Journal of Knee Surgery最新文献

New total knee replacement designs aim to improve patient outcomes through restoration of normal knee joint movements. This study uses in vivo fluoroscopic analysis to quantify the kinematic characteristics of the Physica KR system. Twenty-one patients underwent kinematic fluoroscopic analysis 1 year following implantation of the Physica KR knee using three defined activities (step-up, kneel, and lunge). Assessments were made of initial rollback, maximum flexion, axial rotation, anteroposterior (AP) translation, and the presence or absence of condylar lift-off. A mean maximum passive flexion of 115.8 degrees (standard deviation ± 10.8) was achieved. All joints were congruent throughout range of movement in all three activities. During the step-up activity, the medial femoral condyle exhibited some initial rollback, the lateral condyle moved slightly posteriorly during initial flexion, then back toward its initial alignment with increased flexion. The combined effect produced tibial internal rotation of approximately 5 degrees during the first 90 degrees of flexion with a smooth progression toward slight varus alignment in maximal flexion, with minimal condylar lift-off. During maximal kneeling, both the medial and lateral femoral condyle contact points were just posterior to the AP midline and lift-off of both condyles was noted. During maximal lunge, the medial contact point was slightly anterior to the AP midpoint, with the lateral contact point slightly posterior, resulting in tibial internal rotation. There was no appreciable lift-off of the lateral condyle, although medial condylar lift-off increased from mid-flexion. These in vivo data demonstrate congruent kinematics throughout range of movement, with some initial femoral rollback during early flexion. Our study has shown that the Physica KR knee implant behaved similarly to other established cruciate-retaining implants.

Tibial plateau fractures account for approximately 1% of all fractures and normally occur as low- or high-energy injuries. This study aims to assess risk factors for site infection following external fixation and osteosynthesis of patients with tibial plateau fracture. A retrospective study was conducted involving the records of patients with Schatzker types I, II, III, IV, V, and VI tibial plateau fractures submitted to external fixation by the emergency ward staff, followed by internal fixation with definitive osteosynthesis after improvement of the soft tissues by the knee surgery team. The following data were collected: energy of fracture, presence/absence of exposed fracture, time between injury and emergency care, time between external fixation and definitive osteosynthesis, comorbidities, number of access routes, duration of surgery, number of participants in surgery, type of surgeon (resident or professor), distance from Schanz screws to focus of the fracture, type of fracture according to the Schatzker classification, and patient age. Among the 137 patients studied, mean age was 43.4 ± 13.8 years, 72.9% were male, 5.1% had diabetes; 43% had Schatzker VI tibial fracture; 82.4% of the fractures were caused by high-energy trauma; 90.5% had closed fractures; 100% used an external fixator prior to definitive osteosynthesis; and 49.6% had dual surgical access (medial and lateral). The prevalence of infection at the surgical site was 19.7%. In the comparison of patients with and without infection, a significant difference was found in the distance between the Schanz screws and focus of fracture (p = 0.0093), which was smaller in patients with infection at the surgical site. A longer time of external fixator use was also associated with the occurrence of infection at the surgical site (p = 0.0283). In conclusion, the positioning of Schanz screw that is an important factor for infection of surgical site, with risk of infection higher in individuals with screws closer to the focus of fracture. Duration of external fixator use may also increase risk of infection after definitive osteosynthesis.

Graft impingement is a critical cause of anterior cruciate ligament reconstruction (ACLR) failure. Identifying its contributing factors is essential for improving surgical outcomes. This retrospective study aimed to evaluate the incidence of graft impingement following ACLR using magnetic resonance imaging (MRI) and to investigate potential anatomical and surgical risk factors. The findings are intended to provide theoretical support for reducing impingement rates and enhancing functional recovery. We retrospectively reviewed clinical and MRI data of 122 patients (68 males and 54 females) who underwent ACLR at our institution from January 2015 to December 2023. MRI was used to identify graft impingement and to measure potential anatomical and surgical factors, including graft angle, posterior tibial slope, tibial intercondylar eminence angle, intercondylar notch width, notch height, and roof inclination, tibial tunnel position, preoperative and postoperative tibial displacement (measured as anterior tibial translation), and concomitant injuries. Patients were categorized based on the presence or absence of impingement. Univariate analysis was followed by multivariable logistic regression to identify independent risk factors. Graft impingement occurred in 65 patients (53.3% of cases). Multivariable logistic regression revealed that smaller graft angles (odds ratio [OR] = 0.930, 95% confidence interval [CI]: 0.873-0.991, p = 0.026), anterior-inferior osteophytes of the intercondylar notch roof (OR = 3.620, 95% CI: 1.408-9.311, p = 0.008), bony abnormalities at the tibial tunnel inlet (OR = 3.814, 95% CI: 1.509-9.632, p = 0.005) and postoperative tibial displacement >5 mm (OR = 6.573, 95% CI: 1.120-38.582, p = 0.037) were independent risk factors for graft impingement. Graft impingement after ACLR is independently associated with reduced graft angle, anterior-inferior osteophytes of the intercondylar notch, excessive postoperative tibial displacement, and bony protrusions at the tibial tunnel inlet. These findings emphasize the importance of accurate tunnel positioning and anatomical assessment during surgery to improve patient outcomes.

The impact of primary femoral tunnel position on rerupture rates following revision anterior cruciate ligament reconstruction (ACLR) remains unclear. This study aimed to explore whether the anatomical placement of the primary femoral tunnel affects rerupture risk, tunnel positioning at revision surgery, and postoperative clinical outcomes. Among 165 patients who underwent revision ACLR at our institution between 2018 and 2022, 78 cases with a minimum of 2 years of follow-up were included. The primary femoral tunnel position was evaluated using Bernard and Hertel's quadrant method on 3D CT scans. Patients were categorized into group A (anatomical position) and group N (nonanatomical position). Rerupture rate, tunnel position at revision ACLR, and clinical outcomes were compared between the groups. Subgroup analyses were conducted based on primary surgical technique (single-bundle [SB] vs. double-bundle [DB]). Additionally, multivariate logistic regression analysis was performed to identify independent predictors of rerupture. Rerupture occurred in three of 39 cases (7.7%) in group A and six of 39 cases (15.4%) in group N (p = 0.48). There were no significant differences in age, sex, height, weight, sports type, or posterior tibial slope. Anatomical tunnel placement at revision was achieved in 94.9% of group A and 79.5% of group N (p = 0.087). No significant differences in Knee Injury and Osteoarthritis Outcome Score or ACL-return to sport after injury scale were observed at 2 years postoperatively. Subgroup analysis based on primary surgical technique (SB vs. DB) revealed no significant differences in rerupture rates or femoral tunnel positioning at revision. Multivariate logistic regression identified anatomical tunnel placement during the revision surgery as the only independent protective factor against rerupture (odds ratio: 0.145; 95% confidence interval: 0.022-0.951; p = 0.044). Anatomical tunnel placement during primary ACLR appears to be a key factor associated with a reduced risk of rerupture following revision ACLR. These exploratory findings underscore the importance of accurate tunnel positioning and should be interpreted cautiously due to the limited sample size. LEVEL OF EVIDENCE:  Level III.

As robotic systems become increasingly utilized in total knee arthroplasty (TKA), structured certification programs are necessary to ensure that surgeons are proficiently trained for safe and effective use. This review examines the certification requirements for six major robotic TKA systems: Zimmer Biomet's ROSA, Stryker's Mako, Smith and Nephew's CORI, Depuy Synthes' Velys, Corin's ApolloKnee, and Think Surgical's TSolution One and TMINI. However, variation in certification structures and training requirements between each system is evident. This variability in training programs points to a need for standardized protocols across robotic platforms to ease the learning curve for surgeons and promote transferable skills and consistent outcomes. Establishing evidence-based guidelines for robotic TKA certification could facilitate broader adoption and improve clinical results, contributing to the advancement of robotic technology in orthopedic surgical practices.

Postoperative pain control after total knee arthroplasty (TKA) remains challenging, particularly in patients utilizing chronic opioids preoperatively. Our study aimed to evaluate the effect of regional nerve blockade on perioperative pain control outcomes after TKA in patients using or not using chronic preoperative opioids. A retrospective review of our institutional database identified 434 chronic opioid patients defined as documented ongoing use greater than 3 months prior to contemporary TKA. Patients were 1:1 matched to nonopioid users based upon age, sex, body mass index, and regional block type (single-shot adductor canal block [ACB, 29%], 3-day ACB catheter [31%], or no block [41%]). All patients underwent primary TKA using periarticular injections and contemporary multimodal pain management. Immediate and 90-day postoperative outcomes, including Knee Osteoarthritis Outcome Score, Junior (KOOS, Jr), were compared via univariate analysis among the matched cohort and regional block type among chronic opioid patients. Chronic opioid patients demonstrated higher inpatient opioid use than controls (90 vs. 65 oral morphine equivalents [OMEs], respectively, p < 0.01), but no significant differences existed in length of stay (LOS), discharge pain scores, 90-day readmission or KOOS, Jr (all p ≥ 0.05). When comparing chronic opioid patients according to block type, those receiving no block had the highest LOS (1.6 days, p < 0.01), discharge pain score (5.0, p < 0.01), and inpatient opioid use (80 OMEs, p < 0.01) compared with either ACB. The subgroup receiving an ACB catheter demonstrated a significantly higher 90-day readmission rate (9%, p < 0.05). Patients utilizing chronic opioids preoperatively require more opioids in the immediate postoperative period after TKA compared with nonopioid users despite contemporary modalities. Nonetheless, the use of any type of ACB provides improved pain control in these patients.

The Western Ontario Meniscal Evaluation Tool (WOMET) is a survey developed specifically to assess the health-related quality of life (HRQoL) of patients with meniscal pathology. This study aims to culturally adapt and validate the WOMET in Arabic. The Arabic version of the WOMET was modified according to cross-cultural adaptation best practices. The study included 47 patients with meniscal pathology. The construct validity of the study was assessed using the Lysholm and 36-Item Short Form (SF-36). Overall, 22 participants took the Arabic WOMET test twice to evaluate the test-retest reliability. The Arabic WOMET demonstrated a Cronbach's α value of 0.894 and an intraclass correlation coefficient of 0.906, indicating high reliability. The subscales were affected by the ceiling and floor effects by 0.0 to 2.1% and 0 to 4.3%, respectively. Furthermore, the Arabic WOMET exhibited correlation coefficients of 0.39 and 0.57 with respect to the Lysholm and SF-36 physical functions, respectively. The Arabic version of WOMET is a reliable instrument for assessing the HRQoL of Arabic-speaking patients with meniscal disease.

The aim of this study was to evaluate the deviation from the surgical plan of femoral and tibial components positioning after robotic total knee arthroplasty (R-TKA) compared with conventional TKA (C-TKA) based on postoperative three-dimensional computed tomography (3D-CT). This prospective randomized trial included 60 patients: 29 in the C-TKA group and 31 in the R-TKA one. Early postoperative 3D-CT-based analysis of implants positioning was performed. Measurements were performed twice by two observers, showing good to excellent intra- and interobserver reproducibility (interclass coefficient ranging from 0.71 to 0.96). Absolute deviations from the surgical plan (mechanical alignment in the C-TKA group and personalized alignment in the R-TKA group) were compared between groups. Primary endpoint was coronal lower limb frontal alignment: hip-knee-ankle (HKA) angle. Secondary endpoints were frontal, sagittal, and rotational positioning of both tibial and femoral components. Planned frontal lower limb alignment was similarly achieved in both group: HKA angle mean difference was 2.28 ± 1.81 degrees in the C-TKA group and 1.84 ± 1.46 degrees in the R-TKA group (p = 0.379). Deviations from the surgical plan were lower in the R-TKA group compared with the C-TKA group for all parameters, except tibial rotation (9.02 ± 4.51 vs. 7.42 ± 3.96 degrees, respectively). These differences turned out to be statistically significant only for sagittal alignment of both femoral (1.71 ± 1.34 vs. 3.61 ± 2.05 degrees, p < 0.001) and tibial (3.78 ± 1.15 vs. 4.94 ± 1.99 degrees, p = 0.018) components. Accuracy in achieving planned coronal lower limb alignment is not higher using R-TKA compared with C-TKA. Regarding component positioning, R-TKA appears superior in the sagittal plane while no significant differences were identified in terms of frontal alignment and rotation. LEVEL OF EVIDENCE:  I.

Bicruciate-substituting total knee arthroplasty (BCS-TKA) mimicking normal knee anatomy contributes to the physiological knee kinematics of the tibiofemoral joint; however, potential disadvantages have been predicted regarding the patellofemoral joint environment. This study aimed to compare the postoperative patellar tracking of BCS-TKA with that of posterior stabilized (PS)-TKA and explore the surgical factors necessary for achieving good postoperative patellar tracking. The patellar tilt angle (PTA) of the resurfaced patella 1 month and 1 year after surgery was retrospectively compared in 160 knees (80 BCS-TKA and 80 PS-TKA). The factors influencing patellar tracking, postoperative coronal limb alignment, femoral and tibial component position and axial rotation, patellar resection angle, patellar component position, and change in patellar thickness after resurfacing were evaluated. Then, the correlation between the postoperative PTA and each surgical factor was analyzed. The mean postoperative PTA significantly increased from 1 month to 1 year after surgery in BCS-TKA (6.3 ± 4.9 degrees [standard deviation] to 7.9 ± 5.8 degrees, p < 0.001) but not in PS-TKA. The 1-year postoperative lateral patellar tilt was significantly greater in BCS-TKA than in PS-TKA (7.9 ± 5.8 degrees vs. 4.4 ± 5.0 degrees, p < 0.001). The patellar resection angle positively correlated with the 1-year postoperative PTA in both groups (r = 0.46 and 0.40). Medial patellar component positioning showed a strong negative correlation with the 1-year postoperative PTA in BCS-TKA and a moderate correlation with PS-TKA (r = -0.63 and -0.38). Multivariate regression analysis showed that the patellar resection angle and patellar component position influenced 1-year postoperative patellar tilt in BCS-TKA and PS-TKA. Postoperative patellar tracking in BCS-TKA, in which the femur is positioned more anteriorly relative to the tibia, tended to be more prone to lateral inclination than in PS-TKA. For better patellar tracking, extra attention should be paid to parallel patellar resection and central patellar component positioning during patellar resurfacing in BCS-TKA.