Journal of Knee Surgery最新文献

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.

Numerous studies have compared anterior cruciate ligament reconstruction (ACLR) with and without lateral extra-articular tenodesis (LEAT) in patients with anterior cruciate ligament (ACL) tears and other associated pathologies. These associated conditions significantly affect the outcomes in terms of function and stability. Athletes with isolated ACL tears and high pivot shifts represent a unique and uncommon subgroup. Despite the presence of a high-grade pivot shift, these individuals do not exhibit associated meniscal, chondral, or ligamentous laxity. We have carefully selected this group of patients to evaluate objective stability and functional outcomes, focusing on the comparison between ACLR with and without LEAT in athletes by excluding ligamentous laxity and meniscal tears. This randomized controlled clinical trial compared the functional outcomes and side-to-side instability of ACLR with or without modified Lemaire technique. Patients in this study had the following inclusion criteria: (1) less than 40 years old, (2) isolated ACL tear without meniscal injury or ligamentous laxity, (3) high pivot shift grade (2 and 3), and (4) athlete patients. The main outcomes were the comparison of functional knee scores (Lysholm and International Knee Documentation Committee [IKDC]) and objective stability, measured by the KT1000 Lachmeter. Patients were evaluated every 3 months postoperatively for at least 1 year of follow-up. Postoperative complications or failure to regain knee function were recorded. Patients were considered to have failed surgery if they experienced a persistent pivot shift, and this was confirmed radiologically. A total of 41 patients were included in our study, randomized into two groups. Group A included 20 patients treated with arthroscopic anatomical single-bundle ACLR combined with the modified Lemaire technique. Group B included 21 patients who underwent anatomical single-bundle ACLR only. Two patients were lost during follow-up in group B and were excluded from statistical analysis. At 12 months of follow-up, patients treated with arthroscopic anatomical single-bundle ACLR combined with the modified Lemaire technique showed a statistically significant improvement in functional knee scores (Lysholm score and IKDC; p = 0.011 and 0.003, respectively) and significant improvements in the side-to-side KT 1000 difference (p = 0.002). No complications were experienced, except for one case (1/19) in group B that failed and refused further interventions. ACLR with LEAT, in athletes with isolated anterior cruciate ligament tears without meniscal tears or ligamentous laxity (Beighton score ≥ 5) with high pivot shift (grade 2 and 3), resulted in a significant improvement in objective stability and functional outcomes (Lysholm and IKDC scores) at the 12-month follow-up.

Anterior cruciate ligament reconstruction (ACLR) is a known risk factor for ipsilateral and contralateral anterior cruciate ligament (ACL) tear, influenced by patient age, activity level, and graft choice. The Multicenter Orthopaedic Outcome Network (MOON) calculator predicts risks post-ACLR, aiding in graft selection and prognosis. The MOON calculator is only validated for those patients under 22 years of age and with patellar bone-tendon-bone (BTB) or hamstring tendon graft options, restricting its applicability. This study assessed the MOON calculator's accuracy in a more diverse patient population, including quadriceps tendon (QT) recipients and patients > 22. With institutional review board approval, registry data were reviewed for patients with primary ACLR at our institution over the past 10 years. Patient information was entered into the MOON calculator, adjusting ages over the calculator's maximum to "22 years" for entry. Patients with QT grafts were entered as BTB. MOON retear and contralateral tear risk predictions were recorded. True outcomes were extracted from medical records. A Brier score of <0.25 was chosen a priori as indicative of acceptable model calibration. An area under the curve (AUC) threshold of 0.70 was determined to indicate acceptable discrimination. A total of 78 patients (49 ≤22 years, 29 23+ years), fulfilled inclusion criteria for analyses. A total of 64 patients received QT grafts (82.1%) and 14 received BTB (17.9%). There were three ACL retears, two QT (3.1%), and one BTB (7.1%) patients. MOON predicted a retear rate of 8.3% for the combined BTB + QT graft group. Brier and receiver operating characteristic curve results suggest poor model calibration, but good discrimination-QT Brier score: 0.89, AUC 0.782, and BTB Brier score: 0.84, AUC 0.846. Analysis restricted to those >22years-QT Brier: 0.84, AUC 0.525, showed poor accuracy and poor outcome discrimination. BTB Brier score: 0.81, AUC 0.778, demonstrated acceptable discrimination. The MOON calculator was not effective in predicting ipsilateral ACL retear risk with the inclusion of patients >22 years and QT grafts. Validating the MOON calculator for a broader age range and QT grafts could enhance its clinical applicability.

Anteromedial rotatory instability (AMRI) resulting from medial collateral ligament (MCL) injuries, often combined with anterior cruciate ligament (ACL) tears, poses a significant challenge in knee surgery. This study evaluates the use of a novel technique-semimembranosus (SM) tendon transposition-as an augmentation to ACL and superficial MCL (sMCL) reconstruction, reducing medial knee opening and AMRI. A case series of 15 patients with AMRI underwent ACL and sMCL reconstruction with SM tendon transposition between January 2017 and July 2021, with a minimum follow-up of 24 months. Inclusion criteria included age 18 to 50 years, AMRI diagnosed clinically, and a minimum 24-month follow-up. Exclusion criteria included high-grade osteoarthritis, knee dislocations, and revision surgeries. Outcomes were assessed using the Lysholm Knee Score (LKS) and stress radiographs, manually performed at 0 and 30 degrees of knee flexion, to measure medial compartment gapping preoperatively and at 12 and 24 months postoperatively. Significant improvements were observed in LKS, with mean scores increasing by 121% from 42.8 ± 5.9 preoperatively to 97 ± 2.8 at 12 months and by 132% to 99.2 ± 1.8 at 24 months (p < 0.001). Radiographic medial opening decreased by 81% from 5.46 ± 0.74 mm preoperatively to 1.05 ± 0.9 mm at 12 months and by 83% to 0.92 ± 0.92 mm at 24 months (p < 0.001). All patients (100%) exceeded the minimal clinically important difference for LKS, and no residual instability was observed at final follow-up. The complication rate was 13% (arthrofibrosis), within the expected range for knee reconstructions. SM tendon transposition effectively restored medial stability and improved functional outcomes in AMRI patients, without the need for additional grafts or tunnels, presenting a low complication rate.

Patient-reported outcome measures (PROMs) are increasingly used to evaluate quality and guide reimbursement in total joint arthroplasty. While PROM collection is mandated for Traditional Medicare beneficiaries under value-based care models, little is known about how enrollment in Medicare Advantage (MA) affects PROM completion and follow-up burden in clinical practice. We analyzed a prospectively collected cohort of 7,267 Medicare patients who underwent primary total knee arthroplasty (TKA) between 2019 and 2023 at a large academic health system. Baseline and 1-year PROMs, including Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Physical Function Short Form (PS), Veterans RAND-12 Mental Component Score (MCS) were collected through a structured digital and manual follow-up protocol. Multivariable logistic regression assessed predictors of requiring active (manual) outreach for 1-year PROMs. PROM completion rates were significantly lower among MA patients at both baseline (74.2 vs. 80.3%, p < 0.001) and 1-year (53.5 vs. 61.9%, p < 0.001). However, MA enrollment was not independently associated with the need for active follow-up (odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.89-1.10; p = 0.79). Instead, increased follow-up burden was associated with older age (OR = 1.16 per interquartile range), non-White race (Black: OR = 1.89; Other: OR = 1.79), greater Area Deprivation Index (OR = 1.15), and poorer baseline physical/mental health (Pain - PS - MCS phenotype: OR = 1.40; all p < 0.01). While MA patients are less likely to complete PROMs after TKA, they do not place greater follow-up demands on clinical teams. Disparities in PROM capture appear to reflect underlying patient complexity rather than insurance design. As Centers for Medicare and Medicaid Services may expand PROM-based reimbursement models to include MA populations, equitable reporting will require targeted outreach and structural risk adjustment to avoid penalizing systems that serve more vulnerable groups.

Varus deformity can present a significant challenge for limb alignment correction and balancing in total knee arthroplasty (TKA). One technique to address these challenges is a medial reduction osteotomy. This article describes utilization of a robotic platform to perform a safe and accurate medial subtraction osteotomy prior to balancing and bony resections. Deformity correction can be predicted by the Pythagorean Theorem. Computed tomography-based robotic systems can be used to perform medial reduction osteotomy of the tibia in the setting of significant varus deformity in patients undergoing TKA. Prior to balancing and bony cuts, the tibial component is downsized "virtually" from the planned size. Through lateralization of the component, the excess medial bone can be mapped via tracking of the registration probe and removed. The amount of medial tibial bone resected determines the amount of laxity that will be created when the tibia is reduced under the femur when implants are placed. Following this, soft tissue tensioning, planning, bony resections, and trialing can progress as normal for a robotic total knee. Through the described technique, the authors have been able to predict the amount of coronal plane correction based on the size of the osteotomized fragment using the Pythagorean Theorem. Robotic guidance of a medial subtraction osteotomy provides a safe and predictable means of varus correction. This is beneficial in that it can be performed with great accuracy and prior to any further balancing maneuvers or bony cuts.