Knee Distraction Research Articles

Comparison of Clinical Efficacy and Mechanical Characteristics of Two Knee Distraction Devices With Relevance for Clinical Practice.

Distraction treatment for severe osteoarthritis below the age of 65 successfully postpones arthroplasty. Most patients have been treated with a general external fixator or a device specifically intended for knee distraction. This study compares clinical efficacy of both devices in retrospect and their mechanical characteristics. Clinical efficacy 2 years posttreatment was compared using retrospective data from patients with severe knee osteoarthritis treated with knee distraction; 63 with the Dynamic Monotube (Stryker GmbH, Switzerland) and 65 with the KneeReviver (ArthroSave BV, the Netherlands). Changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, stiffness, and function, general well-being (SF-36), cartilage thickness by radiographic joint space widening, and adverse events during treatment were assessed. Axial stiffness of clinically feasible configurations was assessed by bench testing for the Dynamic Monotube triax system and the KneeReviver. No differences were observed in clinical efficacy, nor in mechanical characteristics and adverse events between the two devices. Although with large variation, both showed a clinically relevant improvement. In mechanical testing, contact between articular surfaces was observed for both devices at physiological loading. Stiffness of applied configurations strongly varied and primarily depended on bone pin length. Patients treated with a general intended-use device or a distraction-specific device both experienced clinical and structural efficacy although with significant variation between patients. The latter may be the result of varying mechanical characteristics resulting from differences in clinical configurations of the devices and actual loading. The exact role of full/partial mechanical unloading of the joint during distraction treatment remains unclear.

Joint distraction using a purpose-built device for knee osteoarthritis: a prospective 2-year follow-up

ObjectiveKnee distraction treatment for end-stage osteoarthritis successfully postpones arthroplasty for years. Studies performed thus far used general intended use, patient-personalised or custom-made devices. In this study, for the first time,...

The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature.

Knee joint distraction (KJD) is a potential technique for cartilage regeneration in young patients with osteoarthritis of the knee. Static distraction has been utilised typically; however, a significant proportion of patients complain of knee stiffness post-distractor removal. The use of a hinged distractor may reduce the duration and severity of post-treatment knee stiffness by maintaining the range of motion during distraction. Furthermore, improved cartilage regeneration has been demonstrated in hinged ankle joint distraction as compared to static, and this may also be demonstrated at the knee. An evidence review was undertaken to inform further research and a potential change in practice. A systematic review of all primary research on hinged knee joint distraction for cartilage regeneration. An online systematic search of citation databases was conducted. Quality assessment and data extraction were undertaken by two separate researchers. The literature search returned a small number of relevant studies, of which 7 were included. Three of these were animal studies, two cadaveric and two case series. The study quality was low or very low. There was significant methodological heterogeneity with difficulties encountered in the transfer of constructs from animal and cadaveric studies to humans. Issues faced included difficulties with hinge placement and pin site pain in motion. The feasibility of hinged knee joint distraction has yet to be proven. Any further research attempting to establish the benefits of hinged-over static knee distraction will have to take construct design considerations into account. Lineham B, van Duren B, Harwood P, et al. The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature. Strategies Trauma Limb Reconstr 2023;18(1):37-43.

Erratum: Return to Sport and Work after Randomization for Knee Distraction versus High Tibial Osteotomy: Is There a Difference?

Erratum: Return to Sport and Work after Randomization for Knee Distraction versus High Tibial Osteotomy: Is There a Difference?

Return to Sport and Work after Randomization for Knee Distraction versus High Tibial Osteotomy: Is There a Difference?

Knee joint distraction (KJD) is a novel technique for relatively young knee osteoarthritis (OA) patients. With KJD, an external distraction device creates temporary total absence of contact between cartilage surfaces, which results in pain relief and possibly limits the progression of knee OA. Recently, KJD showed similar clinical outcomes compared with high tibial osteotomy (HTO). Yet, no comparative data exist regarding return to sport (RTS) and return to work (RTW) after KJD. Therefore, our aim was to compare RTS and RTW between KJD and HTO. We performed a cross-sectional follow-up study in patients <65 years who previously participated in a randomized controlled trial comparing KJD and HTO. Out of 62 eligible patients, 55 patients responded and 51 completed the questionnaire (16 KJDs and 35 HTOs) at 5-year follow-up. The primary outcome measures were the percentages of RTS and RTW. Secondary outcome measures included time to RTS/RTW, and pre- and postoperative Tegner's (higher is more active), and Work Osteoarthritis or Joint-Replacement Questionnaire (WORQ) scores (higher is better work ability). Patients' baseline characteristics did not differ. Total 1 year after KJD, 79% returned to sport versus 80% after HTO (not significant [n.s.]). RTS <6 months was 73 and 75%, respectively (n.s.). RTW 1 year after KJD was 94 versus 97% after HTO (n.s.), and 91 versus 87% <6 months (n.s.). The median Tegner's score decreased from 5.0 to 3.5 after KJD, and from 5.0 to 3.0 after HTO (n.s.). The mean WORQ score improvement was higher after HTO (16 ± 16) than after KJD (6 ± 13; p = 0.04). Thus, no differences were found for sport and work participation between KJD and HTO in our small, though first ever, cohort. Overall, these findings may support further investigation into KJD as a possible joint-preserving option for challenging "young" knee OA patients. The level of evidence is III.

Technical feasibility of personalized articulating knee joint distraction for treatment of tibiofemoral osteoarthritis

BackgroundKnee osteoarthritis is a highly prevalent degenerative joint disorder characterized by joint tissue damage and pain. Knee joint distraction has been introduced as a joint preserving surgical procedure to postpone knee arthroplasty. An often used standard externally fixation device for distraction poses a burden to patients due to the absence of joint flexion during the 6weeks treatment. Therefore, a personalized articulating distraction device was developed. The aim of this study was to test technical feasibility of this device. MethodsBased on an often applied rigid device, using equal bone pin positions and connectors, a hinge mechanism was developed consisting of a cam-following system for reproducing the complex joint-specific knee kinematics. In support, a device was developed for capturing the joint-specific sagittal plane articulation. The obtained kinematic data were translated into joint-specific cam shapes that were installed bilaterally in the hinge mechanism of the distraction device, as such providing personalized knee motion. Distraction of 5mm was performed within a range of motion of 30deg. joint flexion. Pre-clinical evaluation of the working principle was performed on human cadaveric legs and system stiffness characteristics were biomechanically evaluated. FindingsThe desired range of motion was obtained and distraction was maintained under physiologically representative loading. Moreover, the joint-specific approach demonstrated tolerance of deviations from anatomical and alignment origin during initial placement of the developed distraction device. InterpretationArticulation during knee distraction is considered technically feasible and has potential to decrease burden and improve acceptance of distraction therapy. Testing of clinical feasibility is warranted.

Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis

The aim of this study was to evaluate the clinical results of non surgical knee distraction in patients with severe knee osteoarthritis. forty female patients with severe knee osteoarthritis were randomly divided in two groups. A standard physiotherapy treatment was applied to both groups and in one group it was accompanied with 20 min knee joint distraction. The patients were treated for 10 sessions. Clinical examination consisted of functional examination, completion of a quality of life questionnaire, pain scale, and assessment of joint mobility and joint edema. The standard physiotherapy treatment accompanied by knee distraction resulted in significantly higher improvement in pain (P = 0.004), functional ability (P = 0.02), quality of life (P = 0.002) and knee flexion range of motion (p = 0.02) compared to the standard physiotherapy treatment alone post treatment and after 1 month follow up. Adding knee distraction to standard physiotherapy treatment can result in further improvement in pain relief, increased functional ability and better quality of life in patients with severe knee osteoarthritis.

Effect of joint traction on functional improvement and quality of life in patients with severe knee osteoarthritis

Background and aim: Osteoarthritis (OA) is the most prevalent joint disease in adults around the world and its incidence rises with age. Patients with severe knee osteoarthritis often complain of pain and severe functional disability . Most of conservative treatments used in this group of patients induce poor improvements. This study evaluated the effect of joint traction on quality of life of patients with severe knee osteoarthritis. Materials and Methods : In this clinical trial study, forty female patients with severe knee OA were randomly assigned to two following groups; common physiotherapy treatment and common physiotherapy treatment accompanied by knee distraction. Quality of life was evaluated pre- and post-treatment and also one month follow-up using the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. Results: Common physiotherapy treatment accompanied by knee distraction resulted in significantly better quality of life post-treatment and at 1month follow-up, compared to common physiotherapy treatment alone (P<0.01). Conclusion: Common physiotherapy treatment accompanied by knee distraction induces significant improvement in quality of life in patients with severe knee osteoarthritis compared to common physiotherapy treatment alone. Key words: knee, osteoarthritis, traction, quality of life .

Effect of Early and Delayed Mechanical Loading on Tendon-to-Bone Healing After Anterior Cruciate Ligament Reconstruction

Modulation of the mechanical environment may profoundly affect the healing tendon graft-bone interface. The purpose of this study was to determine how controlled axial loading after anterior cruciate ligament reconstruction affects tendon-to-bone healing. Our hypothesis was that controlled cyclic axial loading after a period of immobilization would improve tendon-to-bone healing compared with that associated with immediate axial loading or prolonged immobilization. One hundred and fifty-six male Sprague-Dawley rats underwent anterior cruciate ligament reconstruction with use of a flexor digitorum longus autograft. A custom-designed fixture was used to apply an external fixator across the knee parallel to the anterior cruciate ligament graft. Animals were randomly assigned to be treated with immobilization (n = 36) or controlled knee distraction along the long axis of the graft to achieve approximately 2% axial strain beginning (1) immediately postoperatively (n = 36), (2) on postoperative day 4 ("early delayed loading," n = 42), or (3) on postoperative day 10 ("late delayed loading," n = 42). The animals were killed at fourteen or twenty-eight days postoperatively for biomechanical testing, micro-computed tomography, and histomorphometric analysis of the bone-tendon-bone complex. Data were analyzed with use of a two-way analysis of variance followed by a post hoc Tukey test with p < 0.05 defined as significant. Delayed initiation of cyclic axial loading on postoperative day 10 resulted in a load to failure of the femur-anterior cruciate ligament-tibia complex at two weeks that was significantly greater than that resulting from immediate loading or prolonged immobilization of the knee (mean and standard deviation, 9.6 ± 3.3 N versus 4.4 ± 2.3 N and 4.4 ± 1.5 N, respectively; p < 0.01). The new-bone formation observed in the tibial tunnels of the delayed-loading groups was significantly increased compared with that in the immediate-loading and immobilization groups at both two and four weeks postoperatively (1.47 ± 0.11 mm(3) [postoperative-day-10 group] versus 0.89 ± 0.30 mm(3) and 0.85 ± 0.19 mm(3), respectively, at two weeks; p < 0.003). There were significantly fewer ED1+ inflammatory macrophages and significantly more ED2+ resident macrophages at the healing tendon-bone interface in both delayed-loading groups compared with the counts in the immediate-loading and immobilization groups at two and four weeks (2.97 ± 0.7 [postoperative day 10] versus 1.14 ± 0.47 and 1.71 ± 1.5 ED2+ cells, respectively, per high-power field at two weeks; p < 0.02). The numbers of osteoclasts in the delayed-loading groups were significantly lower than those in the immediate-loading and immobilization groups at two and four weeks postoperatively (0.35 ± 0.15 [postoperative-day-10 group] versus 1.02 ± 0.08 and 1.44 ± 0.2 cells, respectively, per high-power field at two weeks; p < 0.01), and the delayed-loading groups also had significantly reduced interface tissue vascularity compared with the other groups (p < 0.003). Delayed application of cyclic axial load after anterior cruciate ligament reconstruction resulted in improved mechanical and biological parameters of tendon-to-bone healing compared with those associated with immediate loading or prolonged postoperative immobilization of the knee.

Knee Articulated Distraction Arthroplasty for the Middle-aged Osteoarthritic Knee Joint

Objective We developed a knee distraction arthroplasty device that allows continuous joint movement. The objective of this article is to show the surgical procedure of knee distraction arthroplasty with a bone marrow-stimulating technique, for treatment of osteoarthritis of the knee and to evaluate the clinical results. Methods As we showed in Arthroscopy in 2007, we performed this distraction arthroplasty to 6 knees (in 6 patients, aged 42 to 63 y). Then we compared preoperative findings with postoperative ones. The fixation period for the distraction device ranged from 7 to 12 weeks and the follow-up period ranged from 24 months to 53 months (average 36 mo). Results The Japan Orthopaedic Association knee score, range of motion, and the values of the joint spaces were significantly improved in all cases at the latest follow-up (P Conclusions We conclude that treatment using this arthroplasty device in combination with a bone marrow stimulating method is effective for osteoarthritic knees in middle-aged patients.

EFFECTS OF DIABETES AND EXERCISE ON SOFT CONNECTIVE TISSUE PROPERTIES AT THE KNEE IN THE RAT

The primary diabetes-related health concerns are neuropathy and cardiovascular changes. Connective tissue changes can also affect quality of life by increasing ligament and joint capsule stiffness, impairing proprioception, limiting function, and leading to greater risk of falling. Our objectives were to evaluate effects of Type I diabetes and exercise on medial collateral ligament properties and overall knee-joint stiffness and stress relaxation. Thirty-four male Sprague–Dawley rats, approximately two months old, were divided into three groups—sedentary controls (n=10), sedentary diabetics (n=10) and exercised diabetics (n=14). Diabetes was induced by streptozotocin injection. Exercised rats ran 5 days/week, 1 hr/day, at 20 m/min. All animals were sacrificed seven weeks after induction of diabetes. Stiffness and stress relaxation of the whole knee joint was tested in distraction and anterior–posterior tibial displacement. The joint capsule and knee ligaments were then sectioned, preserving the medial collateral ligament (MCL). The MCL structural properties were tested by knee distraction at a flexion angle of 40°. Whole joint stiffness was 23% higher for anterior tibial displacement in the exercised diabetic group, and 31% higher for posterior tibial displacement, compared to controls. Whole joint stress relaxation in distraction was 25% lower for the exercised diabetic group. No differences were found for MCL properties. Diabetes and exercise clearly increased joint stiffness. The effects may be due to tissue adaptation, but appear more likely to be due to increased blood flow that promotes increased tissue glycation in the joint capsule.

Growth rate after limb deformity correction by the Ilizarov method with or without knee joint distraction

Background and purpose Growth inhibition and stimulation have both been reported after juvenile limb lengthening. Distraction of a joint usually suspends and unloads the growth plate and may stimulate growth. We investigated the influence of knee joint distraction on the speed of growth after limb lengthening.Methods In a retrospective study, growth patterns were analyzed in 30 children mean 61 (24–109) months after limb lengthening with the Ilizarov method, each child having more than 2 years of remaining growth. In 14 patients with knee joint instability, the knee was bridged over during lengthening for joint stabilization. Whether or not joint bridging and distraction would affect patterns of growth of the lengthened limb by unloading the growth plate was evaluated with a repeated measurements analysis of variance.Results After lengthening procedures, the proportionate leg-length discrepancy was found to decrease in 16 children, suggesting increased growth rate in the lengthened limbs. A statistically significantly faster growth rate was seen in 8 of 14 patients with knee distraction as compared to patients with single bone frame configurations.Interpretation Further research is required to investigate whether growth stimulation is due to the surgical technique and whether joint distraction should be recommended during limb lengthening in growing children.

Nonlinear Viscoelastic Behavior of Human Knee Ligaments Subjected to Complex Loading Histories

The nonlinear viscoelastic structural response of the major human knee ligaments when subjected to complex loading histories is investigated, with emphasis on the collateral ligaments. Bone-ligament-bone specimens are tested in knee distraction loading, where the ligaments are in the anatomical position corresponding to a fully extended knee. Temporal nonlinearities for time scales in the range of 1<or=t <or=500 s are characterized with a dedicated series of loading histories. In particular, the response to several complex sequences of step-and-hold tests and loading-unloading cycles is investigated. The separability of the time and deformation dependent behavior, as assumed for the often used quasi linear viscoelastic (QLV) theory, is found to be insufficient for describing the response in the time range considered. Non-recoverable inelastic flow is observed in this time range. A phenomenological 1-dimensional nonlinear viscoelastic model that qualitatively describes the experimentally observed inelastic phenomena is presented.

Pedestrian Injuries: Viscoelastic Properties of Human Knee Ligaments at High Loading Rates

Objective. Accidents involving pedestrians are very common, and often lead to severe injuries to the lower extremities. In a large portion of pedestrian-automobile collisions, knee ligament injuries are sustained. In this study, the viscoelastic properties of the four major human knee ligaments were investigated at loading rates representative for pedestrian-automobile collisions. Methods. Bone-ligament-bone specimens were tested in knee distraction loading. The collateral ligaments and the separate functional bundles of the cruciate ligaments were tested in the anatomical position corresponding to a fully extended knee. A series of step-and-hold tests and ramp tests at different rates were conducted to characterize the time-dependent behavior of the knee ligaments for deformation rates associated with the pedestrian impact loading environment. The quasi linear viscoelastic (QLV) theory was used to describe the structural response of the knee ligaments and averaged parameters for this model were determined. Results. The QLV theory was found to be applicable for the time range that is relevant for pedestrian-automobile collisions. The structural behavior of the knee ligaments was found to be particularly rate-sensitive for high elongation rates, as occur during these collisions. The ligament stiffness was found to increase with age for both the collateral ligaments and with weight for the medial collateral ligament. Conclusions. For the loading conditions that are relevant for pedestrian-automobile collisions, the use of the QLV model for the description of the mechanical behavior of knee ligaments is appropriate. The rate-sensitivity is particularly important for these extreme loading conditions. The relaxation behavior was found to be consistent between different ligament types and samples. Variations due to donor anthropometry were found predominantly for the instantaneous elastic behavior.