Journal of Knee Surgery最新文献

Arthrofibrosis can be a major source of dissatisfaction for patients undergoing total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) may be offered to improve motion in selected cases. Advancements in computer-navigated and robotic-assisted technology have been championed to improve component positioning with fewer soft tissue releases. We sought to investigate whether these technologies impact MUA rates. An institutional retrospective review was conducted on 18,815 patients who underwent a primary, elective, unilateral TKA between January 2010 and December 2022. Patients were stratified into conventional (n = 12,659), computer-navigated (n = 4,071), or robotic-assisted TKA (n = 2,085) cohorts. Patient demographics and implant data, including mode of fixation and level of constraint (cruciate-retaining [CR] vs. posterior-stabilized) were collected. MUA rates were the primary outcome. Data were analyzed using analysis of variance with Tukey post hoc testing and multivariate logistic regression analysis. We report a 1.7% overall MUA rate, with a rate of 1.6% for conventional and 1.5% for navigated TKA, which were significantly lower than robotic-assisted TKA at 3.2% (p < 0.001). However, on multivariate analysis, there was no difference in MUA rates for navigated and robotic-assisted when compared with conventional techniques. Cementless and hybrid fixation and CR implant designs were higher with robotic-assisted compared with conventional and navigated TKA. Multivariate regression revealed that TKA with fully cementless (odds ratio [OR]: 1.80 [95% confidence interval [CI]: 1.16-2.78]; p = 0.008) or hybrid fixation (OR: 2.92 [95% CI: 1.77-4.81]; p < 0.001) increased the risk for future MUA. Constraint also significantly influenced MUA rates, with CR designs yielding higher MUA rates (OR: 1.51 [95% CI: 1.16-1.96]; p = 0.002). When controlling for confounding factors, navigated and robotic-assisted TKA generated comparable odds for MUA when compared with conventional techniques. However, robotic-assisted TKA were more likely to utilize cementless or hybrid fixation and CR implant constraint, each of which were independently associated with increased odds of MUA. These operative factors should be considered when risk-stratifying and counseling patients on the likelihood of MUA. LEVEL OF EVIDENCE:  III.

Despite the overall success and widespread utilization of total knee arthroplasty (TKA), studies on inpatient TKA show that an average of 10% of patients are unsatisfied with their outcomes. Patient satisfaction with modern outpatient TKA care pathways in the ambulatory surgery center (ASC) is not well studied. We therefore asked the following questions: (1) What is the prevalence of patient satisfaction and dissatisfaction following outpatient TKA in an ASC? (2) How do preoperative and postoperative patient-reported outcome measures, pain scores, and preparedness for surgery compare between satisfied and nonsatisfied patients? (3) Do radiographic factors such as Kellgren-Lawrence grade, posterior tibial slope, tibiofemoral angle, or postoperative flexion of the femoral component differ between satisfied and nonsatisfied patients? We retrospectively reviewed 678 patients undergoing primary unilateral TKA from 2022 to 2023 at a single ASC. Demographics, baseline function, surgical variables, complications, patient-reported outcomes, and patient satisfaction were recorded. Analysis of the difference between the satisfied and nonsatisfied groups was performed. Based on our criteria, 92.5% (n = 627) of patients were either "satisfied" or "very satisfied," whereas 7.5% (n = 51) of patients were "neutral," "dissatisfied," or "very dissatisfied." Body mass index, age, sex, and preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement were not associated with postoperative dissatisfaction. Low Veterans Rand 12-Item Health Survey Mental Component Summary (VR-12 MCS), and lower preoperative "preparedness for surgery" scores were associated with nonsatisfaction. Patient satisfaction following TKA in an ASC was 92.5% in our cohort. Pain relief, functional improvement, patient expectations, and psychosocial factors were associated with satisfaction. Addressing these factors with perioperative care pathways that include enhanced pain management, personalized patient education, and attention to psychosocial and cultural factors may further improve satisfaction rates.

Artificial intelligence large language models (LLMs) such as ChatGPT are increasingly used in clinical settings, yet their reliability in reproducing evidence-based recommendations remains uncertain. This study aimed to evaluate the performance of ChatGPT-4o in addressing clinical practice guideline (CPG) recommendations for the surgical management of knee osteoarthritis and total knee arthroplasty (TKA). An observational cross-sectional design was conducted in September 2025. Twenty recommendations from the most recent American Academy of Orthopaedic Surgeons CPG on TKA were translated into structured clinical questions and submitted to ChatGPT-4o. Each query was entered three times in independent sessions to evaluate textual consistency. Two independent reviewers with expertise in musculoskeletal physiotherapy and orthopedics appraised the chatbot's answers, classifying them according to the CPG framework ("should do," "could do," "do not do," "uncertain"). Agreement between reviewers and alignment with CPG recommendations were assessed using Cohen's and Fleiss' Kappa coefficients. ChatGPT-4o achieved an overall concordance of 60% with the CPG recommendations, representing fair agreement (κ = 0.392, p = 0.005). Internal text consistency across repeated trials was low, with several responses showing unacceptable similarity levels (<50%). Inter-rater reliability ranged from moderate to perfect (κ = 0.547-0.946). Although ChatGPT-4o provided clinically acceptable answers in several domains, discrepancies persisted, particularly in recommendations regarding functional outcomes and rehabilitation strategies. ChatGPT-4o demonstrated moderate accuracy and heterogeneous reliability when reproducing CPG recommendations for TKA. While the model may serve as a supportive tool for education and patient communication, its variability and incomplete adherence to guidelines highlight the need for cautious integration and professional oversight in clinical decision-making.

To compare patient-reported outcomes and complications of medial collateral ligament (MCL) repair versus reconstruction in patients with grade III MCL injuries, and to report whether these were isolated or associated lesions, with minimum 2-year follow-up. 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. A total of 12 studies met the 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 anterior cruciate ligament (ACL) reconstruction performed in 70.8% of reconstruction and 58.6% of repair cohorts. Postoperative IKDC scores ranged 54.3 to 89 for reconstruction and 79.1 to 88.8 for repair; Lysholm scores ranged 59.4 to 94.8 and 83.8 to 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%). 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. LEVEL OF EVIDENCE: is level IV, systematic review of level II to IV studies.

Up to 20% of patients report dissatisfaction after total knee arthroplasty (TKA), often due to unexplained long-term pain. Component malrotation has been proposed as a contributing factor. This systematic review aimed to evaluate the association between component malrotation and patient-reported outcome measures (PROMs). A systematic search was conducted in PubMed/Medline, Embase, and the Cochrane Library. Studies assessing the effect of femoral, tibial, combined rotation, or rotational mismatch on PROMs were included. Methodological quality was assessed using the Joanna Briggs Institute manual, and evidence levels were assigned based on the Oxford Levels of Evidence. A total of 22 studies involving 1,943 patients met the inclusion criteria. No consistent association was found between component rotation, whether femoral, tibial, combined, or mismatch, and PROMs. There is no clear consensus on the impact of component malrotation on PROMs. However, combined malrotation and rotational mismatch may influence outcomes more than isolated femoral or tibial rotation. Further, high-quality, Level 1 studies are needed to define optimal rotational alignment in TKA.

Superficial surgical site infections (SSIs) limited to the skin and subcutaneous tissue following total joint arthroplasty (TJA) remain a significant source of patient morbidity, often necessitating surgical irrigation and debridement (I&D). While risk factors for deep infections such as periprosthetic joint infections are well studied, predictors of superficial SSIs managed with I&D remain underexplored. A retrospective cohort analysis was performed using the PearlDiver Mariner10 capturing over 161 million patients across inpatient and outpatient settings in the United States. Patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 2010 and 2022 were identified and stratified by the occurrence of subsequent wound I&D. Patients who underwent prosthetic revision were excluded to isolate superficial infections. A total of 54,868 THA and 103,235 TKA patients were identified, with 405 (0.738%) and 568 (0.549%) requiring I&D, respectively. Among THA patients, significant predictors of superficial SSI requiring I&D included obesity (odds ratio [OR]: 1.91, p < 0.001), hypothyroidism (OR: 1.45, p = 0.005), anemia (OR: 1.64, p < 0.001), Type II diabetes mellitus (OR: 1.70, p < 0.001), and chronic obstructive pulmonary disease (COPD) (OR: 1.51, p = 0.004). In the TKA cohort, significant predictors included obesity (OR: 1.40, p = 0.002), anemia (OR: 2.21, p < 0.001), malnutrition (OR: 2.18, p < 0.001), Type II diabetes mellitus (OR: 1.43, p = 0.001), tobacco use (OR: 1.45, p = 0.005), and COPD (OR: 2.02, p < 0.001). The findings emphasize the importance of targeted preoperative optimization in patients with risk factors such as obesity, anemia, malnutrition, diabetes, and COPD. Differential predictors between TKA and THA highlight the need for joint-specific perioperative strategies.

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. The cross-sectional area of the posterior femoral osteophytes is measured on the sagittal plane of the preoperative computed axial tomography (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 effects both extension and flexion. The amount and specific location of bony resection are then determined based on the size and location (posteromedial vs. posterolateral) of the osteophytes. 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. The size and shape of initially inaccessible posterior osteophytes, determined using CAT scan-based imaging, were 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.

The Coronal Plane Alignment of the Knee (CPAK) classification system categorizes nine phenotypes based on constitutional limb alignment and joint line obliquity (JLO). Understanding relationships between CPAK phenotypes and tibial slope (TS) could streamline total knee arthroplasty planning. This study investigated the correlations between CPAK classification and medial TS in patients with osteoarthritis. 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 TS. Statistical analysis included multiple linear regression, Pearson correlation, and one-way analysis of variance (ANOVA) with Tukey post hoc testing. Outliers were removed using interquartile range criteria, resulting in 581 knees for final analysis. Multiple linear regression revealed minimal correlation between coronal alignment and TS (TS = 26.35 - 0.1045 arithmetic hip-knee-ankle [aHKA] - 0.1004 JLO; r ² = 0.0233). aHKA angle and JLO explained only 2.33% of TS variance. Contour mapping demonstrated no discernible patterns in data distribution. Despite weak correlations, ANOVA identified statistically significant differences between CPAK groups for TS (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 degrees. No clinically meaningful relationship exists between CPAK classification and TS 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 TS 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.Level III-Retrospective Comparative Study.

The peroneus longus tendon (PLT) is an increasingly used autograft for anterior cruciate ligament reconstruction (ACLR). Several studies have reported donor site morbidity, gait, muscle strength, and long-term safety. This study provides additional 5-year outcome data, including pedorthist-led gait and foot posture assessment. This study aimed to evaluate 5-year gait symmetry, foot posture, and patient-reported outcomes following ACLR using a PLT autograft. Seventeen patients underwent assessment 5 years after ACLR with PLT autograft. Pedorthist-led gait analysis using pressure-mapping technology measured stance time, midfoot force, center-of-pressure (COP) excursion, and gait force differential. Foot posture was classified as planus, cavus, or neutral. Patient-reported outcomes included the Foot and Ankle Disability Index (FADI) and Tegner Activity Scale. The pedorthist, blinded to the operative side, attempted to identify the reconstructed limb. Statistical analysis used paired t-tests, Spearman correlation, and chi-square testing. At 5 years, no significant differences were detected in stance time, midfoot force, or COP excursion between operated and non-operated limbs. Gait force differentials were similar (p = 0.75). Foot posture was not associated with the operated side (p = 0.183), and FADI scores did not differ by foot type. The pedorthist correctly identified the operative limb in 23.5% of cases. PLT harvest was not associated with detectable differences in gait symmetry or arch morphology at 5 years. Findings are consistent with a favorable biomechanical profile; however, the small sample size, lack of preoperative baseline data, and the absence of a control group limit the strength of these inferences. Larger, controlled studies are needed to confirm long-term safety. The level of evidence was IV-retrospective case series with prospective biomechanical follow-up.

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.