Journal of Knee Surgery最新文献

While proven effective management of multiligament knee injury (MLKI) using allograft is often reported, it has shown an increased risk for graft failure compared with autograft and raises availability and cost issues. Osseous stock preservation and tunnel convergence avoidance led us to develop a compromise innovative surgical procedure using only ipsilateral autograft for anatomic reconstruction of Schenck III-L or higher MLKI. We report the description and early outcomes of our initial experience. Our strategy consisted of an anatomic single-bundle posterior cruciate ligament reconstruction with quadriceps tendon autograft and a "Versailles" reconstruction for the posterolateral corner, which we modified to reconstruct the anterolateral ligament in case of anteromedial rotatory instability, called "full lateral." A second-stage surgery was planned for anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft. Outcomes were Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores for functional status, Short Form 12 (SF-12) for quality of life, and visual analog scale (VAS) for pain. Complications, full weight-bearing, return to work, and sport were also computed. Between March 2019 and August 2020, 10 patients were included. At follow-up, light pain was found in nine patients with a mean VAS of 1.2 ± 2.16 during the day. The mean Lysholm, Tegner, and subjective IKDC scores were good, with 61.2 ± 20.6, 2.8 ± 2.1, and 52.6 ± 20.4, respectively. However, quality of life was altered with poor SF-12 scores. In our first 10 patients with Schenck III-L or higher MLKI, our procedure using only ipsilateral autograft enabled correct daily knee functional activities while preserving osseous stock.

This study characterized the dissolution properties of two commercially available bone substitutes: (1) A calcium sulfate (CaS)/brushite/β-tricalcium phosphate (TCP) graft containing 75% CaS and 25% calcium phosphate; and (2) a CaS/hydroxyapatite (HA) bone graft substitute composed of 60% CaS and 40% HA. Graft material was cast into pellets (4.8 mm outer diameter × 3.2 mm). Each pellet was placed into a fritted thimble and weighed before being placed into 200 mL of deionized water. The pellets were removed from the water on days 1, 2, 3, 4, 6, 8, 14, 18, or until no longer visible. The mass and volume of each pellet were calculated at each timepoint to determine the rate of dissolution. Analysis of variance was performed on all data. Statistical significance was defined as p < 0.05. The CaS/HA pellets were completely dissolved after day 8, while the CaS/brushite/β-TCP pellets remained until day 18. The CaS/brushite/β-TCP pellets had significantly more mass and volume at days 1, 2, 3, 4, 6, and 8 timepoints. The CaS/brushite/β-TCP pellets lost 46% less mass and 53% less volume over the first 4 days as compared to CaS/HA pellets. The CaS/brushite/β-TCP pellets had a rough, porous texture, while the CaS/HA pellets had a smooth outer surface. Overall the CaS/brushite/β-TCP pellets dissolved approximately twice as slowly as the CaS/HA pellets in vitro. As these in vitro findings might have in vivo implications, further clinical data are required to further confirm and establish the optimal synthetic bone substitute strategy or antibiotic delivery carrier.

The necessity of immediate postoperative radiographs following total knee arthroplasty (TKA) has long been debated. With the increasing use of robotic-assisted TKA (RTKA), and thus more precise implant placement, the need for immediate postoperative radiographs to determine implant positioning may be unnecessary. We sought to evaluate implant position on the immediate postoperative radiographs following RTKA to determine their necessity. A retrospective review of 150 RTKAs was performed. The posterior slopes for all TKAs were recorded based on the preoperative three-dimensional template. Additionally, two independent trained researchers (J.G./L.B.) each measured the posterior slope of the postoperative day 0 (POD0) radiograph and postoperative week 2 radiograph. The difference in posterior slope measurement between template and POD0, between template and postoperative week 2, and between POD0 and postoperative week 2 was calculated. Of the 150 TKAs performed, there were no periprosthetic fractures found on the POD0 radiograph. The mean difference between the templated posterior slope and measured posterior slope on POD0 was 0.04 degrees (standard deviation [SD], 1.01; p = 0.615). There was a weak correlation between the two values (rs [95% confidence interval (CI)], 0.38 [0.21, 0.53]). When comparing the template to the postoperative week 2 radiographs, there was a mean difference of 0.02 degrees (SD, 0.48; p = 0.556).  However, a moderate to strong correlation was noted (rs [95% CI], 0.71 [0.61, 0.79]). Comparison of the mean posterior slope from POD0 radiograph to that of postoperative week 2 radiograph showed a mean difference of 0.06 degrees (SD, 1.0; p = 0.427). A weak correlation was found between these two values (rs [95% CI], 0.43 [0.26, 0.56]). Given the accuracy and precision of RTKA, along with the ability to decrease cost and radiation, immediate postoperative radiograph may be unnecessary, when pertaining to the uncomplicated RTKA. However, if there is concern for intraoperative fracture, long stems placed in a revision arthroplasty, or other intraoperative complications, then postoperative radiographs are encouraged.

Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a severe complication causing a significant burden. The study aims were to establish the epidemiology of microorganisms in TKA PJI, the rate of persistent infection requiring further surgery, and the risk factors for this. Microbiological specimens between June 2002 and March 2017 at five regional hospital sites were identified with revision TKA procedures in the National Joint Replacement Registry. The time between procedures, type of revision strategy, and any subsequent further revision operations were collected. At minimum 2-year follow-up, 174 revision TKA were identified, with a mean patient age of 69 ± 11 years. A broad range of pathogens were identified. Fifty cases (29%) had persistent infection requiring at least one further operative procedure, 13 cases required 3 or more. Coagulase-negative Staphylococcus species (CNS) was seen most with failed surgery, polymicrobial infections also posing a significant risk factor. The best chance of a successful PJI surgical strategy was < 12 months from primary TKA, with the greatest risk between 3 and 5 years (p < 0.05). Younger age significantly increased the risk of further surgery (p < 0.05). Management varied; 103 (59%) debridement, antibiotic therapy and implant retention, with further surgery in 29%; 45 (17%) single-stage revision, with further surgery in 13%; and 26 (15%) two-stage revision, with further surgery in 12%. This study presents the most common causative pathogens for PJI in TKA, and the high rate of persistent infection after initial revision surgery. Risk factors for persistent infection and further revision surgery were polymicrobial and CNS infections, patients who presented between 3 and 5 years following primary TKA, and younger age. This study therefore raises important risk factors and areas for future research to reduce the burden of multiple operations after PJI.

Robotic-assisted total knee arthroplasty (TKA) has been developed to improve functional outcomes after TKA by increasing surgical precision of bone cuts and soft tissue balancing, thereby reducing outliers. The DePuy Synthes VELYS robotic-assisted solution (VRAS) is one of the latest entrants in the robotic TKA market. Currently, there is limited evidence investigating early patient and economic outcomes associated with the use of VRAS. The Premier Healthcare Database was analyzed to identify patients undergoing manual TKA with any implant system compared with a cohort of robotic-assisted TKAs using VRAS between September 1, 2021 and February 28, 2023. The primary outcome was all-cause and knee-related all-setting revisits within 90-day post-TKA. Secondary outcomes included number of inpatient revisits (readmission), operating room time, discharge status, and hospital costs. Baseline covariate differences between the two cohorts were balanced using fine stratification methodology and analyzed using generalized linear models. The cohorts included 866 VRAS and 128,643 manual TKAs that had 90-day follow-up data. The rates of both all-cause and knee-related all-setting follow-up visits (revisits) were significantly lower in the VRAS TKA cohort compared with the manual TKA cohort (13.86 vs. 17.19%; mean difference [MD]: -3.34 [95% confidence interval: -5.65 to -1.03] and 2.66 vs. 4.81%; MD: -2.15 [-3.23 to -1.08], respectively, p-value < 0.01) at 90-day follow-up. The incidence of knee-related inpatient readmission was also significantly lower (53%) for VRAS compared with manual TKA. There was no significant difference between total cost of care at 90-day follow-up between VRAS and manual TKA cases. On average, the operating room time was higher for VRAS compared with manual TKA (138 vs. 134 minutes). In addition, the discharge status and revision rates were similar between the cohorts. The use of VRAS for TKA is associated with lower follow-up visits and knee-related readmission rates in the first 90-day postoperatively. The total hospital cost was similar for both VRAS and manual TKA cohort while not accounting for the purchase of the robot.

Knee extension range of motion (ROM) measurement is important in patients with anterior cruciate ligament (ACL) injury. The main objective is to evaluate the reliability and the minimal detectable change (MDC) of three methods of measuring knee extension ROM in ACL patients. The three common goniometric devices were a universal goniometer, an inclinometer, and a smartphone app. During a single-visit, knee extension ROM was measured in both knees of 92 ACL-injured or -reconstructed patients by two testers blinded to the other's measures. Intrarater, interrater, and test-retest intraclass correlation coefficients (ICC_2,1) were calculated. Intrarater ICC_2,1 was excellent for the three devices ranging from 0.92 to 0.94, with the inclinometer yielding the best results (ICC_2,1 = 0.94 [95% confidence interval, CI: 0.91-0.96]). Interrater ICC_2,1, however, varied from 0.36 to 0.80. The inclinometer and the smartphone app yielded similar results 0.80 (95% CI: 0.71-0.86) and 0.79 (95% CI: 0.70-0.86), respectively, whereas the universal goniometer was 0.36 (95% CI: 0.17-0.53). Test-retest ICC_2,1 for the inclinometer was 0.89 (95% CI: 0.84-0.93), 0.86 (95% CI: 0.79-0.91) for the app, and 0.83 (95% CI:0.74-0.89) for the goniometer. The intrarater, interrater, and test-retest MDC₉₅ values ranged from 2.0 to 3.5, 3.7 to 10.4, and 2.6 to 5.4 degrees, respectively. The goniometer was the least reliable. The inclinometer is the recommended device due to its highest ICC scores among the three devices and ease of use.

The purpose of this study was to evaluate outcomes of late manipulation under anesthesia (MUA) for stiffness performed from ≥12 weeks to more than a year after primary total knee arthroplasty (TKA). A total of 152 patients receiving MUA ≥12 weeks after primary TKA from 2014 to 2021 were reviewed. The primary outcome measured was change in range of motion (ROM). We tracked intraoperative complications and the need for repeat MUA or open procedure for continued stiffness after initial MUA. Three subgroups were analyzed: Group 1 included 58 knees between 12 weeks and 6 months after TKA, Group 2 included 44 knees between 6 and 12 months after TKA, and Group 3 included 50 knees ≥12 months after TKA. Analysis included descriptive statistics and univariate analysis, with α <0.05. Groups 1 to 3 all significantly increased their overall ROM by 20.9, 19.2, and 22.0 degrees, respectively. All groups significantly increased their flexion and extension from preoperatively. Group 1 had one intraoperative supracondylar femur fracture (1.7%) requiring open reduction and internal fixation, and five patients required repeat MUA or open procedure (8.6%). Group 2 had no intraoperative fractures, and five patients required repeat MUA or open procedure (11.4%). Group 3 had one intraoperative tibial tubercle avulsion fracture managed conservatively (2.0%) and one repeat MUA (2.0%). Late MUA resulted in significantly improved ROM in all groups. ROM improved more as the time from index TKA increased, although statistically insignificant. Repeat MUA or open procedure rate decreased with MUA ≥12 months from TKA, although statistically insignificant. The overall intraoperative fracture risk was 1.3%.

The aim of our study is to evaluate preserving gracilis tendon in anterior cruciate ligament reconstruction (ACLR) surgery and its effect to the flexion of the knee joint and tibial internal rotation strength and the stability of the knee. Patients who underwent primary single-bundle arthroscopic ACLR using all-inside technique and using hamstring tendon autograft were evaluated retrospectively. Patients were divided into two groups as gracilis preserved (St) and gracilis harvested (StG) groups. The International Knee Documentation Committee (IKDC) score, Lysholm, Knee Injury and Osteoarthritis Outcome Score-Knee-related quality of life (KOOS-QOL) score, ACL-Return to Sport after Injury scale score were used to evaluate as postoperative functional scores at last follow-up. Anterior tibial translation was evaluated using the KT-1000 device. Knee joint flexion, extension, and internal rotation strength were evaluated using isokinetic dynamometer. Dynamic balance performances were measured using the Biodex Balance System. There were 24 patients in the St group and 23 patients in the StG group. Demographic data and clinical results showed no significant difference. Anteroposterior movement of the tibia was found to be significantly higher in the StG group than in the St group in measurements at 89 and 134 N, respectively (p = 0.01 and <0.001). No statistically significant difference was found between both standard and deep flexor and extensor and internal rotator strength. No statistically significant difference was found in the amount of total, anteroposterior, and mediolateral balance deficit between the two groups. Additional gracilis harvesting does not have a negative effect on both standard and deep knee flexion, and tibial internal rotation strength compared with the St group. Although semitendinosus and StG group showed significantly more anterior tibial translation, there was no significant difference in clinical and dynamic stability measurements.

Acquired idiopathic stiffness (AIS) following total knee arthroplasty (TKA) often requires manipulation under anesthesia (MUA). Robotic-assisted TKA (RA-TKA) systems provide gap balance templates for objective correlation with the rate of AIS. The purpose of this study was to assess intraoperative balancing parameters that were associated with MUA utilizing an "anatomical" implant design.We performed a retrospective chart review of 265 imageless RA-TKA procedures performed by R.M. and K.D. between 2018 and 2020. The primary outcome for AIS or clinically significant "arthrofibrosis" was MUA. Patient intraoperative gap planning data were examined for association.The rate of MUA was 8.7% (23/265), which was performed at a mean follow-up time of 75.9 ± 32.2 days. The lateral to medial gap difference in extension was significantly less in patients requiring MUA (odds ratio [OR] = 0.86, 95% confidence interval [CI], 0.75-0.99) (p = 0.034). Significantly less preoperative varus mechanical axis was associated with knees requiring MUA (1.83° vs. 4.04°, OR = 1.09, 95% CI, 1.00-1.19). Decreased templated mechanical axis correction was associated with MUA (2.09° vs. 4.75°, p < 0.0001).A tighter lateral-to-medial gap in extension, less preoperative varus, and smaller templated mechanical axis corrections were associated with increased rates of MUA.