Journal of Knee Surgery最新文献

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.

Several studies have demonstrated the importance of patient expectation management following surgery, as this is a crucial factor influencing postoperative outcomes. Informing patients on the likelihood on return to sport (RTS) following a knee arthroplasty is therefore important. This systematic review aimed to compare RTS rates and RTS rates per sport-impact level for primary total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or patellofemoral knee arthroplasty (PFA). A literature search was conducted in PubMed, Embase, and Cochrane up to June 1, 2024. Studies reporting on RTS rate following TKA, medial UKA, or PFA were included. RTS rates per sport impact level, Tegner-Lysholm, and University of California and Los Angeles (UCLA) activity scores were extracted. Outcomes were compared with meta-analysis using random-effect models. Thirty-eight studies were included for qualitative assessment, of which eight for meta-analysis, comprising 7,634 patients. Meta-analysis demonstrated a significantly greater likelihood for UKA patients (80.7% [18.4-100%]) to RTS than TKA patients (69.0% [4.1-100%]; odds ratio: 1.87 [1.23-2.85], p = 0.004). In high-impact sports, UKA patients (65.4% [18.4-100%]) were able to RTS at a higher rate than TKA patients (TKA 4.4% [4.1-12.5%]). RTS to low- and moderate-impact sports were similar. Postoperative UCLA activity score was superior for UKA patients and postoperative Tegner scores between UKA and TKA were similar. PFA patients returned to sports at a low rate (low-impact 42.4% [41.2-43.5%]; moderate-impact 35.0% [34.8-41.2%]; high-impact 20.5% [17.4-35.3%]). UKA Patients had a significantly higher overall RTS rate than TKA patients. Over 50% of UKA patients were able to return to high-impact sports, whereas only 5% of TKA patients achieved this outcome. The likelihood of RTS appeared lowest among patients who underwent PFA. A more liberal counseling regarding return to high-impact sports following UKA may be justified.

Cobalt-chromium-molybdenum (Co-Cr-Mo) femoral components are widely used in total knee arthroplasty (TKA) due to their mechanical strength and wear performance. However, concerns regarding corrosion, metal ion release, and hypersensitivity have prompted the development of alternative materials, including nitrided titanium-aluminum-vanadium (nTi-6Al-4V). This study aimed to compare the simulated wear performance of Co-Cr-Mo and nTi-6Al-4V femoral components when articulated against conventional polyethylene articular surface bearings and evaluate the fatigue performance of nTi-6Al-4V components. In vitro wear testing, per ISO 14243-3, was conducted for 5 million cycles (Mc) using posterior-stabilized Persona Primary knee system femoral components manufactured from Co-Cr-Mo and nTi-6Al-4V coupled with conventional ultra-high-molecular-weight polyethylene articular surfaces. Mean steady-state wear rates (mg/Mc) of the articular surface bearings were gravimetrically determined. Surface roughness (Ra) measurements of the femoral components and the articulating surfaces were captured using a contacting stylus profilometer. Polyethylene wear debris morphology was also analyzed. Two fatigue loading scenarios (cantilever loading and three-point bend) of the posterior condyles of femoral components were completed for 10 Mc. The mean steady-state wear rate of the nTi-6Al-4V bearing couple (17.0 ± 1.8 mg/Mc) was noninferior to the Co-Cr-Mo bearing couple (22.8 ± 6.7 mg/Mc). No statistically significant differences were found in the Ra measurements of femoral components or articular surfaces before and after 5.0 Mc (p = 0.21). No statistical difference in polyethylene debris morphology was observed between components (p = 0.07). In both fatigue loading scenarios, no fracture or cracking of the nTi-6Al-4V femoral components occurred. The Co-Cr-Mo and nTi-6Al-4V bearing couples performed similarly regarding mean steady-state wear rates, Ra measurements, and debris morphology in simulated wear conditions. These results provide insights into the wear properties of Co-Cr free femoral TKA components. Additionally, the nTi-6Al-4V components met the performance requirements related to posterior condyle fatigue strength. Further clinical studies are needed to confirm these in vitro findings.

Anterior tibial subluxation (ATS) in knee extension is observed in knees with anterior cruciate ligament (ACL) injuries. Preoperative ATS adversely affects the postoperative anterior stability and increases the risk of early graft failure. To investigate the factors associated with preoperative ATS in knees with ACL injury. A total of 191 patients who underwent primary ACL reconstruction between 2017 and 2022 were included. Preoperatively, all patients underwent lateral radiography with full extension of both knees to evaluate the ATS. These 191 patients were divided into two groups based on ATS positivity. Positive ATS was defined as a side-to-side difference (SSD) in ATS > SD from the average SSD in ATS. The evaluation items included age, sex, height, weight, time from injury to surgery, mechanism of injury, posterior tibial slope, knee hyperextension angle, anterior tibial translation (ATT), meniscal tear on arthroscopy, and intraoperative pivot shift grade. There were 32 patients in the ATS-positive group. The overall average SSD in ATS was 1.7 ± 1.9 mm. Therefore, ATS > 3.6 mm was regarded as positive ATS. A logistic regression analysis indicated that positive ATS predictors were the ATT (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.13-1.44; p < 0.001), >6 months from injury to surgery (OR: 2.89; 95% CI: 1.19-7.06; p = 0.02), and the contralateral hyper-extension angle (OR: 1.10; 95% CI: 1.00-1.21; p = 0.049). No significant difference was observed between the groups regarding meniscal tears. Anterior knee laxity, chronicity of ACL-deficiency, and hyperextension affect preoperative ATS in knees with ACL injuries. This study is a cross-sectional study providing level III evidence.

There is a high incidence of anterior cruciate ligament (ACL) tears in National Football League (NFL) players. There is a relative paucity of long-term data characterizing the effects of artificial versus natural playing surfaces on ACL tear incidence. A comprehensive search of publicly available data identified any NFL player who sustained an ACL injury from 2012 to 2022. The publicly available databases allowed for characterization of playing surface, player position, timing of injury in season, mechanism of injury, and player's age. Incidence of ACL injuries by playing surface, player position, and position group relative to all other positions or position groups were compared by chi-squared test. Correlates of in-game ACL injury were determined by stepwise multivariate logistic regression. There were 520 NFL players who experienced an ACL tear between seasons 2012-2013 and 2022-2023. There was no significant difference in incidence of ACL tears on artificial turf versus natural playing surfaces (265 versus 255, p = 0.670). Wide receivers (p = 0.027) were associated with a significantly higher incidence of ACL tears compared with other positions. Receivers (wide receivers and tight ends) (p = 0.007) were associated with significantly higher incidence of ACL tears compared with other position groups, while specialists (punters, kickers, and long snappers) (p < 0.001) were associated with significantly lower incidence of ACL tears compared with other position groups. No significant difference between mechanism of injury between playing surfaces was found (p = 0.765). More ACL tears occurred before week 9 than on or after week 9 in-season, and the proportion of ACL tears occurring during a game (67%) was significantly higher than those occurring during practice. There was no statistically significant difference in incidence of ACL tears in NFL players from the 2012-2013 to 2022-2023 seasons based on playing surface (artificial versus natural). Wide receivers had a significantly higher incidence of ACL tears compared with other positions and tears were more common during games and before week 9 in-season.

Novel implant systems have design modifications that seek to improve total knee arthroplasty (TKA) survivorship. We evaluated overall and cause-specific revision risk for a newer generation implant system compared with its predecessor from the same manufacturer. We conducted a cohort study using data from the United States-based Kaiser Permanente Total Joint Replacement Registry. Adult patients who underwent primary, fully cemented, fixed-bearing TKA for osteoarthritis between 2009 and 2022 were identified. Only two implant systems from the manufacturer were included: the newer generation (n = 22,287) and the older generation (n = 37,105). Multivariable Cox regression was used to evaluate overall and cause-specific aseptic revision risk. In the adjusted analyses, no difference in risk was observed for the newer compared with older generation system in the first 4-year follow-up (hazard ratio [HR] = 0.94, 95% confidence interval [CI] = 0.74-1.19); however, a higher risk was observed after 4-year follow-up (HR = 2.09, 95% CI = 1.41-3.08). This higher risk was due to loosening (within 4 years: HR = 0.90, 95% CI = 0.59-1.37; after 4 years: HR = 2.88, 95% CI = 1.84-4.51); no differences were observed for other revision reasons. When considering constructs utilizing different trays of the newer generation system, the higher risk of revision for loosening was observed only when the first iteration of the tray was used (HR = 1.94, 95% CI = 1.37-2.77); no difference was observed for constructs utilizing the subsequent iterations of the tray, which underwent design changes, when compared with the older generation TKA system (HR = 0.45, 95% CI = 0.20-1.01). We found no survivorship advantage with a newer TKA design compared with a preceding design from the same manufacturer. The higher risk of revision for loosening in the newer generation constructs was limited to those utilizing the first tray iteration, which is now discontinued by the manufacturer. The higher revision risk was not observed with subsequent iterations of the newer generation construct relative to the older generation. LEVEL OF EVIDENCE:  Level III.

Renal osteodystrophy (ROD), a skeletal complication of chronic kidney disease (CKD)-mineral and bone disorder, may influence perioperative outcomes after total knee arthroplasty (TKA), but its impact remains unclear. This study examined patient characteristics, hospital resource utilization, and postoperative complications in ROD patients undergoing primary TKA. We performed a retrospective cohort analysis of the National Inpatient Sample (2010-2019). Adults undergoing primary TKA were identified and stratified by ROD status. Propensity score matching (PSM; 1:20) was used to balance age, sex, race, comorbidities, and CKD stage. Outcomes included length of stay (LOS), hospital charges, and medical and surgical complications. Among 1,196,522 TKA patients, 283 (0.02%) had ROD. After matching (n = 5,337 controls), ROD patients had a longer median LOS (3 vs. 3 days; p < 0.001) and markedly higher median hospital charges ($58,550 vs. $18,004; p < 0.001). ROD was associated with increased odds of medical complications, including thrombocytopenia (OR: 3.2; 95% CI: 1.9-5.2), convulsion (OR: 6.9; 2.5-19.6), heart failure (OR: 2.3; 1.5-3.4), chest pain (OR: 3.4; 1.2-10.0), acute cerebrovascular disease (OR: 3.0; 1.4-6.4), stroke (OR: 3.3; 1.6-6.8), pneumonia (OR: 3.9; 1.7-9.0), and acute renal failure (OR: 2.3; 1.6-3.5). Surgical risks were also elevated, notably periprosthetic fracture (OR: 7.1; 2.2-22.9), joint dislocation (OR: 4.6; 1.7-12.3), and lower limb peripheral nerve injury (OR: 2.5; 1.4-4.7). ROD patients undergoing primary TKA incur greater hospital resource use and substantially higher rates of diverse medical and surgical complications. These findings highlight ROD as an independent risk factor warranting targeted preoperative risk stratification, multidisciplinary perioperative planning, and bone health optimization to improve outcomes and resource efficiency in this high-risk population.The level of evidence is 3.Trial registration is not applicable.