Previous Knee Surgery Research Articles

Association of daily walking with the risk of total knee replacement over 5 years: an observational study

Purpose: The presence of functional limitation, such as difficulty getting up from a chair or out of bed, is a reason adults elect for a total knee replacement (TKR), the definitive treatment for end-stage knee osteoarthritis (OA). Regular participation in physical activity, such as walking ≥6000 steps/day, reduces the risk of functional limitation in people with knee OA. However, it is not known whether walking more and in particular walking ≥6000 steps/day are associated with less risk of TKR. Moreover, given that functional limitation is more common in older (≥65 years) versus younger (<65 years) adults, it is not known whether the association of daily walking with TKR may be different for older versus younger adults. Therefore, the purpose of our study was to determine the association of daily walking and risk of TKR over 5 years. We also separately investigated this association in older and younger adults with or at high risk of knee OA to identify to whom daily walking may be most important for reducing the risk of TKR. Methods: Using data from the Osteoarthritis Initiative (OAI), we included participants who did not have TKR at or before the 48-month follow-up visit, which we considered our study baseline. Physical activity was measured with an accelerometer (Actigraph GT1M) worn during waking hours over the right hip during the baseline and quantified as steps/day. Time to TKR was quantified in months from the baseline visit date to the date of TKR through the 108-month OAI follow-up visit, i.e., 5 years later. The date for TKR was confirmed through adjudicated medical records whenever it was available during the course of OAI study. Participants without TKR at the 5-year follow-up were censored. Death and loss to follow-up in those without a TKR were considered competing events to TKR when they occurred between baseline and the 5-year follow-up. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated from the Fine and Gray sub-distribution hazard model to assess the strength of the association between daily walking and risk of TKR in presence of competing events while adjusting for potential confounders (baseline age, BMI, sex, race, education, comorbidities, frequent knee pain, previous knee injuries or surgeries, and radiographic OA status). Daily walking was quantified as a continuous (i.e., per 1000 steps/day) and a categorical (< or ≥6000 steps/day) exposure measure in separate models. To examine if the association for daily walking and risk of TKR may be different by age groups, we performed subgroup analyses stratified by older (≥65 years) and younger (<65 years) adults. Results: Of the 1816 participants without TKR at baseline and who wore the monitor for >4 days (age [mean ± sd] 65.0 ± 9.1 years, BMI [mean ± sd] 28.4 ± 4.8 kg/m2, 55% female), 108 (6%) participants had TKR over 5 years. There was no significant association between daily walking (i.e., either continuous or dichotomous measures) and risk of TKR over 5 years in the overall sample or in younger adults (table). However, older adults were 12% less likely to have TKR for each additional 1000 steps/day walked (adjusted HR 0.88, 95% CI [0.79–0.99]). Moreover, older adults who walked > 6000 steps/day were 52% less likely to have TKR (adjusted HR 0.48, 95% CI [0.26–0.89]) compared to people who walked <6000 steps/day (table). Conclusions: Taking more steps/day and particularly walking >6000 steps/day may moderately reduce the risk for TKR in older (>65 years), but not younger (<65 years) adults. Our findings highlight the potential benefit of walking for older adults with or at risk of knee OA. A moderate reduction in risk of TKR may be an added benefit of walking more for older adults with or at risk of knee OA.TableAssociation of daily walking with the risk of TKR over 5 years.Daily walkingAdjusted HR(95% CI)1Overall sample (N = 1816)Adults (age in years)Older adults (≥65 years) (N = 912)Younger adults (<65 years) (N = 902)Per 1000 Steps/day0.94 (0.86-1.02)0.88 (0.79-0.99)∗0.98 (0.85-1.14)<6000 steps/dayReferenceReferenceReference≥6000 steps/day0.71 (0.45-1.14)0.48 (0.26-0.89)∗1.00 (0.44-2.29)1Adjusted for baseline age, BMI, sex, race, education, comorbidities, frequent knee pain, previous knee injuries or surgeries, and radiographic OA status.∗Significant at P value < 0.05 Open table in a new tab 1Adjusted for baseline age, BMI, sex, race, education, comorbidities, frequent knee pain, previous knee injuries or surgeries, and radiographic OA status. ∗Significant at P value < 0.05

Prediction of Pain and Opioid Utilization in the Perioperative Period in Patients Undergoing Primary Knee Arthroplasty: Psychophysical and Psychosocial Factors.

To identify factors associated with pain severity and opioid consumption in the early perioperative period. Prospective observational cohort study. Tertiary academic medical center. Patients with osteoarthritis older than age 45 years undergoing primary total knee replacement at Brigham and Women's Hospital. A total of 126 patients enrolled. Preoperatively, pain questionnaires and quantitative sensory testing were performed on patients to develop a psychosocial and psychophysical profile. Postoperatively, pain scores and opioid consumption were measured as primary end points. Univariate and multiple linear regression analyses were performed to determine the predictive value of these characteristics on perioperative pain scores and opioid consumption. Regression analysis revealed several predictors of acute postoperative pain scores including temporal summation of pain (TSP; P = 0.001), body mass index (BMI; P = 0.044), number of previous knee surgeries (P = 0.006), and female gender (P = 0.023). Similarly, predictors of opioid utilization included TSP (P = 0.011), BMI (P = 0.02), age (P = <0.001), and tourniquet time (P = 0.003). The only significant, unique predictors of both pain and opioid consumption were TSP, an index of central pain facilitatory processes, and BMI. Interestingly, psychosocial factors, such as catastrophizing and somatization, although correlated with postoperative pain scores and opioid consumption, generally did not independently explain substantial variance in these measures. This study suggests that BMI and quantitative sensory testing, specifically the temporal summation of pain, may provide value in the preoperative assessment of patients undergoing total knee arthroplasty and other surgeries via predicting their level of risk for adverse pain outcomes.

O papel das microfraturas associadas a osteotomia tibial no tratamento da gonartrose com geno varo

ObjectiveTo evaluate the microfracture intervention with tibial valgus osteotomy associated in the treatment of varus gonarthrosis. MethodsFrom November 2005 to May 2013, 129 patients with medial gonarthrosis, varus deformity (8°‐12°), and range of movement greater than 90° were evaluated. Patients with advanced gonarthrosis (Alhbäck 3, 4, and 5), Outerbridge lesion inferior to IV, previous knee surgery, body mass index greater than 35kg/m2, and/or cruciate ligament injuries were not included. All patients were treated with videoarthroscopy followed by tibial valgus osteotomy. In the group osteotomy associated with microfracture (n = 56, mean age = 39.3), tibial valgus osteotomy and microfracture techniques to address chondral defects were used. In the isolated osteotomy group (n = 73, mean age = 41.4), only this procedure was performed. Post‐surgical follow‐up was 24 months, with four evaluations in the first six months, proceeding to biannual twice‐a‐year evaluation in the subsequent period. The Lysholm scale was used for functional monitoring. ResultsThere was a significant improvement in the pain, limping, and squatting domains of the Lysholm scale but only in the isolated osteotomy group. A greater variance of results was observed in the osteotomy group associated to microfracture, in addition to an increased risk of functional deterioration (OR = 8.64). ConclusionThe association of microfractures and tibial valgus osteotomy was correlated to lower functional outcomes than tibial valgus osteotomy alone, and may be related to the risk of worsening in the first two postoperative years.

Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population—A 2-Year Follow-up Study

To compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction in young and middle-aged Asians. A retrospective study was performed using prospectively collected data from a tertiary institution ACL registry. All Asian patients with ACL tears who underwent primary arthroscopic ACL reconstruction by a single surgeon between 2008 and 2014, with minimum 2-year follow-up, were included. Patients with previous knee surgery or multiligamentous knee injuries were excluded. Two groups were formed: young patients (YP) (age <30) and middle-aged patients (MP) (age >40). They were compared preoperatively and 6months, 1year, and 2years postoperatively for demographics, knee range of motion, anterior laxity, Tegner level, Lysholm and International Knee Documentation Committee grade, ability to return to preinjury level of activity, and patient satisfaction. YP (n=84) and MP (n= 22) had differences in mean age (YP= 23.1years, range 18-29years; MP= 46.4years, range 41-59years, P < .001), preinjury Tegner level (YP= 7.4, MP= 6.4, P= .005), and preoperative Lysholm scores (YP=65.3, MP= 53.0, P= .034). The incidence of meniscal and chondral injuries was similar. Two years postoperatively, both groups had comparable knee range of motion and anterior laxity. The Tegner score was different (YP= 6.3, MP=5.2, P= .028), but the proportion of patients returning to preinjury Tegner level (YP= 45.2%, MP= 46.9%, P=.812), Lysholm scores (YP= 92.5, MP= 93.8, P= .794), proportion of patients with knees rated International Knee Documentation Committee A/B (YP= 77.4%, MP= 81.8%, P= .777), and satisfaction levels (YP= 98.5%, MP= 94.1%, P= .370) were similar. There were no graft ruptures or reoperations. In an Asian, predominantly male population, the clinical outcomes of arthroscopic ACL reconstruction in YP and MP are equally good at 2-year follow-up. MP can benefit as much as younger patients from ACL reconstruction in terms of restoration of knee function and return to preinjury activity level, are equally satisfied with outcomes, and should not be excluded from surgery on the basis of age alone. Level III, retrospective comparative study.

Cardiovascular Phenotypic Heterogeneity in Marfan Syndrome

To evaluate the clinical efficacy and safety of an intra-articular injection of bone marrow aspirate concentrate (BMAC) as a treatment option for osteoarthritis (OA) of the knee.Between June 2014 and February 2017, data from 233 patients with knee osteoarthritis treated with BMAC injection at a single center, were retrospectively evaluated. Only patients with idiopathic osteoarthritis were included. Exclusion criteria were post-traumatic osteoarthritis, previous knee surgery, age less than 50 years old or more than 85 years old, active infection, uncontrolled diabetes mellitus, rheumatological or other systemic disease, malignancy, or treatment with immunosuppressive drugs. Bone marrow from the iliac crest was aspirated/concentrated with a standardized technique using a single-spin manual method. Patients were evaluated before and after the procedure, using the numeric pain scale (NPS) and Oxford knee score (OKS). Mean follow-up period was 11 months, range (6–30 months).A total of 121 of 233 patients had completed data as previously defined and were included in the statistical analysis. There were 85 females and 36 males, with mean age 70 years (range 50–85). Compared to baseline, the mean NPS decreased from 8.33 to 4.49 (p < 0.001) and the mean OKS increased from 20.20 to 32.29 (P < 0.001) at final follow-up. There were no complications.A single intra-articular injection of BMAC is a safe and reliable procedure that results in clinical improvement of knee OA.

Total Knee Arthroplasty in Patients with Retention of Prior Hardware Material: What is the Outcome?

There is an information gap in literature regarding postoperative outcome of total knee arthroplasty (TKA) in patients with hardware in-situ from the previous knee surgery. The present study aims to evaluate impact of retained hardware on short-term outcome of TKA patients. Perioperative radiographs of patients who had undergone TKA between 2007 and 2012 were reviewed and patients in whom partial or complete retention of hardware was evident after TKA were included. These patients were matched in 1 to 2 ratio based on age (+/- 2 years), gender, surgeon and year of surgery to a group of patients that underwent primary TKA without hardware in the affected knee. The average follow up of these patients was 43.45 (range 12-155.2) months. Complication rates were compared between the two groups using statistical tests that took into account the matched data structure. We included a total of 55 cases and 110 controls. The incidence of complications was higher, although not all statistically significant, in the case group. Only mechanical complications were significantly different in the cases group (5.5% versus 0%, P=0.01). Time to event analysis using the mixed-effects Cox model didn't show a statistically significant difference between two groups for various outcomes. Presence of retained hardware around the knee may predispose the patient to a higher rate of complications particularly mechanical complications of the implant after TKA. Further studies are required to investigate impact of retained hardware around the knee in patients undergoing TKA.Level of evidence: III.

Outcomes of Implant-Arthrodesis as Limb Salvage for Failed Total Knee Arthroplasties with Significant Bone Loss: Case Series.

We sought to evaluate our consecutive series of knee-implant arthrodesis patients for failed total knee arthroplasties with medium term clinical and radiographic outcomes. We conducted a retrospective review of a consecutive series of 4 patients (average age, 75 years; range, 69-79) with failed knee arthroplasties and deficient extensor mechanism who underwent implant arthrodesis with a minimum 2-year follow-up. The primary outcome measure was the patient's reported outcome measures (Short-Form 12) and visual analogue scale for knee pain at final follow-up. All patients had multiple medical comorbidities, multiple previous knee surgeries with failed nonfunctional knee arthroplasties. Three patients had chronic infections and one had chronic pain and instability, and all had deficient extensor mechanism. Average follow-up was 5.5 years (range, 2-8), and the primary goal of surgery was achieved in all four patients. The average VAS score for knee pain was 3 of 10, and SF-12 was 36.16 (physical score) and 55.70 (mental score), indicating satisfactory outcomes. Satisfactory clinical and patient-reported outcomes can be achieved with implant arthrodesis as limb salvage for failed total knee arthroplasties with significant bone loss at medium-term follow-up.

Lateral femoral notch depth is not associated with increased rotatory instability in ACL-injured knees: a quantitative pivot shift analysis

A deep lateral femoral notch (LFN) on lateral radiographs is indicative of ACL injury. Prior studies have suggested that a deep LFN may also be a sign of persistent rotatory instability and a concomitant lateral meniscus tear. Therefore, the purpose of this study was to evaluate the relationship between LFN depth and both quantitative measures of rotatory knee instability and the incidence of lateral meniscus tears. It was hypothesized that greater LFN depth would be correlated with increased rotatory instability, quantified by lateral compartment translation and tibial acceleration during a quantitative pivot shift test, and incidence of lateral meniscus tears. ACL-injured patients enrolled in a prospective ACL registry from 2014 to 2016 were analyzed. To limit confounders, patients were only included if they had primary ACL tears, no concurrent ligamentous or bony injuries requiring operative treatment, and no previous knee injuries or surgeries to either knee. Eighty-four patients were included in the final analysis. A standardized quantitative pivot shift test was performed pre-operatively under anesthesia in both knees, and rotatory instability, specifically lateral compartment translation and tibial acceleration, was quantified using tablet image analysis software and accelerometer sensors. Standard lateral radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for LFN depth. There were no significant correlations between LFN depth on either imaging modality and ipsilateral lateral compartment translation or tibial acceleration during a quantitative pivot shift test or side-to-side differences in these measurements. Patients with lateral meniscus tears were found to have significantly greater LFN depths than those without on conventional radiograph and MRI (1.0 vs. 0.6mm, p < 0.05; 1.2 vs. 0.8mm, p < 0.05, respectively). There was no correlation between lateral femoral notch depth on conventional radiographs or MRI and quantitative measures of rotatory instability. Concomitant lateral meniscus injury was associated with significantly greater LFN depth. Based on these findings, LFN depth should not be used as an indicator of excessive rotatory instability, but may be an indicator of lateral meniscus injury in ACL-injured patients. Prognostic level IV.

Preoperative Diagnosis Can Predict Conversion Total Knee Arthroplasty Outcomes

BackgroundCompared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA. MethodsSeventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes. ResultsThe postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042). ConclusionPatients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.

Prior Knee Arthroscopy Does Not Influence Long-Term Total Knee Arthroplasty Outcomes and Survivorship

BackgroundArthroscopic knee surgery frequently precedes total knee arthroplasty (TKA). There have been mixed data on the effect of prior arthroscopic surgery on results of TKA. The purpose of this study was to compare the 10-year Knee Society Score (KSS), survivorship, and complications of TKA in a cohort of patients who had a previous knee arthroscopy to a control cohort. MethodsA retrospective review of 1315 TKAs who underwent a primary TKA between 2003 and 2004 was performed. Of these, 160 TKAs had previous arthroscopy (excluding ligamentous reconstruction). A matched cohort study 2:1 was carried out with a group of 320 controls (no prior surgery). Outcomes were assessed with the original KSS, range-of-motion, complications, and survivorships. Mean follow-up was 9 years. ResultsThe mean KSS increased from 36-84 in the arthroscopy group vs 35-86 in the control group (P = .5). The mean preoperative and postoperative range-of-motion was not different between groups (P = .2). The survivorship free of complication at 5 years was similar in both groups (94.3% in arthroscopy group vs. 95.3% in the control; P = .7) with infection in 2 controls and 3 arthroscopy cases (P = .2). The survivorships free of revision for aseptic loosening, revision for any reason, and reoperation were similar at 10 years (96.5%, 94.6%, and 89.2%, respectively, in the arthroscopy group vs 96.2%, 95.9%, and 91.5% in the control group). ConclusionThere were no significant differences between both groups. These data are reassuring and valuable in an era in which many candidates for TKA will have had previous arthroscopic knee surgery.

Do Outcomes of Osteochondral Allograft Transplantation Differ Based on Patient Sex: A Comparative Matched Group Analysis of Male and Female Patients

Objectives:Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, though to date, the impact of patient sex on outcomes and failure rates has not been assessed. The purpose of this study was to determine clinical outcomes for male versus female patients undergoing OAT.Methods:A retrospective review of prospectively collected data of patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. Males who underwent OAT were compared to a matched group of females who underwent OAT (age ± 3 years, gender, BMI ± 5 kg/m2, the presence of previous ipsilateral knee surgeries, and the presence of meniscal transplantation). The reoperation rate, failure rate, timing of reoperation, procedures performed, findings at surgery, and patient reported outcome scores were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at 2nd look arthroscopy. Descriptive statistics, fisher’s exact or chi-square testing, and Mann-Whitney U testing were performed, with P<0.05 set as significant.Results:A total of 98 patients (average age 32.1±9.9 years, 49 males, 49 females) who underwent OAT with an average follow-up of 4.7±2.33 years (range, 2.1-12.1) were included. These patients underwent an average of 2.6±1.8 prior surgical procedures on the ipsilateral knee prior to OAT. A total of 33 patients underwent reoperation at an average 2.4±2.4 years, with 27% (9/33) undergoing additional reoperations (range, 1-2 additional reoperations). Male patients did not have significantly different reoperation rates (42% vs. 27%), time to reoperation (2.50±2.12 vs. 2.29±1.71 years) or failure rates (20% vs. 8%) compared to female patients (P>0.05 for all). Both male and female patients showed significant improvement in Lysholm, IKCD, KOOS, WOMAC, and SF-12 physical subscale as compared to preoperative values (P>0.05 for all for both groups). The SF-12 mental subscale was not significantly improved at final follow-up for either group (P>0.05). There were no significant differences in patient reported outcomes scores at most recent follow-up when comparing males and females. Males demonstrated significantly larger defect areas compared to females (371.65±168.89 vs. 310.63±117.15 mm2, P=0.037), though the defect:condyle ratio was not significantly different (male: 0.19 vs. female: 0.20, P>0.05).Conclusion:Males and females have similar clinical outcomes at 5 years following OAT, though males trended toward increased reoperation rates and increased failure rates. This data implies that overall, similar favorable outcomes may be expected for patients regardless of sex, with an 86% graft survival rate at 5 years. This information can be used to counsel patients when being offered OAT as part of a knee joint preservation strategy.

Outcomes of Osteochondral Allograft Transplantation with versus without Concomitant Meniscus Allograft Transplantation: A Comparative Matched Group Analysis

Objectives:While osteochondral allograft transplantation (OAT) is often performed with concomitant meniscus allograft transplantation (MAT) as a strategy for knee joint preservation, the impact of concomitant MAT on outcomes following OAT has not been assessed. The purpose of this study was to determine clinical outcomes for patients undergoing OAT with MAT compared to a matched cohort of patients undergoing isolated OAT.Methods:A review of consecutive patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. Patients who underwent OAT without concomitant MAT were compared to a matched group of patients who underwent OAT with concomitant MAT (age ± 3 years, gender, BMI ± 5 kg/m2, number of previous ipsilateral knee surgeries ± 1, and the presence of concomitant ligamentous surgery). The reoperation rate, failure rate, timing of reoperation, procedures performed, findings at surgery, and patient reported outcome scores were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at 2nd look arthroscopy. Descriptive statistics, fisher’s exact or chi-square testing, and Mann-Whitney U testing were performed, with P<0.05 set as significant.Results:A total of 100 patients (average age 32.2±9.9 years; 52 males, 48 females) who underwent OAT (50 isolated, 50 with MAT) with an average follow-up of 4.84±2.7 years (range, 2.0-15.1) were included. These patients underwent an average of 2.6±1.2 prior surgical procedures on the ipsilateral knee prior to OAT. A total of 38 patients underwent reoperation at an average 2.4±2.2 years, with 24% (9/38) undergoing additional reoperations (range, 1-2 additional reoperations). MAT patients did not have significantly different reoperation rates (MAT: 40%; non-MAT: 36%), time to reoperation (MAT: 2.20±2.31 years; non-MAT: 2.56±2.11 years) or failure rates (14% vs. 14%) compared to non-MAT patients. Both MAT and non-MAT patients showed significant improvement in Lysholm, IKCD, KOOS, WOMAC, and SF-12 physical subscale as compared to preoperative values (P>0.05 for all for both groups). The SF-12 mental subscale was not significantly improved at final follow-up for either group. MAT patients demonstrated significantly higher SF-12 physical subscale as compared to non-MAT patients at most recent follow-up (45.81±7.42 vs 42.07±7.97, P<0.05). There were no significant differences detected in the defect size (MAT: 338.64±116.31 mm2; non-MAT: 344.42±171.04 mm2, P>0.05) or defect:condyle size ratio (MAT: 0.19; non-MAT: 0.20, P>0.05).Conclusion:Patients undergoing OAT with MAT have similar survival rates, reoperation rates, and clinical outcomes compared to patients undergoing isolated OAT at an average follow-up of 5 years. This information can be used to counsel patients undergoing concomitant MAT as part of a knee joint preservation strategy.

Is Lateral Femoral Notch Depth Associated with Rotatory Instability in ACL Deficient Knees: A Quantitative Pivot Shift Analysis

Objectives:Persistent rotatory knee instability after anterior cruciate ligament (ACL) reconstruction is relatively common. While the causes of this persistent instability are multifactorial, bony morphologic characteristics have been proposed to play a role. Therefore, the purpose of this study was to evaluate the relationship between the well-described lateral femoral notch (LFN) depth and quantitative measures of rotatory knee stability. We hypothesized that greater LFN depth would be associated with increased rotatory knee instability.Methods:A consecutive series of patients undergoing primary ACL reconstruction at our university medical center from June 2014 to April 2016 were analyzed. Inclusion criteria included primary ACL tear, no concurrent ligamentous or bony injury requiring operative treatment, no history of previous knee injury or surgery to the ACL-injured extremity, and no history of injury or surgery to the contralateral knee. A standardized pivot shift test was performed by the senior surgeon preoperatively under anesthesia in both knees and quantified using tablet image analysis software and accelerometer sensors as previously described and validated. Lateral knee radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for depth of the LFN as previously described. A line tangent to the lateral femoral condyle articular surface was drawn across the notch. Notch depth was measured perpendicular from this line to the deepest point of the LFN. Pearson correlation coefficient was used to analyze correlations between continuous variables. Chi-square test was used to analyze relationships between notch depth and presence/absence of medial or lateral meniscus tears. Analyses were performed with SPSS 22.0 and significance was set at a p<0.05.Results:Fifty patients met inclusion criteria and were included in this study (mean age 24 years, range 13-45; 28 females, 22 males). Mean LFN depth as measured via x-ray was 0.8 mm (SD=0.63, n=50) and via MRI was 1.0 mm (SD=0.73, n=47). Twenty-two (44%) patients had a medial meniscus tear and 27 (54%) had a lateral meniscus tear. LFN on x-ray had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.402, p=0.004) and acceleration side-to-side differences (r=0.407, p=0.003). LFN depth on MRI had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.334, p=0.022) and acceleration side-to-side differences (r=0.363, p=0.012). LFN depth on x-ray was significantly associated with the presence of a lateral meniscus tear (p=0.014). There were no significant associations between LFN depth (x-ray or MRI) on ipsilateral or contralateral lateral compartment translation, contralateral lateral compartment acceleration, or the presence of medial meniscus tears.Conclusion:The results from this study demonstrated that a well described bony morphologic feature - LFN depth - was correlated with higher lateral compartment acceleration as measured by quantitative pivot shift analysis. Furthermore, greater LFN depth was associated with an increased incidence of lateral meniscus tears, which supports findings from previous studies. Assessment of LFN depth may help clinicians identify patients with greater rotatory instability prior to ACL reconstruction and potentially direct surgical treatment to account for additional rotatory knee instability.Table 1: Mean Quantitative Pivot Shift Values of the Injured and Uninjured KneeInjuredUninjuredSide-to-Side DifferenceCompartment Acceleration (m/s2)5.14 (SD=0.73)3.45 (SD=0.95)1.68 (SD=2.09)Lateral Compartment Translation (mm)3.67 (SD=2.30)1.22 (SD=0.75)2.46 (SD=2.24)

Clinical Outcomes of Patellofemoral Osteochondral Allograft Transplantation: A Prospective Analysis

Objectives:The use of osteochondral allograft transplantation (OAG) for chondral defects of the knee is increasing, particularly for defects involving the femoral condyles. The purpose of this study was to prospectively evaluate the clinical outcomes for patients undergoing patellofemoral OAG for symptomatic chondral lesions.Methods:Consecutive patients undergoing OAG for full-thickness patella and trochlear lesions between 2007 and 2014 by two senior surgeons were analyzed. Pre- and post-operative patient reported outcomes scores were collected, with a minimum 21-month follow-up. Patient demographics, preoperative clinical data including information on prior ipsilateral knee surgeries, and intraoperative details were analyzed for all patients. Complications, reoperations, and conversion to total knee or patellofemoral arthroplasty were recorded. Statistical analysis was conducted with student’s T-tests, with P<0.05 considered significant.Results:A total of 14 patients (10 females, 4 males) with an average age of 32.8±7.5 years (range, 20-48) were identified for inclusion with an average follow-up of 3.6±1.8 years (range, 1.8-7.8) (Table 1). The average body mass index was 27.5±6.9 kg/m2. Patients experienced an average 5.4±4.2 years of symptoms prior to OAG and 100% of patients had undergone previous ipsilateral knee surgery with an average 4.1±3.5 prior procedures before undergoing patellofemoral OAG. The average defect size on the patella was 855mm2 while that on the trochlea was 322mm2. At the time of OAG, 6 (43%) patients received trochlear grafts, 6 (43%) received patellar grafts, and 2 (14%) received bipolar grafts. Nine patients (64%) received a single allograft, 3 (21%) received 2 allografts to 2 separate lesions, and 2 (14%) received grafts to 4 separate lesions. At final follow-up, there were significant improvements in Lysholm, IKDC, KOOS, WOMAC, and SF-12 Physical outcomes scores; no significant improvements were found in the SF-12 Mental subscale (Figure 1). Two patients (both female, ages 27 and 41) were considered failures as they had converted to knee arthroplasty at an average 2.7 years following OAG. Both of these patients had received allografts to the patella with lesion sizes of 506mm2 and 1800mm2, respectively.Conclusion:Osteochondral allograft transplantation of the patellofemoral joint can be considered a viable restoration procedure for patients with symptomatic chondral lesions to the trochlea and patella. At an average follow-up of 3.6 years, the majority of patients will experience significant improvements in nearly all outcomes scores, with an arthroplasty conversion rate of 14%. Additional information on this difficult-to-treat patient population, including a better understanding of risk factors for failure, prognostic factors for success, and long-term outcomes, is needed.Table 1Patient informationCaseBody Mass Index (kg/m2)Symptom Duration(yrs.)History of Failed Prior Articular Cartilage ProcedureType of Previous Cartilage Procedure# OA GraftsLocation of GraftsLesion Area (mm)Failed to TKA/PFATime to Failure (Yrs.)1 (36yo M)33.225NoN/A2Trochlea, MFC400, 225NoN/A2 (27yo M)27.123YesACI1Patella324NoN/A3 (48yo F)23.402No1Trochlea400, 225NoN/A4 (24yo M)27.609No4Trochlea, MFC (x2), LFC625, 324, 225, 625NoN/A5 (34yo M)28.322YesMFX1Trochlea/MFC Junction225NoN/A6 (24yo F)19.583.5Yes1Trochlea225NoN/A7 (30yo F)26.623No2Trochlea, MFC324, 225NoN/A8 (34yo F)33.61YesMFX4patella, trochlea, MFC x21500,254, 254, 201NoN/A9 (41yo F)20.810No1Patella506Yes2.910 (27yo F)42.62.5YesTruFit Plug, DeNovo1Patella1800Yes2.411 (37yo F)35.72YesDeNovo1Patella988NoN/A12 (33yo F)17.311YesOA Graft2Patella, Trochlea375, 300NoN/A13 (20yo F)25.16YesDeNovo, ACI1Patella975NoN/A14 (38yo F)24.415No1Patella375NoN/A

Tibiofemoral Instability After Primary Total Knee Arthroplasty: Posterior-Stabilized Implants for Obese Patients.

Tibiofemoral instability is a common complication after total knee arthroplasty (TKA), accounting for up to 22% of all revision procedures. Instability is the second most common cause of revision in the first 5 years after primary TKA. In this study, 13 knees with tibiofemoral instability after TKA were identified among 693 consecutive primary TKA procedures. Patient demographics, body mass index, clinical symptoms, previous deformity, previous knee surgery, complications, interval between index TKA and first tibiofemoral instability, causes of instability, and interval between index TKA and revision TKA were retrospectively reviewed. Clinical outcomes were assessed with the Lysholm Knee Scoring Scale. All patients were women, and mean body mass index was 37.7 kg/m2 (range, 27.2-52.6 kg/m2). Mean interval between index TKA and first tibiofemoral instability was 23.4 months (range, 9-45 months), and mean interval between index TKA and revision TKA was 25.6 months (range, 14-48 months). All patients had posterior cruciate ligament-retaining implants. Of the 13 knees, 11 had flexion instability and 2 had global instability. In all patients, instability was caused by incompetence of the posterior cruciate ligament; additionally, 1 patient had undersized and malpositioned implants. In 4 knees, the polyethylene insert was broken as well. All patients underwent revision TKA. Lysholm Knee Scoring Scale score had improved from a mean of 35.8 (range, 30-46) to a mean of 68.3 (range, 66-76). All patients included in this study were female and obese. The main cause of instability was secondary posterior cruciate ligament rupture and incompetence. The use of posterior-stabilized implants for primary TKA may prevent secondary instability in obese patients. [Orthopedics. 2017; 40(5):e812-e819.].

Creation of an Australian Osteotomy Knee Registry Datasheet Instrument using a Modified Delphi Method

Background:In 2015, the Australian Knee Society(AKS) agreed to initiate and fund an Australian Knee Osteotomy Registry (AKOR) in 2015 in conjunction with the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). A concise and robust dataset was required to proceed to AKOR preliminary site trialing.Study Design:Modified Delphi consensus building.Methods:Seven participants who were orthopaedic surgeons, AKS members and AKOR working group members performed a four round modified Delphi consensus building electronic non-blinded questionnaires using Google Sheets, a cloud-based spreadsheet. Round 1 involved the attribute rating using 0-10 of surgeon assessed utility of 41 initial datasheet instrument questions with 168 stem options. Surgeons could comment on each question or stem, giving comments on their rating and or proposing new variations or additions. Round 1 questions were based on the Swedish HTO Registry dataset with additional questions from surgeon interview. Questions and or stems with a mean utility rating of less than 2 were excluded. Questions and or stems with a mean utility raking of 8 or greater were accepted. Questions and or stem with a mean utility ranking of between 8 and 2 were included in subsequent rounds. Surgeons comments and votes were non-blinded. New or alternative questions or stems could be proposed by any surgeon during the process and voted on in the next round. This process was repeated until dataset consensus was achieved.Results:A final dataset of 32 questions was created after 4 rounds. Consensus was reached on the following items; patients demographics, hospital, state, surgeon’s code, date, primary or re-operation, diagnosis at primary procedure, diagnosis at re-operation, type of primary osteotomy, type of re-operation, form of fixation, bone graft, coincidental surgery, approach to correction calculation, pre-operative status of ACL, pre-operative status of PCL, previous knee surgery, preoperative mechanical axis, planned post-operative mechanical axis, preoperative fixed flexion deformity, pre-operative Ahlbäck grading of knee OA. Questions that had a final utility rating less than 10 included; coincidental surgery, approach to correction calculation, pre-operative Ahlbäck grading of knee OA, planned post-operative mechanical axis and preoperative fixed flexion deformity.Conclusion:The final AKOR dataset requires pragmatic validation prior to nation-wide implementation. Questions with low final attribute rating may not be included in the final instrument after validatation.

Postoperative Analgesia in Patients Undergoing Primary or Revision Knee Arthroplasty with Adductor Canal Block.

BackgroundMultimodal analgesia featuring peripheral nerve blocks decreases postoperative pain for patients undergoing primary total knee arthroplasty (TKA). Many anesthesiologists and surgeons advocate for the use of adductor canal blocks (ACBs) for analgesia, which result in less weakness compared to femoral nerve blocks. Few data exist to guide analgesic management in total knee revision (TKR), considered to be more painful than primary TKA. We hypothesized that TKR patients with a continuous ACB would use more opioids than primary TKA patients who received the same analgesic regimen.MethodsA retrospective study of 58 TKA and TKR patients who received ACBs in a multimodal protocol was conducted from 1/2014 to 3/2016. Exclusion criteria included patients who took ≥ 20 mg of morphine daily preoperatively. The primary outcome was 48-hour opioid consumption. Secondary outcomes included pain ratings, catheter boluses, and catheter infusion rate changes over 48 hours.ResultsFor the primary outcome of 48-hour opioid consumption, there was no significant difference between groups. Postoperative pain ratings were not significantly different during the overall 48-hour time period. There were also no significant differences in catheter boluses and infusion rate changes. Least squares regression analysis revealed a positive correlation between number of previous knee surgeries and postoperative pain level.ConclusionsPatients who underwent TKR with continuous ACB experienced a similar postoperative analgesic course as primary TKA patients. Within the TKR cohort, the number of previous revisions was positively associated with pain level. Larger prospective studies with TKR are needed to confirm these findings.

Tibial Tuberosity Anteromedialization for Patellofemoral Chondral Disease: Prognostic Factors

Background: Tibial tuberosity anteromedialization (TTA) is a well-established treatment option for patellofemoral chondral disease that is resistant to nonoperative treatment. However, the prognostic factors of this procedure are unknown. Purpose: To analyze the prognostic factors correlated with the midterm outcomes of TTA for patellofemoral chondral disease and determine the survivorship. Study Design: Case series; Level of evidence, 4. Methods: Indications of TTA for chondral disease included skeletal maturity, age <65 years, <grade 3 Kellgren-Lawrence degeneration, and isolated patellofemoral pain for ≥6 months despite nonoperative treatment. Inclusion criteria were (1) patellofemoral chondral disease, (2) TTA with or without lateral release, and (3) minimum 2-year follow-up. Exclusion criteria were (1) previous knee surgeries, (2) previous patellar dislocations, (3) inflammatory/rheumatic conditions, (4) major combined procedures other than lateral release, (5) focal chondral lesions amenable to cartilage repair, and (6) severe trochlear dysplasia. The patients were prospectively evaluated radiographically and clinically using the Western Ontario and McMaster Universities Osteoarthritis Index–Short-Form (WOMAC-SF) and Kujala scores. Different clinical and radiological data were collected (preoperative, intraoperative, and postoperative) and correlated with the outcomes using multiple logistic regression. The Kaplan-Meier survivorship was also evaluated. Results: From January 2003 to December 2013, among 76 eligible patients, 69 patients (78 knees, 74.4% female) were included, with a mean follow-up of 67.9 ± 34.5 months (range, 24-163 months) and a mean age at the time of surgery of 43.5 ± 16.1 years. The mean preoperative WOMAC-SF (17.8 ± 5.3) and Kujala (49.3 ± 15.6) scores significantly (P < .001) improved after surgery (WOMAC-SF: 6.6 ± 6.9; Kujala: 74.2 ± 20.5). The patients graded their operated knee as 7.2 ± 2.1 of 10 points, on average, and stated that they would undergo the surgery again in 58 (74.4%) cases. A WOMAC-SF score of >7 points (34.6% of knees) in the multiple regression model was associated with age >45 years (odds ratio [OR], 10.4; 95% CI, 2.0-55.0) and increased femoral anteversion (OR, 7.9; 95% CI, 1.4-44.1). A Kujala score of <80 points (61.5% of knees) was associated with age >45 years (OR, 12.0; 95% CI, 2.6-56.2) and foot pronation (OR, 5.1; 95% CI, 1.3-20.4). Patient satisfaction of <7 of 10 points (32.1% of knees) was associated with positive postoperative patellofemoral crepitus (OR, 3.6; 95% CI, 1.1-11.7). The Kaplan-Meier survivorship of TTA with dissatisfaction (<5/10 points) as an end point was 94% at 43 months, 88% at 77 months, and 77% at 108 months. Conclusion: Overall, good outcomes and survivorship (77% at 108 months) were obtained in this case series. However, 25.6% of the patients would not undergo the surgery again. Increased age, increased femoral anteversion, foot pronation, and postoperative patellofemoral crepitus were identified as negative prognostic factors.

Evaluation of Infection after Anterior Cruciate Ligament Reconstruction during a Short Period.

PurposeWe encountered 7 cases (7.1%) of infection (5 deep and 2 superficial) in 98 cases of anterior cruciate ligament (ACL) reconstruction using hamstring autografts in a 17-month period. The aim of this study was to analyze the causes of infection and to introduce our treatment strategy.Materials and MethodsWe investigated the shelf-life of the fixation implants, the order of surgery, previous knee surgery, infectious pathogen, treatment of infection, and results of treatment.ResultsThere was no problem with the expiration date of the fixation implants. The order of surgery was either the last or second to the last of all those performed on the same day. One patient had undergone knee surgery 8 months previously. The treatment after infection included aggressive debridement in all cases. Revision ACL reconstruction with graft removal was performed in 1 case of persistent infection with methicillin-resistant Staphylococcus aureus. All cases had satisfactory clinical results without recurrence during a mean 24.9 months of follow-up.ConclusionsWe could not verify the exact cause of the high incidence of infection during the 17-month period. However, preventive measures are important to decrease the incidence of infection after ACL reconstruction.

Increased Risk of Revision, Reoperation, and Implant Constraint in TKA After Multiligament Knee Surgery.

The risk of major complications and revision arthroplasty after TKA in patients who previously underwent multiligament knee surgery have been poorly characterized. Is multiligament knee surgery before TKA associated with (1) worse implant survival, (2) increased use of TKA design constraint, (3) a greater risk for major complications, and (4) poorer scores for pain and function compared with similar patients receiving TKA for primary osteoarthritis? Fifty-nine TKAs were performed at our institution between 1985 and 2014 in 59 patients (36 men, 23 women; mean age, 53 years) with a history of previous multiligament knee surgery (≥ two ligaments). Of those, we had followup for 39 (66%), 18 (31%), and six (10%) patients at 5, 10, and 15 years, respectively; mean followup was 5.4 years (range, 1-25 years). A two-to-one matched control group consisting of patients undergoing primary TKA for the diagnosis of osteoarthritis was selected for comparison. Patients were matched based on gender, age at primary TKA (within 5 years), and date of the TKA (within 5 years). Medical records were reviewed for survivorship, TKA design, complications (reoperation, revision, infection, manipulation under anesthesia, and periprosthetic joint infection), TKA design, and clinical outcomes (Knee Society Scores [KSS], Knee Society Function Score [KSS-F]). The overall 15-year revision-free survival in patients with prior multiligament knee surgery was decreased in comparison to the matched controls (42% [95% CI, 16%-73%] vs 94% [95% CI, 81%-99%]; p < 0.001). Varus-valgus constraint implant design was used for more patients in the multiligament cohort at index TKA than in the matched control group (9/59 [15%] vs 0/110 [0%], respectively; odds ratio [OR], 45; 95% CI, 3-781; p = 0.009). Patients with a history of multiligament knee surgery also were at increased risk of reoperation for any cause (14/59 [24%] vs 7/118 [6%]; OR, 5; 95% CI, 2-14; p = 0.001). With the numbers available, there was no difference in the frequency of manipulation under anesthesia after TKA (10% [6/59] versus 3% [4/118]; p = 0.08) A higher proportion of patients in the multiligament cohort had infections develop compared with the matched controls (4/59 [7%] vs 1/118 [< 1%)], respectively; p = 0.04). There was no difference in the KSS improvement after TKA between the multiligament group and the control group (34 ± 18 vs 28 ± 15; p = 0.088). The final KSS and KSS-F scores likewise showed no difference between those groups (88 ± 13 vs 85 ± 10; p = 0.232) (85 ± 17 vs 84 ± 14; p = 0.75). A history of multiligament surgery is associated with lower long-term survivorship, higher use of constrained TKA designs, and higher risk of major complications, including reoperation and infection. Further research is necessary to determine if a particular multiligamentous surgical technique can prevent posttraumatic arthritis and TKA complications. Level III, therapeutic study.