-ups remain important tools, perhaps an important approach to consider is a tiered, multimodal pain management regimen. This strategy begins with baseline administration of non-opioid agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids, escalating only as needed to tramadol and, if necessary, stronger opioids. Preoperative cryoneurolysis, intraoperative regional nerve blocks, and long-acting local anesthetics further enhance this regimen's ability to minimize opioid exposure. These clinical gains are now reinforced by the Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act, which provides separate Medicare reimbursement for select non-opioid pain treatments beginning in 2025, helping to eliminate financial barriers to adoption of these measures. In addition, real-world data-including results from the Innovations in Genicular Outcomes Research (iGOR) registry-have demonstrated the effectiveness of these techniques in reducing opioid use and improving functional and quality-of-life outcomes following TKA. Together, this convergence of clinical strategy, supportive policy, and data infrastructure provides a scalable and sustainable framework for advancing opioid stewardship in orthopaedic surgery without compromising patient comfort or recovery.

Bisphosphonates have been the gold standard for osteoporosis treatment in the past decade. However, other medications available on the market are also valuable in the treatment of osteoporosis. Knowledge is limited regarding the incidence of postoperative complications following total knee arthroplasty (TKA) for patients taking these osteoporosis medications. Therefore, our primary objective was to examine the incidence of post-TKA complications in patients taking denosumab, selective estrogen receptor modulators (SERMs), teriparatide, or bisphosphonates at 90 days, 1 year, and 2 years. Our secondary objective was to examine the odds of post-TKA complications in patients taking denosumab, SERMs, or teriparatide, at 90 days, 1 year, and 2 years compared with bisphosphonates. Employing a retrospective cohort design, we used an all-payer national database to identify 28,514 post-TKA osteoporotic patients from 2015 to 2022 taking either bisphosphonates, denosumab, SERMs, or teriparatide. Postoperative complications investigated for each osteoporosis medication included prosthetic joint infection (PJI), surgical site infection, aseptic revision, manipulation under anesthesia, aseptic loosening, venous thromboembolism, and periprosthetic fracture. There was a higher incidence of aseptic revision in post-TKA patients taking denosumab (1.2 vs. 0.6%, 0.7%, 0.9%, p = 0.033) compared with patients taking bisphosphonates, SERMs, or teriparatide, respectively, at 90 days. There was a higher incidence of PJI (0.5 vs. 0.1%, 0%, 0.1%, p = 0.049) and aseptic revision (0.3 vs. 0.01%, 0.1%, 0.1%, p = 0.030) in post-TKA patients taking teriparatide compared with patients taking bisphosphonates, denosumab, or SERM's at 90 days and 1 year, respectively. After multivariate analysis with bisphosphonates set as the control, denosumab showed higher odds of aseptic revision at 90 days (odds ratio [OR] = 2.17, p = 0.007), and teriparatide showed higher odds of PJI at 90 days (OR = 3.46, p = 0.043) and aseptic loosening at 1 year (OR = 5.82, p = 0.026). Teriparatide and denosumab were associated with a higher incidence and odds of certain post-TKA complications compared with bisphosphonates. Our results indicate that bisphosphonates and SERMs are associated with the fewest post-TKA complications, but more studies are needed to appreciate the effectiveness of each medication.