Journal of Knee Surgery最新文献

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.

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.

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.

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.