Medial Knee Research Articles

The Traditional Intramedullary Axis Underestimates the Medial Tibial Slope Compared to Transmalleolar Sagittal Axis in Image-based Robotic-Assisted Unicompartimental Knee Arthroplasty.

The medial unicompartmental knee arthroplasty (mUKA) has been recognized as an excellent treatment for medial knee osteoarthritis. The posterior tibial slope (PTS) is measured radiographically with the intramedullary axis (IMA) to the tibial baseplate on the sagittal plane radiograph. However, in most computer-navigated or robotic mUKAs, the PTS is set from a transmalleolar axis (TMA).The PTS difference was evaluatedbetween the sagittal TMA and the sagittal IMA of patients undergoing a CT-based primary robotic-assisted mUKA.We retrospectively reviewed the preoperative computed tomography (CT) scans taken according to the MAKO system protocol (Stryker) of 67 patients undergoing mUKAs. We measured the angular difference between the IMA and the TMA in the sagittal plane.Using the TMA to set the PTS the estimation of the slope of the medial tibial plateau would increase by an average of 1.9 ± 3.2 degreescompared to the IMA. Furthermore, in nineknees, PTS was decreased.Tibial components implanted with the help of a CT scan-based preoperative planning MAKO will show an average of 1.9 degrees more than those measured on sagittal radiographs potentially of concern for knee kinematics. A universal language is needed to standardize the slope calculation and the respective reference axis used.

Different intraoperative joint laxity patterns do not impact clinical outcomes in robotic-assisted medial unicompartmental knee replacement with 1-to-1 surface reconstruction.

Robotic-assisted technology in medial unicompartmental knee arthroplasty (mUKA) allows for customized adjustments of joint laxity through virtual preoperative component positioning before bone preparation. Nevertheless, the optimal balancing curve has yet to be delineated. This study sought to investigate if varying intraoperative knee laxity patterns had any impact on postoperative patient outcomes. A retrospective analysis was conducted on prospectively collected data from 326 fixed-bearing RAUKA procedures performed between 2018 and 2022 with a minimum 2-year follow-up. Patients were categorized into three cohorts based on intraoperative joint laxity patterns (millimetres of joint gap during valgus stress) imparted at 20°, 60°, 90°and 120° of knee flexion: cohort 1 < +0.5 mm (tight); cohort 2 between 0.6and 1.9 mm (physiologic); cohort 3 > 2 mm (loose). Wilcoxon and Kruskal-Wallis tests were conducted to assess patient-reported outcome measure(PROM) improvementsand preoperative and postoperative differences across the cohorts. A Spearman's test evaluated the correlation between knee balance at all degrees of flexion and preoperativeand postoperative HKA. No differences in preoperative and postoperative PROMs were identified across the cohorts (p > 0.05). All three cohorts with different joint laxity patterns showed a significant improvement in the postoperative PROMS (p < 0.05). The preoperative or postoperative limb alignment did not significantly affect clinical outcomes relative to different laxity patterns. No differences were found in the outcomes across different joint laxity patterns in robotic-assisted medial UKA using fixed-bearing mUKAs. There was no evident advantage for maintaining a closer to physiologic laxity compared to tighter or looser balancing. Level III therapeutic study.

Prevalence of Concomitant Injuries by Sport in Pediatric Patients With ACL Rupture.

Although the risk of concomitant injury with anterior cruciate ligament (ACL) tears as a function of specific sports participation has been studied in adults, the topic has not been examined in pediatric and adolescent patients. The purpose of the study was to determine if certain sports were associated with a higher risk of concomitant injuries in the setting of an ACL tear. It was hypothesized that the risk of concomitant injuries with ACL tears will differ by type of sport participation in the pediatric population. Cross-sectional study; Level of evidence, 3. Patients ≤18 years old from 2 tertiary children's hospitals who had undergone primary ACL reconstruction between 2006 and 2018 were included. Sport at the time of injury, demographic factors, and injury pattern (medial meniscal [MM] tears, lateral meniscal [LM] tears, posterior cruciate ligament [PCL] tears, medial collateral ligament [MCL] tears, lateral collateral ligament [LCL] tears, and any concomitant injury) were identified. A total of 855 patients with a mean age of 15.5 ± 1.7 years (range, 7-22 years) met the inclusion criteria. Of the included patients, 353 (41.3%) had an isolated ACL tear. A concomitant MM tear was identified in 27.6% of patients, LM tear in 42.9%, PCL injury in 0.4%, MCL injury in 3.0%, and LCL injury in 0.5%. There was no difference in the likelihood of concomitant MM injuries by sex (29.3% for male patients vs 26% for female patients; P = .31) or by sex within basketball (29.3% for male patients vs 25.6% for female patients; P = .96) or soccer (32.3% vs 26.3%; P = .06). Boys had higher proportions of LM injuries overall (51.7% for male patients vs 34.6% for female patients; P < .001) but not within the basketball subgroup (50.5% vs 40.0%; P = .86) or the soccer subgroup (59.7% vs 40.0%; P = .19). No statistically significant associations were found between patient age and specific ACL concomitant injury patterns. When stratifying by body mass index, it was found overweight and obese individuals constituted a greater proportion of LM (49.6% vs 39.1%; P = .01) but not MM (29.4% vs 25.5%; P = .28) injuries when compared to normal-weight patients. Using basketball as the comparison group, soccer and football injuries were 18% more likely to result in any concomitant injury, including concomitant MM, LM, PCL, MCL, and LCL injuries. In the pediatric population, soccer and football players were more likely to present with a concomitant injury in addition to ACL injury relative to basketball players. This study aids in understanding sport-associated ACL injury patterns and can help physicians with patient counseling and injury prevention.

Medial Ligament Complex Reconstruction With Allograft Using Less Invasive Onlay Fixation and Suture Tape Augmentation

Injury to the medial complex of the knee may result in persisting valgus and rotatory instability. In combination with concomitant meniscotibial ligament disruption, maldistributed contact forces are placed on the medial compartment, which may result in the progression of osteoarthritis. When facing chronic valgus and/or posteromedial instability, definitive treatment with medial ligament complex reconstruction in combination with additional repair of the meniscotibial ligament when necessary should be done to anatomically restore proper knee biomechanics and kinematics. This technique describes reconstruction of both the superficial medial collateral ligament (sMCL) and posterior oblique ligament with a single allograft, with additional suture tape augmentation used to reinforce the sMCL. Additionally, less invasive onlay fixation is used via a knotless loop mechanism to secure the posterior oblique ligament to its tibial insertion and the sMCL at 2 points along its distal tibial insertion.

Altered dynamic joint space in the lateral condyle compartment following medial unicompartmental knee arthroplasty

PurposeThe progression of osteoarthritis in lateral compartment has been identified as a primary complication in medial unicompartmental knee arthroplasty (UKA) revisions, irrespective of whether employing fixed bearing (FB) or mobile bearing (MB) designs. Compared to the previous contact point analyses, the tibiofemoral contacts during knee movements are comprehended by a more comprehensive understanding of joint spaces. This study aims to dynamically map the joint spaces in the lateral compartment during the single-leg lunge following FB and MB UKA procedures, and compare them with the respective contralateral native knees. It is hypothesized that the significant change in joint space for post-UKA compared to their native knees. MethodsTwelve patients with unilateral medial FB UKA and eleven patients with unilateral medial MB UKA were included and underwent computed tomography scans. The exclusion criteria included anterior cruciate ligament deficiency, postoperative knee pain, any postoperative complications, and musculoskeletal illnesses. A dual fluoroscopic imaging system was utilized to capture the single-leg lunge, and 2D-to-3D registration facilitated the visualization of knee motion. According to the knee motions, joint spaces on tibial and femoral surfaces in the lateral compartments of native, FB, and MB UKA knees were calculated and mapped. ResultsIn comparison to the native knees, FB UKA knees exhibited significant increases in medial, lateral, central, and posterior joint spaces in the lateral compartment (p < 0.05), while MB UKA knees showed significant increases only in central and posterior joint spaces (p < 0.05). Moreover, FB UKA demonstrated greater increases in medial, central, and posterior joint spaces compared to MB UKA. Tibial varus and valgus during lunges, as well as the Oxford Knee Score (OKS) and Hip-Knee-Ankle angle (HKA), correlated with joint spaces. ConclusionsDynamic joint space analysis provided a more comprehensive insight into contact dynamics. FB UKA led to an enlargement of joint spaces, whereas MB UKA resulted in joint spaces closer to native knees. These findings contribute to understanding potential postoperative complication in UKAs.

In vivo movement interrelationships among the medial meniscus, joint capsule, and semimembranosus during tibial rotation

The meniscal position within the knee is critical to maintain normal knee function. The joint capsule might dynamically coordinate the medial meniscus (MM) by transmitting a semimembranosus action. However, their interrelationships in vivo are unclear. We aimed to determine relationships among the MM, joint capsule, and semimembranosus during passive tibial external-internal and isometric tibial internal rotation at the medial and posteromedial knees of 10 healthy individuals in vivo using ultrasound. We analyzed images of the MM and joint capsule locations at the medial and posteromedial knee and the velocity waveform similarity of each structure during rotational tasks. Both isometric internal rotation with semimembranosus action and passive tibial external rotation displaced the MM inward at the medial knee. The MM and joint capsule during these MM displacements coordinately moved with more than moderate cross-correlation coefficients (passive external and isometric internal rotations, ≥ 0.54 and ≥ 0.90, respectively). The movements of the MM and joint capsule to the semimembranosus during isometric internal rotation also coordinated with moderate cross-correlation coefficients (≥ 0.62). Therefore, the joint capsule might dynamically coordinate the MM by transmitting semimembranosus action. Whether increased tibial internal rotation or semimembranosus shortening causes MM extrusion awaits further investigation.

Increased nerve growth factor expression and osteoclast density are associated with subchondral bone marrow lesions in osteoarthritic knees

ObjectivesSubchondral bone marrow lesions (BMLs) detected on magnetic resonance imaging in knee osteoarthritis (OA) are associated with knee pain, though the mechanisms remain unknown. Increased nerve growth factor (NGF) expression and osteoclast density in subchondral bone appear to be the key features associated with bone pain in knee OA. Therefore, we aimed to identify associations among NGF, osteoclasts, and BMLs in knee OA. MethodsTwenty tibial plateaus were obtained from patients undergoing total knee arthroplasty for medial knee OA with BMLs at the medial tibial plateau (MTP). Osteochondral tissue samples from the weight-bearing part of the MTP, with and without BML, and from the weight-bearing part of the lateral tibial plateau (LTP), without BML, were collected. NGF expression and density of osteoclasts were compared among the three osteochondral tissue types. ResultsMTP bone with BMLs exhibited significantly higher NGF expression in bone marrow space and osteochondral channel, and higher osteoclast density than MTP bone without BML and LTP bone. The mean differences in NGF-positive area in the bone marrow space and the percentage of NGF-positive channels between MTP bones with and without BML were 9.0% (95% confidence interval [CI]: 5.9–12.1%) and 23.1% (95% CI: 11.3–35.0%), respectively. The difference in osteoclast density between MTP bones with and without BML was 0.6 osteoclasts per mm (95% CI: 0.3–0.9 osteoclasts per mm). ConclusionsIncreased NGF expression and osteoclast density are associated with subchondral BMLs in knee OA, contribute to understanding the mechanisms underlying BML-related bone pain in knee OA.

Decision-making in unicompartmental knee arthroplasty using radiological parameters in South Asian populations

Background: Many patients who visit orthopedic surgeons mainly complained of knee pain, which is often diagnosed as osteoarthritis affecting the medial compartment, whereas the lateral compartment and patello-femoral joint remain relatively unaffected. AIM: This study aimed to establish criteria for patient selection and validate an evidence-based approach for selecting candidates for unicompartmental knee arthroplasty (UKA). Key considerations in patient selection for UKA include identifying the presence of bone-on-bone osteoarthritis in the medial compartment, ensuring a functionally normal anterior cruciate ligament, maintaining full-thickness cartilage in the lateral compartment, verifying a functionally normal medial collateral ligament, and confirming the absence of severe damage lateral to the patello-femoral joint. MATERIALS AND METHODS: From a consecutive cohort of 390 patients with medial knee pain, preoperative radiographs of bilateral knee including anteroposterior/lateral/Rosenberg/20° valgus stress views were collected, and results were tabulated. Patients were categorized into appropriate groups. The suitability for UKA was determined based on the Oxford radiological decision aid, history, examination, and radiographic assessment including stress radiographs. RESULTS: The Oxford radiological decision aid demonstrated 92% sensitivity and 88% specificity. According to the radiographic assessment, 49% of the knees were considered suitable for Oxford UKA (OUKA), whereas 51% were deemed unsuitable. Among the 51 knees identified as unsuitable for OUKA, 40% did not meet one radiographic criterion, 38% did not meet two criteria, 22% did not meet three criteria, and 1% did not meet four criteria. CONCLUSION: The Oxford radiographic decision aid safely and reliably identifies the appropriate patients for meniscal-bearing UKA and achieves good results in this population. The widespread use of this radiological decision aid should improve the results of UKA.

Comparison of Six-Week, Three-Month, and One-Year Postoperative Clinical Results of Kinematic and Mechanical Alignment in Primary Medial Pivot Total Knee Arthroplasty.

Total knee replacement (TKR) is a common surgical solution for severe osteoarthritis. Kinematic alignment (KA) and mechanical alignment (MA) are two popular techniques. There is ongoing debate over the optimal method, influenced by varying long-term results and a scarcity of data on short-term postoperative outcomes. Early evaluation of these techniques is vital for improving rehabilitation outcomes and ensuring patient satisfaction. Methods: This study retrospectively analyzed outcomes from 71 KA-TKRs and 85 MA-TKRs performed between 2019 and 2021. Knee flexion, visual analog scale (VAS) scores, EuroQol-5d (EQ-5d) quality of life measures, and dependence on walking aids were evaluated. Evaluations were conducted at baseline, six-weeks, three-months, and 12-months postoperatively using two-sample t-tests for continuous data and Pearson's chi-squared test for categorical data. At six-weeks and three-months postoperatively, the KA group exhibited significantly better outcomes in knee flexion (98.6° vs. 90.2° at six-weeks; 114.7° vs. 94.2° at three-months), pain management, and reduced walking aids compared to the MA group. By 12-months, these differences were no longer significant, with both groups showing comparable results in knee flexion, pain scores, and patient-reported outcomes. Conclusion: KA offers substantial short-term advantages over MA for pain relief, increased knee flexion, and independence from walking aids. However, these benefits do not persist at one-year post-surgery, indicating a convergence of outcomes between the two techniques. Larger studies with extended follow-ups are required to determine the long-term implications of these alignment strategies.

Changes in injury and illness incidence and burden in elite junior male Australian footballers over a 6–year period

ObjectivesThe study aimed to determine a contemporary multi-year junior Australian football (AF) injury and illness profile and secondly, explore changes in incidence and burden over the six-year period. DesignProspective cohort study. MethodsThis study involved an elite male junior Under-18 competition and included six seasons of injury data between 2015 and 2021. A total of 1559 eligible players were included in the analysis. An injury was defined as ‘any physical or medical condition that resulted in a player missing one or more regular competition season matches.’ A Poisson regression model determined injury and illness incidence and burden across the league over a 6-year period and explored changes in injury incidence and burden over time. ResultsThe frequency of injuries was 1023 over the six seasons. The most frequently reported injuries were ankle sprain or joint injuries (26.5 injuries/season), hamstring strains (15.8 injuries/season), and concussion (15.1 injuries/season). The most burdensome injuries were ankle sprain or joint injuries with 82.5 missed matches/season, followed by anterior cruciate ligament injuries with 53.7 missed matches/season and hamstring strains with 46.9 missed matches/season. Injury incidence did not change for the most common injury types over time (all p > 0.05). Injury burden significantly increased for concussions, ACL injuries, MCL injuries, and ankle sprain or joint injuries (all p < 0.05). ConclusionsThe multi-year injury surveillance methodology identified injuries with the highest consistent incidence and those that caused the most burden to elite male junior AF players. The results can be used to reliably guide future injury prevention methodologies to reduce the impact on players and clubs.

One-day surgery is safe and effective in unicompartmental knee arthroplasty: A prospective comparative study at 1 year of follow-up.

To compare the outcomes and complications of two perioperative protocols for the management of patients who underwent medial unicompartmental knee arthroplasty (UKA): 24 h (1-day surgery [OS]) versus 72 h (enhanced recovery after surgery [ERAS]) of the length of hospital stay (LOS). In our hypothesis, the reduction of the LOS from 3 to 1 day did not influence the outcomes and complications. A total of 42 patients (21 in each group) with isolated anteromedial knee osteoarthritis and meeting specific criteria were prospectively included in the study. Clinical outcomes included Knee Society Score (KSS) and Forgotten joint score while pain evaluation was performed using a Visual Analogue Scale (VAS). Functional outcomes were assessed measuring the knee range of motion (ROM) while radiographic outcomes were evaluated measuring the amelioration of the varus deformity through the hip-knee-ankle angle (HKA). Clinical and functional outcomes did not significantly differ between the two groups. Complications occurred in 9.5% of OS and 4.7% of ERAS group patients. Significant improvements in knee ROM, VAS pain, KSS and HKA angle were observed postsurgery, with no significant differences between groups except in KSS expectations and function trends. The OS protocol is safe and effective and LOS, in a well-defined fast-track protocol, did not significantly impact clinical and functional outcomes. OS may lead to reduced hospitalisation costs and potential reductions in complications associated with prolonged stays, benefiting both patients and healthcare facilities. However, further research with larger sample sizes and longer follow-up periods is needed to confirm these findings. Early mobilisation and rehabilitation protocols are key components of successful patient recovery following UKA procedures. Level II.

Influence of Internal and External Foot Rotation on Peak Knee Adduction Moments and Ankle Moments during Gait in Individuals with Knee Osteoarthritis: A Cross-Sectional Study.

The aim of the study was to verify the effects of foot progression angle (FPA) modification during walking on the internal moments of the ankle and knee joints in individuals with knee osteoarthritis (OA). Biomechanical changes such as increased knee adduction moment (KAM) during walking are known to be involved in the development and severity of knee OA. Although various FPA modifications during gait have been applied to reduce peak KAM, few studies have investigated the effects of applying toe-in or toe-out walking modifications for knee OA on peak KAM and three-dimensional (3D) moments of the ankle joint. Kinetic moment variables were acquired from 35 individuals with medial knee compartment OA. A 3D motion analysis system and two force platforms were used to acquire KAM and 3D moments of both ankle joints during gait. Visual3D was used to obtain final moment data for statistical processing. Repeated-measures analysis of variance with Bonferroni adjustment was used to compare kinetic and kinematic values for each FPA walking condition. There was a significant decrease (p < 0.01) in first peak KAM when walking with an internal rotation foot position compared to normal foot position walking. Also, there was a significant decrease (p < 0.01) in second peak KAM when walking with an external rotation foot position compared to normal foot position walking. Compared to a normal foot position, peak ankle inversion moment of the external rotation foot position walking showed a significant decrease (p < 0.05). There were no interactive effects between FPA condition and limb sides for any KAM values (p > 0.05). The results showed no significant increase in the ankle joint moment value during gait for FPA modification conditions. Thus, the clinical implications of this study suggest that modification of the FPA in patients with OA to reduce KAM does not negatively impact the 3D ankle moments.

Associations between static foot posture, dynamic in-shoe plantar foot forces and knee pain in people with medial knee osteoarthritis: A cross-sectional exploratory study

ObjectiveTo investigate relationships between static foot posture, dynamic plantar foot forces and knee pain in people with medial knee osteoarthritis (OA). DesignData from 164 participants with symptomatic, moderate to severe radiographic medial knee OA were analysed. Knee pain was self-reported using a numerical rating scale (NRS; scores 0-10; higher scores worse) and the Knee Injury and Osteoarthritis Outcome Score pain subscale (KOOS; scores 0-100; lower scores worse). Static foot posture was assessed using clinical tests (foot posture index, foot mobility magnitude, navicular drop). Dynamic plantar foot forces (lateral, medial, whole foot, medial-lateral ratio, arch index) were measured using an in-shoe plantar pressure system while walking. Relationships between foot posture and plantar forces (independent variables) and pain (dependent variables) were evaluated using linear regression models, unadjusted and adjusted for sex, walking speed, KL grade, shoe category, and body mass (for dynamic plantar foot forces). ResultsNo measure of static foot posture was associated with any knee pain measure. Higher medial-lateral foot force ratio at midstance, and a higher arch index during overall stance, were weakly associated with higher knee pain on the NRS (regression coefficient=0.69, 95% confidence interval (CI) 0.09 to 1.28) and KOOS (coefficient=3.03, 95% CI 0.71 to 5.35) pain scales, respectively. ConclusionDynamic plantar foot forces, but not static foot posture, were associated with knee pain in people with medial knee OA. However, the amount of pain explained by increases in plantar foot force was small, thus these associations are unlikely to be clinically meaningful.

Application of Autologous Bone Graft versus Non Grafting in Medial Opening Wedge High Tibial Osteotomy Less than 14 mm: A Systematic Review and Meta-Analysis

Abstract Background Unicompartmental Knee osteoarthritis KOA due to varus malalignment is increased in young active patients which occurs predominantly in the medial compartment. Aim of the Work The objective of this study to compare MOWHTOs with autologous bone graft and without bone graft (wedge space mean less than 14 mm) in treatment of unicompartmental KOA and varus malalignment of the knee to determine which is better in decision-making according to outcomes. Patients and Methods Studies that matched the inclusion criteria were included in this meta-analysis. participants with medial compartmental knee osteoarthritis and varus malalignment were shown in the investigation. The age of the participants was unrestricted. Plate as a fixation method was the only option regardless of plate type. During 2000 and 2021, a research study of internet databases (Egyptian Universities Research, Medline, PubMed, Cochran library, medical journals) was conducted. Following that, the references from the user research were examined, and specialists were approached for assistance in locating other papers. Two independent reviewers extracted data separately and cross-checked it. Results The Knee Society Knee score (KSKS) and Knee Society Function score (KSFS) are most commonly used for the assessment of the knee joint reveled that there is no statically significant difference between bone graft vs non graft. Regarding this systematic review the radiological outcomes, the clinical bone union and the full weight bearing movement, are rendering any statistical analysis meaningless. Regarding complications presented, there was a similar tendency for complication rate when compared according to grafting or non- grafting. The use of autograft accelerates radiographic healing of the osteotomy gap after OWHTO while shorten the union time but confers no advantages in terms of functional or patient elated out comes at 3 or 12 months postoperatively. Conclusion MOWHTO can be performed without a graft with less operative time and avoiding graft harvest comorbidity with similar clinical and radiological results regarding bone union and posterior tibial slope alteration and knee scores.

Better clinical outcomes and return to sport rates with additional medial meniscus root tear repair in high tibial osteotomy for medial compartmental knee osteoarthritis.

This retrospective study aimed to investigate whether the repair of medial meniscus posterior root tears (MMPRTs) is effective for improving clinical outcomes and return to sports rates in young patients (50 years old or younger) with medial compartment knee osteoarthritis (KOA) and MMPRTs. Between 2016 and 2019, 153 patients with KOA and MMPRTs who underwent open-wedge high tibial osteotomy (OWHTO) were retrospectively included. The patients were divided into OWHTO combined with MMPRT repair (n = 73) and isolated OWHTO (n = 80) groups. Lysholm scores, Hospital for Special Surgery (HHS) scores, Tegner scores, flexion contracture, range of knee flexion, return to sports rates and postoperative complications were compared. Radiological outcomes, including hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA) and Kellgren-Lawrence (K-L) grade, were compared between the two groups. After a mean follow-up of 30.1 ± 3.0 months, the OWHTO + Repair group observed better clinical outcomes compared with the OWHTO group (Lysholm score: 86.7 ± 7.4 vs. 81.6 ± 6.9, p = 0.023. HHS score: 85.4 ± 8.20 vs. 80.5 ± 7.1, p = 0.039). The OWHTO + Repair group had higher Tegner scores and return to sports rates than the OWHTO group (Tegner score: 6 vs. 5, p = 0.020; return to sports rates: 38% vs. 15%, p = 0.001). No fracture or major complications occurred. Radiological outcomes showed no significant differences between the two groups (HKA: 181.1 ± 2.7 vs. 180.1 ± 1.5 n.s; MPTA: 90.1 ± 1.8 vs. 89.2 ± 1.4, n.s; JLCA:1.9 ± 0.7 vs. 2.1 ± 0.7, n.s). Additional MMPRT repair during OWHTO was associated with better clinical outcomes and higher rates of return to sports in young patients with medial compartment KOA and MMPRTs. Level III.

Does Combined Reconstruction of the Medial Collateral and Anterior Cruciate Ligaments Provide Better Knee Function? A Systematic Review and Meta-Analysis.

Objective: This study aimed to determine if medial collateral ligament reconstruction (MCLR) alongside anterior cruciate ligament reconstruction (ACLR) preserves knee functionality better than isolated ACLR in combined ACL and MCL tears. Methods: MEDLINE, EMBASE, Scopus, CENTRAL, and Web of Science were searched systematically on 31 March 2023. Studies reporting post-operative function after ACLR and ACLR + MCLR in combined injuries were included. Outcomes included International Knee Documentation Committee (IKDC) score, side-to-side difference (SSD), Lysholm, and Tegner scale values. Results: Out of 2362 papers, 8 studies met the criteria. The analysis found no significant difference in outcomes (MD = 3.63, 95% CI: [-5.05, 12.3] for IKDC; MD = -0.64, 95% CI: [-3.24, 1.96] for SSD at 0° extension; MD = -1.79, 95% CI: [-4.61, 1.04] for SSD at 30° extension; MD = -1.48, 95% CI: [-16.35, 13.39] for Lysholm scale; MD = -0.21, 95% CI: [-4.29, 3.87] for Tegner scale) between treatments. Conclusions: This meta-analysis found no significant difference in outcomes between ACLR and ACLR + MCLR, suggesting that adding MCLR does not provide additional benefits. Due to the heterogeneity and quality of the included studies, further high-quality randomized controlled trials are needed to determine the optimal treatment for combined severe MCL-ACL injuries.

Both Hamstring and Quadriceps Tendon Autografts Offer Similar Functional Outcomes After Arthroscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 50 Years or Older

PurposeThe purpose of this study was to compare the outcomes of hamstring tendon (HT) and quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction in patients older than 50 years in terms of patient-reported functional outcomes, graft failure rates, complications, return to sports activity and the preference for sports. MethodsBetween 2010 and 2022, prospectively collected data were obtained from an institutional database. Patients older than 50 years with primary arthroscopic ACL reconstruction using either HT or QT autograft and a minimum of 2 years of follow-up were included. Patients with concomitant meniscus, cartilage and MCL injury were also included. Patients undergoing a revision ACL reconstruction or undergoing a primary ACL reconstruction using a graft other than HT or QT autograft, and patients with a contralateral knee injury or ipsilateral osteoarthritis (Ahlback stage 2 or higher) were excluded. Patients were evaluated for pre-injury and 2-year follow-up Lysholm knee score, Tegner activity level, Visual Analog Scale (VAS) for pain, graft failure, quadriceps tendon rupture, and return to sport. Mann-Whitney test was used for unpaired samples, whereas the Friedman test was used for analyzing variables over time. The chi-square statistic test was used to determine differences in categorical data between groups ResultsThe number of patients in the QT and HT groups was 85 and 143 respectively. The mean age was 54.4 [50-65] and 56.4 [50-65] for the QT and HT groups respectively, 49% and 51% were males in the QT and HT groups respectively. The two groups did not differ significantly in terms of age, gender, time from injury to surgery and concomitant injuries. No significant differences were found in the pre-injury patient-reported outcome scores (PROMs) as Lysholm, Tegner activity level and VAS for pain between the two groups (p>0.05). At the 2-year follow-up, Lysholm knee score, Tegner activity level and VAS for pain improved to pre-injury level and no significant difference was noted between pre-injury and 2-year follow-up functional scores between the two groups (p>0.05).Furthermore, at the 2-year follow-up, Lysholm score, and VAS didn't show significant differences between QT and HT groups. (p=.390; p= .131). Similarly, no differences have been reported in Tegner activity level scores between HT and QT groups at 2 years of follow-up. No significant differences in terms of minimal clinically important difference (MCID) have been detected between the two groups for Lysholm and Tegner activity scores (p = 0.410 and p = 0.420 for Lysholm score and Tegner activity level score respectively).The two groups did not differ in terms of patient’s percentage of sports participation at baseline, and 2 years of follow-up (p>0.05). A significant decrease (p=0.01) in skiing/snowboarding was reported in the HT group at a 2-year follow-up compared to baseline [116 (81%) vs 98 (69%)]. No case of graft failures and quadriceps tendon rupture was reported in either of the groups. ConclusionArthroscopic ACL reconstruction by using HT or QT autograft in athletically active older than 50 years patients provide satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity.

A Morphological Study of Distal Femoral Varus Deformity.

Background In the management of medial compartment knee osteoarthritis via around-knee osteotomy (AKO) and total knee arthroplasty (TKA), evaluating the lateral distal femoral angle (LDFA) is crucial. This angle reflects the presence of distal femoral varus deformity. This study aims to explore the relationship between LDFA and lower extremity bone morphology and identify factors contributing to a high LDFA. Methods A retrospective analysis was conducted on 59 patients who underwent AKO or TKA at our hospital. Alignment of the lower extremity was assessed using X-rays, and bone morphology was investigated through computed tomography (CT) employing the ZedKnee® system(LEXI, Tokyo, Japan). Each measured parameter was analyzed. Results Our findings indicate a significant correlation between LDFA and several parameters, including age, femoral tibial angle (FTA), hip knee ankle angle (HKA), percentage of mechanical axis (% MA), femoral bowing angle, femoral tibial joint torsion, and the height of lateral and medial femoral condyles. A multiple-regression analysis determined that the most significant influences on LDFA were the heights of the femoral condyle, age, and HKA. Conclusion LDFA is significantly affected by the heights of the medial and lateral femoral condyles and tends to increase with age, possibly as a result of attrition of the medial femoral condyle. Given its significance, LDFA should be carefully considered as a preoperative indicator in AKO and TKA to guide surgical caution when LDFA is elevated.

Enlightenment on Knee Flexors Strength Loss in Cases of Posterior Knee Pain After Anterior Cruciate Ligament Reconstruction.

The persistence and the recurrence of posterior medial knee pain (PKP) after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon graft are often overlooked during rehabilitation. Cross-sectional observational study. The study aimed (1)to evaluate the prevalence of these types of PKP before 4months post-ACLR, (2)to measure their consequences on the knee flexors strength, and (3)to evaluate the role of the type of ACLR. From a cohort of patients operated on with hamstring tendon procedures, the persistent and the recurrent PKP were sought at 4months post-ACLR. The evolution of isokinetic muscle strength recovery in PKP subjects was compared with those of nonpainful subjects. The functional deficit was measured at 6/7months post-ACLR by a hop test. Three hundred seventeen subjects (25.8 [6.0]y) were included. At 4months post-ACLR, 2 populations were identified based on the recurrent onset of PKP (PKP+, n = 40) or the absence of knee pain (PKP-, n = 277). The prevalence of PKP was 8.3%. At the fourth month post-ACLR, the PKP+ group had a higher flexor strength deficit compared with the PKP- group (limb symmetry index at 60°/s: 67.2% [12.4%] vs 84.3% [12.6%]; P < .05). At 6/7months, the loss of strength persisted (limb symmetry index at 60°/s: 82.3% [13.4%] vs 87.7% [12.8%]; P < .05). The hop test deficit was comparable, and no difference was shown according to the type of graft. Persistent and recurrent PKP during the rehabilitation period were not uncommon and were associated with a worsening of flexors strength loss on the ACLR side.

Analysis of load distribution on the plate and lateral hinge of a valgus opening high tibial osteotomy during weight-bearing: a finite element analysis

IntroductionValgus high tibial osteotomy (HTO) is indicated for managing isolated medial knee osteoarthritis in a young patient with a metaphyseal deformity of the proximal tibia. In a medial opening HTO, maintaining the integrity of the lateral hinge is crucial for ensuring proper healing and correction retention. Using a locked plate to stabilize an HTO is common practice, allowing for earlier weight-bearing. The objective of this study was therefore to measure and track the mechanical load distribution on a locked fixation plate and the lateral hinge of an HTO using a finite element (FE) model simulating single-leg stance loading. HypothesisThe working hypothesis was that during weight-bearing, the plate and the lateral hinge absorb stress asymmetrically, predominantly on the plate. Material and methodsA numerical model of an HTO stabilized with a locked plate was developed based on the actual geometry of a healthy proximal tibia (using Autodesk Fusion 360 and Altair HyperWorks software). In this finite element simulation of loading, a mesh convergence study was conducted to optimize the accuracy of the numerical model results. The primary outcome measure was the maximum stress value in the affected areas (Von Mises stress, in MPa) of the plate and the lateral hinge. ResultsThe maximum stress intensity in the plate was approximately 20.29 MPa. The maximum stress intensity in the bony hinge was about 5.6 MPa. The results of the mesh convergence study for the hinge and the plate enabled defining the most suitable model for future FE studies: a 4 mm mesh for all model elements except for the high-stress area in the plate and the hinge, which were meshed with a 0.7 mm element size. This adaptation provided greater precision in the study. DiscussionThere is a distribution and allocation of stress both on the plate and the hinge, underlining the significance of the plate and the absolute necessity of preserving the hinge. Predictably, the plate absorbs the majority of the load, more than three times that of the hinge. ConclusionThe hypothesis is confirmed; however, additional studies would be necessary to validate these numerical results: an experimental component on instrumented cadaveric bones, as well as comparative studies of different fixation plates. Level of EvidenceV, expert opinion; controlled laboratory study.