Journal of Knee Surgery最新文献

An adductor canal block (ACB) is widely accepted as a regional nerve block for pain management following total knee arthroplasty (TKA). However, no consensus exists concerning whether the analgesic effect is greater when joint surgeons perform intra-articular ACBs (IA-ACBs) or when anesthesiologists perform ultrasound-guided ACBs (UG-ACBs). We hypothesized that IA-ACBs performed by joint surgeons and UG-ACBs performed by anesthesiologists based on periarticular injections (PAIs) would yield equivalent analgesic effects. This prospective randomized controlled trial included 61 patients who underwent IA-ACBs and 56 patients who received UG-ACB with additional PAI for post-TKA pain management. The primary outcome was postoperative pain assessed using numeric rating scale scores at rest and during exercise. Secondary outcomes included opioid consumption and functional recovery. We also investigated local and systemic adverse events, including nausea, vomiting, and wound complications. Both groups of patients experienced comparable analgesic effects for both IA-ACB and UG-ACB pain management; however, those who received IA-ACBs were prescribed more opioid equivalents than those in the UG-ACB group on postoperative day 1 (p = 0.048). No differences between the groups were observed regarding local or systemic adverse events. IA-ACBs performed by joint surgeons provided equivalent analgesic effects to UG-ACBs performed by anesthesiologists. However, IA-ACBs may lead to a higher postoperative requirement for opioid analgesics.

Single-bundle (SB) and double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) have been compared for years, and long-term outcomes of the two techniques remain inconclusive. We compared the 10-year outcomes of SB and DB reconstruction, in terms of subjective scores, knee stability, graft failure, and osteoarthritis (OA). We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for relevant studies, without restrictions on study design, language, or publication date. The risk of bias and methodological quality were assessed using the Cochrane risk of bias tools (RoB 2 and ROBINS-I) and the Modified Coleman Methodology Score (MCMS), respectively. Reconstructions scoring at least 8 on the Anatomic ACLR Scoring Checklist (AARSC) were considered anatomic. The results were narratively summarized and graphically represented using tables and forest plots. Our search included six studies (two randomized control trials [RCTs] and four cohort studies [CSs]), comprising 222 SB and 214 DB reconstruction patients, with an average follow-up of 11.4 years. Of these, four studies achieved a methodological rating of "good" or above. Bias risk was evaluated as "some concerns" in the RCTs and "serious" in the CSs. Six, four, four, and two studies reported on subjective scores, knee stability, graft failure, and OA, respectively. Except for one study that reported a higher Lysholm score (p = 0.007) in the DB group, no group differences in subjective scores were identified. According to one study, the DB group performed better on the Lachman test (p = 0.02) and the KT-2000 arthrometer (p = 0.024 and 0.034 for pulling and back pushing, respectively). Three studies revealed higher negative rates of the pivot shift test in the DB group. The incidence of graft failure and OA were not statistically significant between the SB and DB groups. The existing evidence does not conclusively determine whether DB reconstruction provides long-term advantages over SB reconstruction. Future research with larger sample sizes and higher levels of evidence is warranted.

Debridement with antibiotics and implant retention (DAIR) is commonly utilized for treatment of prosthetic joint infection (PJI) in total knee arthroplasty (TKA), particularly in cases of acute PJI. Reported success rates of DAIR have been highly variable, but the overall success rate of DAIR cohort studies is approximately 70 to 80%. However, no large database studies have investigated the success rate of DAIR. Therefore, we seek to provide a framework for large-database analysis of PJI interventions and their outcomes and to assess the success rate of DAIR. We queried the MarketScan Database for patients who underwent a DAIR (CPT 27310 and/or CPT 27486) procedure for indication of PJI (ICD-10 T84.53 OR T84.54) between January 1, 2017 and December 31, 2021. We identified reoperations (i.e., stage 1 revision, amputation, or arthrodesis) indicating failure of DAIR. Failure of DAIR treatment was defined by subsequent reoperation. We also identified prescriptions of suppression antibiotics more than 6 months after DAIR. We identified 1,018 patients who underwent a DAIR procedure for PJI. Of these patients, 195 (19.2%) underwent reoperation within 1 year and an additional 178 (17.5%) were prescribed suppressive antibiotics. For 780 patients with a minimum of 2 years of follow-up, 164 (21%) underwent reoperation and an additional 179 (22.9%) were prescribed suppressive antibiotics. Patients with obesity and patients younger than 60 years had significantly higher rates of having reoperation or suppressive antibiotics at 1 year following DAIR. DAIR is a viable option in the treatment of PJI, with an approximately 19% rate of reoperation at 2 years. Our findings are consistent with that of previously published literature.

Knee osteoarthritis significantly impacts mobility and quality of life. This condition is a leading cause of disability in aging populations, with total knee replacement commonly sought in advanced cases. Traditional nonoperative management strategies, including anti-inflammatories, corticosteroid injections, and hyaluronic acid, often provide limited relief, especially in severe cases. Recently, regenerative therapies such as amniotic suspension allografts (ASA) have emerged as promising alternatives due to their anti-inflammatory and regenerative properties, which may counteract the catabolic effects of osteoarthritis. This systematic review evaluated the efficacy and safety of ASA in reducing pain and improving function among knee osteoarthritis patients. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a comprehensive search of PubMed and Embase databases initially identified 1,733 studies pertaining to ASA, of which 1,575 were screened, and 9 studies ultimately met the inclusion criteria for detailed analysis of ASA in the treatment of knee osteoarthritis. Data extraction and narrative synthesis focused on outcomes such as pain reduction and functional improvement using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), as well as safety profiles. The results demonstrated notable improvements in pain scores following ASA treatment, as shown by studies reporting increases in KOOS pain scores over 6 months, which generally outperformed hyaluronic acid and saline treatments in pain reduction. Similarly, ASA treatment was associated with substantial improvements in physical function outcome scores, enhancing patients' ability to perform daily activities. Patient-reported outcomes also indicated higher quality of life and functional status, with most patients experiencing high levels of satisfaction. Additionally, ASA's safety profile was favorable, with adverse events primarily mild to moderate in nature, including a few transient events such as knee stiffness and myalgias. This systematic review highlights ASA as an effective therapeutic option for knee osteoarthritis, although further studies focusing on long-term radiographic outcomes and mechanisms of action are recommended to fully establish its benefits and optimize treatment protocols.

Bone marrow lesions (BMLs) have a strong correlation to patient-reported pain, functional limitations, joint deterioration, and rapid progression to total knee arthroplasty. The Subchondroplasty (SCP) procedure uses AccuFill, a calcium phosphate bone substitute material (BSM), to treat bone defects such as microtrabecular fractures and BML. This observational, prospective, multicenter, cohort study evaluated the effect of the SCP procedure at the 2-year follow-up for 70 patients with knee BML. Under arthroscopic and fluoroscopic guidance, the BML was injected with AccuFill. Patient-reported outcomes, including Visual Analog Scale (VAS) pain, Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and modified Knee Society Score (mKSS) were collected through 24 months postoperatively. Radiographs and magnetic resonance imaging (MRI) were performed at baseline and up to 24 months postoperatively. Patient selection was not limited based on the degree of osteoarthritis (OA) as determined radiologically by the Kellgren-Lawrence (K-L) grade. For a subset of patients, patient-reported outcomes were collected up to 5 years including pain evaluation, patient knee global assessment, and satisfaction with the procedure. Preoperative radiographs indicated moderate to severe OA (K-L grades 2-4) in 65 patients (92.8%). Significant improvements (p < 0.0001) in mean VAS pain, IKDC, mKSS, and KOOS scores were observed compared with baseline. Kaplan-Meier survivorship free from conversion to knee arthroplasty was 76.2% at 2 years. The subset of patients followed for 5 years demonstrated low pain scores and high procedure satisfaction. This study presents statistically significant and clinically meaningful evidence of improvement in clinical outcomes following SCP for BMLs of the knee after 2 years. The survivorship rate from arthroplasty at 2 years was 76.2%. SCP for BMLs can relieve pain with a minimally invasive procedure and may delay the need for knee arthroplasty. REGISTRATION:  NCT01621893 (ClinicalTrials.gov). LEVEL OF EVIDENCE:  Level II, Prospective Cohort Therapeutic Study.

The anterolateral ligament (ALL) is considered a secondary stabilizer of internal rotation and, due to proximity to the lateral collateral ligament (LCL), it may contribute to anterolateral rotatory stability. This study characterized the anatomy of the ALL and associated tissues of the anterolateral complex (ALC) to determine if structural and histological compensatory adaptations exist in patients without an ALL. Forty-nine cadaveric knees were dissected from distal-to-proximal using established landmarks with the aid of internal rotation stress to localize the ALL (if present), LCL, iliotibial band (ITB), and anterolateral capsule. The width and thickness of ALL and LCL were measured with digital calipers at the origin, middle, and insertion, and cross-sectional areas were calculated. ALL and LCL length and ITB thickness were also obtained. Samples of each tissue were stained with hematoxylin and eosin and picrosirius red, and histological images were evaluated with ImageJ to quantify collagen density (mean gray value [mgv]) and quantity (percent coverage). Size measurements and collagen characteristics were compared between ALL-present and ALL-deficient knees. The ALL was identified in 63% of knees with mean cross-sectional areas of 8.9, 5.8, and 9.7 mm² at the origin, middle, and insertion, respectively. Mean collagen density of the ALL was 106.9 mgv on a scale of 0 (black) to 255 (white), and overall collagen quantity was 40.3%. Proximal LCL width (p = 0.04), distal LCL thickness (p = 0.03), and cross-sectional area (p = 0.01), and ITB thickness (p = 0.02) were significantly greater in ALL-deficient knees. A significantly higher collagen density was found within the LCL (p = 0.04), and higher overall quantity of collagen within the LCL (p < 0.01) and ITB (p < 0.01), of ALL-deficient knees. Gross anatomical and histological alterations exist in knees without an ALL compared with those with an ALL. These may reflect adaptations in the ALC and LCL that are present to compensate for the absence of the anterolateral rotatory stability afforded by the ALL.

This study aimed to compare clinical outcomes and second-look arthroscopic findings between double-bundle anterior cruciate ligament (ACL) reconstruction for complete ACL rupture and anteromedial (AM) bundle augmentation with preservation of the posterolateral (PL) bundle in isolated AM bundle rupture. Between 2014 and 2021, we retrospectively analyzed 95 ACL reconstructions with at least 2 years of follow-up. Patients undergoing primary ACL reconstruction from January 2014 to June 2021 were included in the study. Double-bundle ACL reconstruction (group 1) was performed in the cases involving male patients, high activity levels, age below 40 years, or when there was a patient preference for double-bundle reconstruction. In contrast, for partial ACL ruptures with an intact PL bundle confirmed on preoperative magnetic resonance imaging, AM augmentation was performed (group 2). Preoperative and final follow-up clinical outcomes, along with synovial coverage during second-look arthroscopy, were compared between group 1 (65 cases) and group 2 (30 cases). Statistical analysis included correlation coefficients between the groups. The Lysholm score, Tegner activity scores, and International Knee Documentation Committee (IKDC) knee evaluation form score at final follow-up were 81.8 (±5.5), 7.2 (±0.9), and 79.4 (±6.7), respectively, in group 1, and they were 88.0 (±6.4, p = 0.038), 7.9 (±0.5, p = 0.042), and 86.2 (±5.4, p = 0.081), respectively, in group 2. For group 1, the Lachman test (p = 0.093) and the pivot shift test (p = 0.176) at the final follow-up showed no laxity in 57 and 59 knees, and there was plus one laxity in 8 and 6 knees. For group 2, there were no laxity in 27 and 28 knees, and plus one laxity in 3 and 2 knees. Synovial coverage area percentages of the grafted tendon were 74.3 (±10.7) and 86.9 (±7.3, p = 0.002) in groups and group 2, respectively, with superior synovial coverage observed in group 2. The AM bundle augmentation with preservation of the PL bundle in ACL injury yielded better synovial coverage and clinical scores compared with double-bundle ACL reconstruction for complete ACL rupture.

Purpose The purpose of this study was to evaluate whether IV dexamethasone, within the current multimodal pain management protocol, (1) could maintain postoperative pain at a comparable level without IV PCA, (2) could reduce opioids-related side effects, and (3) whether an additional dose of dexamethasone on POD 2 would offer further pain-relieving effect without increasing the risk of complications. Methods A total of 178 patients (182 knees) who underwent total knee arthroplasty (TKA) for osteoarthritis were included in the study. The patients were divided into Dexa 2 & PCA and Dexa 3 & NoPCA group. From operative day to POD 5, pain visual analogue score (VAS), rescue opioids consumption, episodes of postoperative nausea and vomiting (PONV), antiemetics usage, and side effects of opioids such as postoperative urinary retention (POUR) and constipation were checked. For safety, wound complication and infection were checked. Results There was no difference in pain VAS between the two groups during all six perioperative days. Rescue opioids consumption was lower in Dexa 2 & PCA group. Total dosage of used opioids for six perioperative days was lower in Dexa 3 & NoPCA group. Dexa 3 & No PCA group had less PONV and POUR. There was a marked increase in pain VAS and the use of rescue opioids from POD 1 to POD 2 in the Dexa 2 & PCA. There were no wound problems or infections in either group. Conclusion Under the current multimodal pain management protocol, comparable level of postoperative pain could be achieved by dexamethasone without the need of IV PCA. By not using IV PCA, overall opioid usage was reduced, which could lead to a lower frequency of PONV and POUR. While there is still room for further research on the duration and frequency of administering dexamethasone, additional administration on POD 2 is believed to provide additional pain management benefits compared to administering only until POD 1.

Randomized controlled trial (RCT) studies in revision total joint arthroplasty (rTJA) are essential to investigate the effectiveness of interventions. However, there has been limited research investigating how patient cohorts comprising rTJA RCT samples resemble the U.S. patient population undergoing rTJA in terms of demographic and clinical characteristics. Thus, the purpose of this systematic review was to compare the patient characteristics of rTJA RCT cohorts with the characteristics of national patient database cohorts. RCT studies for rTJA were aggregated. Patient demographics in this group were compared against Healthcare Cost and Utilization Project-National Inpatient Sample (NIS) and American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) patient cohorts. Forty-six RCTs met inclusion criteria. There were 3,780 total patients across 46 RCTs. The average age of patients in the rTJA RCT cohort was 66.4 ± 9.4 while in the NIS cohort was 67.3 ± 11.1 (d = 0.08, effect size = small). The average body mass index (BMI) of the rTJA RCT cohort was 31.1 ± 5.7 while the NSQIP cohort was 31.7 ± 8.3 (d = 0.08, effect size = small). For rTJA, effect sizes for age, BMI, sex, ethnicity, smoking, and diabetes were all small or very small.Overall, the rTJA RCT patient cohort does not differ significantly compared with the general patient population undergoing rTJA. Differences in demographic and clinical characteristics between the rTJA RCT cohort and database cohorts were minimal to small, indicating that these differences are unlikely to impact clinical outcomes.

The Women's National Basketball Association (WNBA) has grown in popularity since its induction in 1996. Furthermore, it is well known that female athletes are at an increased risk of anterior cruciate ligament (ACL) tears compared with their male counterparts. The purpose was to examine the player positions and player movements during basketball games and practices that contribute to ACL tears in WNBA players. Player position and demographics from WNBA players who suffered an ACL tear from 1996 to 2021 were collected from publicly available sources. Entertainment and Sports Programming Network news reports and video analysis were reviewed to determine what movements each player was performing when the injury occurred. Injured players were matched with two noninjured players by age, position, height, and league experience. Performance statistics were collected one season prior to injury and compared with the matched controls. A total of 62 WNBA players with ACL injuries were identified with an average age of 26.7 (±3.9) years. More guards and forward were seen in the injured cohort and more players were injured while driving to the basket (p < 0.05). ACL injuries occurred more commonly during games than in practice (p < 0.05). Compared with controlled match cohort, the players who suffered ACL tears started more games (p = 0.007), had higher minutes played per game (p = 0.003), more field goals per game (p = 0.04), more field goal attempts per game (p = 0.03), more 3-point attempts per game (p = 0.04), more rebounds per game (p = 0.04), more steals per game (p = 0.02), and more points per game (p = 0.02). WNBA guards and forward were more likely to tear their ACL, especially while driving to the basket during real game play. Additionally, players with higher playing times, rebounds, and steals per game had higher rates of ACL tears. However, there was no impact on their performance on season statistics after returning to sport. LEVEL OF EVIDENCE:  III.