Journal of Knee Surgery最新文献

Femoral component rotation (FCR) in total knee arthroplasty (TKA) is critical for flexion balance and patellofemoral tracking. Deviations from the transepicondylar axis (TEA) have been linked to poor outcomes. This study aimed to assess the impact of FCR on patient-reported outcomes in functionally aligned (FA) TKAs. A total of 448 robotic-assisted FA TKAs with preresection gap balancing were performed in 393 patients between June 1, 2018, and December 31, 2021. Demographic, radiographic, and patient-reported outcome measures (PROMs) were prospectively collected at baseline and 1 year postoperatively. FCR was set within a range of ± 6 degrees relative to the TEA as part of an FA TKA alignment strategy. The primary outcome was the relationship between final intraoperative FCR and PROMs at 1 year, including the Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12) and the EuroQol 5-Dimension-5-Level (EQ5D-5L) score. Mean FCR was 0.0 degrees (SD ± 2.1 degrees, range: -5.8 to 7.0 degrees). At 1 year, KOOS-12 increased by a mean of 44.1 points (p < 0.01), and EQ5D-5L by 7.6 points (p < 0.01). No significant correlation was found between FCR and KOOS-12 (r = -0.09, p = 0.3). A weak negative correlation existed between increasing external FCR and EQ5D-5L (r = -0.12, p = 0.03). Categorizing FCR into internal (<-2 degrees), neutral (± 2 degrees), and external rotation (≥2 degrees) showed no significant differences in outcomes. FA TKA leads to significant improvements in PROMs, regardless of FCR within a functional range, at 1 year postoperatively. The study is a cross-sectional study providing Level III evidence.

The emergence of artificial intelligence (AI) in health care has created novel opportunities for enhancing patient education and alleviating anxiety. This study seeks to evaluate the effectiveness of two leading AI platforms, ChatGPT and Gemini, in delivering accurate and satisfactory responses to patients with gonarthrosis, considering total knee arthroplasty (TKA). A prospective, randomized controlled trial was conducted involving 100 patients diagnosed with gonarthrosis and indicated for TKA. Each patient posed five questions regarding the surgery and postoperative rehabilitation to both ChatGPT and Gemini. Responses were evaluated by two blinded orthopaedic specialists on a 10-point scale for accuracy and patient satisfaction. Patients additionally evaluated their satisfaction with each response using a 10-point scale. The main outcome measures consisted of the average accuracy scores assessed by specialists and the average satisfaction scores reported by patients. Statistical analysis revealed significant differences between ChatGPT and Gemini in both accuracy and patient satisfaction (p < 0.001). ChatGPT demonstrated better performance with a mean accuracy score of 8.7 ± 0.9 compared with Gemini's 7.2 ± 1.1. Patient satisfaction scores aligned with expert evaluations, with ChatGPT achieving a mean satisfaction score of 8.9 ± 0.8 versus Gemini's 7.5 ± 1.2. Notably, ChatGPT excelled in providing comprehensive explanations of surgical procedures (mean score: 9.2 ± 0.7) and postoperative care (9.1 ± 0.8), whereas Gemini performed better in offering concise summaries of recovery timelines (8.4 ± 0.9). This study demonstrates that ChatGPT offers more accurate and satisfactory responses to patient queries regarding gonarthrosis and TKA compared with Gemini. The findings suggest that AI platforms, particularly ChatGPT, can serve as valuable tools in augmenting patient education and potentially reducing preoperative anxiety. Future studies should investigate the incorporation of AI-assisted information delivery into clinical practice and its long-term effects on patient outcomes.

Introduction: The Coronal Plane Alignment of the Knee (CPAK) classification system categorizes nine phenotypes based on constitutional limb alignment and joint line obliquity. Understanding relationships between CPAK phenotypes and tibial slope could streamline total knee arthroplasty planning. This study investigated the correlations between CPAK classification and medial tibial slope in patients with osteoarthritis.

Materials and methods: 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 tibial slope. Statistical analysis included multiple linear regression, Pearson correlation, and one-way ANOVA with Tukey post-hoc testing. Outliers were removed using interquartile range criteria, resulting in 581 knees for final analysis.

Results: Multiple linear regression revealed minimal correlation between coronal alignment and tibial slope (TS = 26.35 - 0.1045 aHKA - 0.1004 JLO; r² = 0.0233). Arithmetic hip-knee-ankle angle and joint line obliquity explained only 2.33% of tibial slope variance. Contour mapping demonstrated no discernible patterns in data distribution. Despite weak correlations, ANOVA identified statistically significant differences between CPAK groups for tibial slope (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°.

Conclusions: No clinically meaningful relationship exists between CPAK classification and tibial slope 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 tibial slope 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.

Introduction: 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.

Materials and methods: The cross-sectional area of the posterior femoral osteophytes is measured on the sagittal plane of the preoperative 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 affect both extension and flexion. The amount and specific location of bony resection is then determined based on the size and location (posteromedial vs posterolateral) of the osteophytes.

Results: 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.

Conclusion: The size and shape of initially inaccessible posterior osteophytes, determined using CAT scan-based imaging, was 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.

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.