Journal of Knee Surgery最新文献

Degenerative meniscal injuries are a common occurrence in orthopedic practice. However, there is currently no consensus regarding the optimal treatment algorithm and the efficacy of different treatment modalities. Therefore, this study aimed to analyze the clinical reflections of arthroscopic partial meniscectomy (APM) and physical therapy (PT) methods, as well as the potential development of osteoarthritis (OA) following treatment. The study group comprised patients diagnosed with degenerative meniscal tears who were treated with either conservative or APM methods at a center between March 2021 and January 2022. The radiographs of these patients prior to the commencement of treatment were classified according to the Kelgren-Lawrence system, and clinical and pain scores were recorded. Following a 2-year period of treatment, the radiographs and scores at the conclusion of the third, 12th, and 24th months were analyzed. Among 213 patients followed up with a diagnosis of degenerative meniscal damage, at the 3-month follow-up, the APM group demonstrated significantly better pain relief and functional outcomes compared with the PT group, with notable improvements in WOMAC (between score difference: -15.96; 95% confidence interval [CI]: -17.08 to -14.83), Lysholm (23.43; 95% CI: 22.15-24.71), and VAS (-6.98; 95% CI: -7.25 to -6.71) scores (p < 0.001). However, by the 12th and 24th months, both groups showed comparable long-term improvements. Radiographic assessments over 2 years revealed no significant differences in OA progression. These findings suggest that APM provides superior short-term benefits, but both APM and PT are equally effective in the long-term management of degenerative meniscus tears. A comparison of the APM and PT groups revealed that patients under 50 years of age who underwent APM demonstrated superior outcomes in terms of pain and functional scores at the 3-month follow-up. At the 2-year mark, the efficacy of the treatment methods was established, yet no significant differences were observed in their capacity to prevent OA.The level of evidence is III.

Insurance status has been shown to impact clinical outcomes after several orthopaedic procedures. Current evidence examining the role of insurance provider on outcomes following anterior cruciate ligament (ACL) reconstruction is limited. Therefore, the purpose of this investigation was to explore the effect that insurance carrier had on physical therapy (PT) access, knee range of motion (ROM), and Knee Outcome Survey (KOS) scores. A retrospective cohort study identified patients who underwent ACL reconstruction at an academic health system from January 1, 2019 to December 31, 2021. Patients were partitioned into two cohorts based on their insurance provider: Managed care (MC) or commercial (COM). Outcomes recorded change in knee active range of motion (AROM), passive ROM (PROM), KOS score, and reason for conclusion of PT. Univariate and multivariate analyses were performed by chi-squared tests, Welch's t-tests, as well as multivariable logistic and linear regression with Bonferroni corrections applied to control the family-wise error rate. The study cohort included 149 patients who underwent ACL reconstruction and completed rehabilitation within affiliated PT locations. The MC cohort experienced a longer time until the first PT visit, shorter duration of PT, fewer total PT visits as well as insurance-authorized visits, and a smaller maximum number of visits per patient's benefit. However, there was no difference between cohorts in the number of visits divided over the treatment duration or the number of visits attended over the total number authorized. Both the groups displayed statistically similar improvements in AROM, PROM, and KOS in addition to comparable reasons for concluding PT. Furthermore, regression demonstrated that no insurance parameter predicted changes in AROM, PROM, KOS, or reason for concluding PT. MC-provided patients who underwent ACL reconstruction had inferior access to PT compared with those insured by COM. However, MC and COM yielded a similar percentage utilization of authorized PT visits and number of insurance denials leading to early PT termination. Both the cohorts also demonstrated similar improvements in AROM, PROM, and KOS.

Patellar tendon shortening (PTS) following primary total knee arthroplasty (TKA) is thought to occur because of excessive soft tissue tensioning during wound closure. Few studies have examined the incidence of acute PTS in TKA patients. The purpose of this prospective study was to evaluate the incidence and clinical implications of acute PTS after primary TKA. All patients undergoing primary TKA for osteoarthritis (OA) from January 2024 through April 2024 by a single, fellowship-trained surgeon were included. Patient demographics and range of motion (ROM) were recorded preoperatively. Range of motion and physical therapy (PT) requirements were recorded at 6-week follow-up. Patellar tendon length was determined by the Insall-Salvati ratio (ISR) and measured preoperatively, on postoperative day (POD) 0, and at 6 weeks following surgery. Significant PTS was defined as a decrease in the ISR of ≥10%. In total, 89 patients were included in the analysis. Of these, 54 (60.7%) patients experienced significant PTS and 35 (39.3%) did not experience significant PTS immediately following TKA. Preoperative ISR and ROM was similar between cohorts; however, on POD 0, the ISR decreased by 21.9 ± 8.7% in the significant PTS cohort versus 0.8 ± 10.9% (p < 0.001) in the insignificant PTS cohort. From POD 0 to 6 weeks postoperatively, ISR increased by 25.0 ± 15.8% in the significant PTS cohort versus 7.6 ± 12.0% in the insignificant PTS cohort (p < 0.001). The ISR decreased by 2.9 ± 10.9% for patients in the significant PTS cohort and increased by 5.7 ± 7.9% for patients in the insignificant PTS cohort (p < 0.001). There was no significant difference in PT requirements or ROM between cohorts at 6-week follow-up. Patellar tendon shortening following TKA resolved by 6 weeks postoperatively; no ROM deficits or additional PT requirements were found to exist between cohorts.

Consequences of ACL reconstruction (ACLR) utilizing the patellar tendon (PT) autograft include a residual defect in the PT and the potential for donor site morbidity, such as anterior knee pain and difficulty kneeling. The purpose of this study was (1) to evaluate the presence and size of PT defects following ACLR and (2) to determine if there is an association with knee pain and function. Patients who underwent ACLR with PT autograft by two surgeons between 2011 and 2023 were identified. One surgeon routinely reapproximated the PT harvest site with suture, and the other left the tendon open while closing the overlying paratenon. Included patients were at least 1 year postoperative and 13 years or older at the time of surgery. Patients underwent ultrasound evaluation of the operative knee by an independent sonographer, measuring residual PT defect width and depth. International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, and Single Assessment Numeric Evaluation surveys were collected. Regression analysis determined correlations between defect size and knee outcomes. Eighty-one subjects met the criteria and completed the ultrasound and surveys. A PT defect was present in all patients at a mean follow-up of 2.97 years (1.0-9.6 years). Mean percent residual defect was 36.5 ± 17.5% of the original harvest width (mean: 10.3 mm), with a mean defect width of 3.8 ± 1.8 mm. Mean percent residual defect was significantly greater in the 57 patients who had the graft site left open (41.4 ± 13.5%) compared to the 24 patients who had the graft site reapproximated (26.1 ± 21.1%; p < 0.001). While 44.4% of patients reported moderate to extreme difficulty kneeling, it was not correlated with defect size. Patient-reported outcome scores were not correlated with defect size. A PT defect was present in 100% of patients even up to 9 years postoperatively. Defect width did not correlate with knee pain or the ability to kneel. Repeat harvesting of the PT for subsequent ACLR should be considered with caution.

Local delivery of high-dose antibiotics via absorbable calcium sulfate beads has been investigated as a treatment of prosthetic joint infection (PJI). We investigate this strategy as a prophylactic measure for high-risk patients undergoing primary total knee arthroplasty (TKA). A retrospective review of a single-surgeon consecutive series of primary TKA patients with identified risk factors for PJI development was performed. These patients were treated with calcium sulfate beads containing 1 g of vancomycin and 1.2 g of tobramycin per 10 cc, with 10 cc placed intraarticularly. Outcomes included PJI, wound complications, revision surgery, and medical complications. There were 114 knees in 103 patients, with 76 women (66.7%), a mean age of 66.8 years (range: 21-91), and a mean follow-up of 16 months (range: 3-55). The mean preoperative lifetime PJI risk based on the 2018 International Consensus Meeting on the PJI calculator was 11.3% (standard deviation: 16.3%, range: 0.9-94.3%). Risk factors included medical comorbidities, homelessness, chronic urinary tract infection, other PJI or septic arthritis history, or prior ipsilateral knee surgeries. One delayed PJI occurred 1 year postoperatively from presumed hematogenous seeding following dialysis. There were no other known deep infections. There were nine patients who had delayed wound healing with marginal skin necrosis-six resolved with wound care and three underwent superficial extraarticular surgical debridement. There was one patient who underwent aseptic revision for patellar instability and nine patients required manipulation under anesthesia for stiffness. There was one patient who died after readmission for cardiac arrhythmia and one patient had bilateral DVT. No cases of chronic PJI, persistent wound drainage, or postoperative hypercalcemia were identified. Prophylactic use of antibiotic-eluting calcium sulfate beads in primary TKA has resulted in low rates of early PJI in a high-risk cohort, warranting further prospective studies and investigation.

Use of testosterone replacement therapy (TRT) has increased significantly in the last few years and has been linked to tendon ruptures after a number of orthopedic procedures. Knee extensor mechanism disruption (EMD) after total knee arthroplasty (TKA) leads to significant morbidity and a decline in patients' quality of life. However, its association with TRT use remains unclear. We aimed to determine the association between TRT and the risk of EMD in patients undergoing primary TKA. This retrospective cohort study utilized the Merative MarketScan database to identify adults aged ≥ 18 years who underwent primary TKA between 2015 and 2022, with a minimum follow-up of 3 years. Knee EMD, defined as ruptures of the quadriceps tendon, patellar tendon, or fractures of the patella, was identified using ICD-10 (International Classification of Diseases, Tenth Revision) codes. TRT use was defined as patients filling prescriptions for at least 3 months before the index surgery. Multivariable logistic regression was employed to determine the independent risk of TRT on risk of EMD. Among 34,911 patients, 1,711 (4.9%) were on TRT, and 166 (0.48%) were identified with knee EMD. More than half of the cohort were aged 40 to 59 years (57.3%, n = 20,018) and female (59.6%, n = 20,820). Preoperative TRT was associated with more than twice the likelihood of developing knee EMD (odds ratio [OR]: 2.38, 95% confidence interval [CI]: 1.39-4.09; p = 0.002). In sex-stratified analyses, the association was observed in males (OR: 3.00, 95% CI: 1.64-5.49; p = 0.0002) but not in females (OR: 1.10, 95% CI: 0.27-4.46). Other significant risk factors included smoking (OR: 1.46, 95% CI: 1.02-2.08; p = 0.038), postoperative fluoroquinolone use (OR: 1.58, 95% CI: 1.06-2.36; p = 0.024), and female sex (OR: 1.44, 95% CI: 1.03-2.01; p = 0.034). Preoperative TRT was identified as the most important risk factor for developing knee EMD after TKA. These findings underscore the importance of recognizing and addressing this risk factor and counseling patients on its potential risks on postoperative outcomes.

Previous studies reported greater knee extensor muscle weakness in female patients compared with males after anterior cruciate ligament (ACL) reconstruction. However, the mechanisms underlying this sex difference remain unclear. We investigated whether there are sex differences in muscle atrophy after ACL reconstruction. Rats were divided into four groups: Male control, male ACL reconstruction, female control, and female ACL reconstruction. To quantify the amount of weight-bearing, gait analysis was performed during the experimental period. Muscle atrophy was assessed by measuring muscle fiber cross-sectional area (CSA) at 7, 28, and 84 days after starting the experiment. In the rectus femoris, a similar extent of atrophy was observed at 7 days after ACL reconstruction, but atrophy recovered by 28 days in both males and females. However, at 84 days, rectus femoris atrophy occurred again in females only. In the semitendinosus and gastrocnemius, significant atrophy was detected at 7 days after ACL reconstruction in males, but not in females. Both males and females showed a reduction in weight-bearing early after ACL reconstruction, with a more pronounced reduction in males. Early semitendinosus and gastrocnemius atrophy was more severe in males, and this may be explained by differences in weight-bearing. Delayed rectus femoris atrophy, observed exclusively in females, may explain the weakened knee extensor strength observed in female patients.

Tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) are antifibrinolytic agents commonly used to reduce blood loss in total knee arthroplasty (TKA). Although TXA is widely adopted, EACA offers a potentially more economical alternative. However, head-to-head comparisons using paired designs remain limited. The present randomized controlled trial included 294 patients undergoing bilateral TKA. Each patient received topical TXA in one knee and topical EACA in the contralateral knee in a randomized sequence. Primary outcomes included total perioperative blood loss and total drain output over 3 days. Secondary outcomes included transfusion requirement, postoperative complications, and cost-effectiveness. The statistical analyses included paired t-tests, linear mixed-effects models for effect modification, logistic regression for transfusion and complications, and cost-effectiveness analysis comparing drug costs against blood loss reduction. Data from 294 patients (588 knees) were analyzed. TXA was associated with a statistically significant but modest reduction in total blood loss compared with EACA (mean difference: 10.03 mL, p < 0.001), well below the predefined non-inferiority margin of 200 mL. Similarly, drain output was also found to be lower in TXA-treated knees (mean difference: 10.07 mL; p  =  0.0001), but the difference was not considered clinically significant. The rates of transfusion and postoperative complications were low (2.72 and 3.74% respectively). Cost-effectiveness analysis revealed EACA to be more cost effective as compared with TXA. Topical EACA was found to be non-inferior to TXA in reducing perioperative blood loss in TKA, with equivalent clinical outcomes and greater cost-effectiveness. These findings support the use of EACA as a cost-saving alternative to TXA, particularly in resource-limited settings.

Arthrofibrosis is a debilitating complication following total knee arthroplasty (TKA), affecting 3 to 13% of primary TKA patients and leading to 10% of revision surgeries. This review evaluates the current management strategies for arthrofibrosis, answering key questions on treatment modalities: (1) nonsurgical interventions, (2) arthroscopic and open surgical approaches, (3) revision procedures, and (4) adjunct and emerging therapies. Nonsurgical treatments, including aggressive physical therapy and continuous passive motion devices, show some improvements in range of motion (ROM), but long-term efficacy remains uncertain. Arthroscopic lysis of adhesions improves knee flexion by 26.7 to 51.2 degrees, with a mean final flexion of 100 to 103 degrees, but carries higher infection and revision risks. Open arthrolysis provides ROM improvements up to 43.4 degrees, with higher morbidity and complications. Revision TKA yields better functional outcomes, with mean flexion improvements of 15 to 25 degrees, but 43% of patients require further care. Emerging therapies, such as low-dose irradiation and pharmacologic agents like celecoxib and dexamethasone, show promise but require further validation. Despite advancements, gaps in high-quality data and standardized protocols persist, underscoring the need for more prospective trials.

The Centers for Medicare and Medicaid Services (CMS) recently mandated the collection of Patient-Reported Outcome-Based Performance Measures (PRO-PMs) for Medicare patients undergoing inpatient total knee arthroplasty (TKA). The policy's generalizability remains a concern. Therefore, we aimed to compare PROMs capture rates, patients' characteristics, and achieving the substantial clinical benefit (SCB) threshold between inpatient and outpatient Medicare TKA. A prospective cohort of Medicare patients aged ≥ 65 who underwent primary TKA between 2016 and 2022 at a single health system was analyzed (n = 7,926). Patients were categorized as inpatient (length of stay [LOS] > 24 hours, n = 2,812) or outpatient (LOS ≤ 24 hours, n = 5,114). Capture rates of CMS-mandated variables, baseline characteristics, and 1-year outcomes were compared. SCB was defined as a 20-point improvement in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) per CMS criteria. Baseline capture rates were similar between groups (approximately 82.8%), but 1-year KOOS-JR completion was lower for inpatients (53.3% vs. 62.4%). Inpatients had higher comorbidity burden (CCI ≥ 2: 40% vs. 33%, p < 0.001), worse KOOS-JR (median 44.9 vs. 47.5, p < 0.001), lower VR-12 MCS scores (50.2 vs. 54.1, p < 0.001), and more frequent nonoperative joint pain (75.1% vs. 68.6%, p < 0.001) and back pain (67.4% vs. 63.8%, p < 0.001). Outpatients trended toward better SCB achievement (OR: 0.89, 95% CI: 0.78-1.00, p = 0.054). Compared to outpatients, inpatient Medicare TKA patients had lower 1-year PROM capture rates, more comorbidities, and worse baseline PROMs, with a trend toward not meeting CMS SCB thresholds. These differences highlight limitations in using inpatient-only data to assess national TKA outcomes, especially as outpatient procedures grow. Nonetheless, future studies with higher power should validate these findings. The level of evidence is III (retrospective).