Knee
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Dom Henrique Research Centre,
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Arthroscopic Surgery Unit, Hospital Vithas Vitoria,
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Dom Henrique Research Centre,
Porto Biomechanics Laboratory (LABIOMEP), Faculty of Sports, University of Porto,
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Clínica Espregueira-FIFA Medical Centre of Excellence,
Dom Henrique Research Centre,
ICVS/3B’s–PT Government Associate Laboratory,
3B’s Research Group-Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine,
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Purpose
Investigate intra- and post-operative complications and revisions following distal femoral and/or high tibial derotational osteotomies to correct rotational malalignments of the lower limb in patients with anterior knee pain (AKP) and/or patellofemoral instability (PFI).
Methods
A literature search was conducted on PubMed, EMBASE and Web of Science (until 30 September 2023), including studies reporting complications, reinterventions and revisions following knee derotational osteotomies. Incidence rates were collected for each level of derotational osteotomy (distal femur, high tibia or double-level). A meta-analysis using the Freeman–Tukey double arcsine transformation was conducted to estimate the pooled proportions with their 95% confidence intervals (CIs).
Results
Twenty-one studies involving 564 osteotomies (n = 484) were included, with a mean follow-up of 45.6 ± 15.7 months. The overall complication proportion was 7.5% (95% CI: 3.9–11.8%). Postoperative residual AKP was seen in a pooled proportion of 7.6% (95% CI: 0.7–18.8%), and persistent PFI was not common (0.1%; 95% CI: 0.0–1.7%). Intraoperative complications occurred in a pooled proportion of 3.8% (95% CI: 2.4–6.0%), with peroneal nerve injury being the most common (1.3%) after derotational high tibial osteotomy. Reintervention was needed in a pooled proportion of 13.0% (95% CI: 2.9–27.2%), primarily for hardware removal (n = 158; 28.3%). There was a pooled proportion of knees requiring revision procedures of 12.3% (95% CI: 2.6–26.1%).
Conclusions
Distal femur and high tibial derotational osteotomies exhibit a considerable incidence of intra- and post-operative complications. Peroneal nerve injury, although infrequent, is a significant complication, underscoring the importance of implementing intraoperative preventive measures during derotational high tibial osteotomy.
Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University,
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Purpose
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A staged bilateral total knee arthroplasty (BTKA) procedure is considered when a patient is not deemed suitable for simultaneous BTKA due to concerns about the risk of mortality and complications. However, no network meta-analysis has been conducted to compare simultaneous vs staged BTKA procedures with different intervals in terms of postoperative mortality and overall complication rates.
Methods
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Four databases – Medline, Embase, Cochrane Library and Web of Science – were searched from inception to December 19, 2023, for studies comparing patients who underwent staged BTKA with different intervals and simultaneous BTKA. The primary outcome domains were 1-year mortality and 90-day overall complications. Secondary outcomes included neurological, cardiovascular, pulmonary, infectious and venous thromboembolic complications within 90 days.
Results
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Fifteen observational studies were included. Staged BTKA with intervals between 6 weeks and 3 months (odds ratio (OR): 0.69, 95% CI: 0.53–0.91), between 3 and 6 months (OR: 0.67, 95% CI: 0.53–0.84) and longer than 6 months (OR: 0.67, 95% CI: 0.55–0.83) exhibited a lower mortality risk compared to simultaneous BTKA. Staged BTKA with an interval shorter than 6 weeks and longer than 6 months exhibited a higher risk of pulmonary (OR: 1.24, 95% CI: 1.03–1.49; OR: 1.64, 95% CI: 1.10–2.44) and infectious complications (OR: 1.50, 95% CI: 1.15–1.96; OR: 1.52, 95% CI: 1.14–2.02) compared to simultaneous BTKA. An interval between 3 and 6 months ranked best in outcomes of 1-year mortality (P score = 0.7849) and 90-day complications (P score = 0.7077).
Conclusions
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Staged BKTA with an interval of more than 6 weeks but less than 6 months is associated with a lower risk of postoperative mortality and complications. However, these results should be interpreted with caution due to potential biases inherent in the inclusion of nonrandomized studies.
Level of Evidence
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II
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Knee osteoarthritis (OA) is a common chronic condition that leads to joint pain and disability among older adults. An interprofessional collaborative approach has nowadays been widely advocated in knee OA management although little is known about the characteristics of care, roles and responsibilities of healthcare providers and how they collaborate as a team to optimise treatment outcomes.
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The Donabedian structure–process–outcome framework was used in the review. Six databases were searched from February 2013 to March 2023.
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A total of 26 articles that met our inclusion criteria were reported. All studies (n = 26) identified the physiotherapist as a critical member of the interprofessional team. Several studies (n = 5) have offered training to healthcare providers in the management of knee OA. The intervention components in most studies included disease-based education (n = 21) and exercise therapy (n = 16).
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A comprehensive understanding of the existing interprofessional knee OA care in this review could potentially assist the government and healthcare organisations in developing interprofessional practice guidelines and designing intervention programmes that maximise their benefits.
Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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This review highlights the pivotal role of Kaplan fibers (KFs) in knee stability, particularly in the anterolateral aspect. Studies reveal their complex anatomy with varying attachments to the distal femur, demonstrating a significant impact on knee joint mechanics across different populations.
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Investigations into the biomechanics of KFs show their crucial role in maintaining rotational stability of the knee, especially during rotational movements. Their synergistic function with other knee structures, like the anterolateral ligament, is emphasized, underscoring their importance in knee integrity and function.
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MRI emerges as a key tool in detecting KFs, with varying visibility and prevalence of injuries. The review discusses the development of MRI criteria for accurate diagnosis, highlighting the need for further research to refine these criteria and understand the interplay between KF injuries, anterior cruciate ligament (ACL) ruptures, and associated knee pathologies.
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The review covers various lateral extra-articular tenodesis (LET) techniques used to address residual laxity and instability following ACL reconstruction. Among them, the modified Lemaire technique, which resembles the anatomical and functional characteristics of distal KFs, shows effectiveness in reducing internal rotation and residual laxity.
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The review emphasizes the need for further research to understand the healing dynamics of KF injuries and the efficacy of different LET techniques. It suggests that a comprehensive approach, considering both biomechanical and clinical aspects, is crucial for advancing knee joint health and rehabilitation.
Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Department of Traumatology, Orthopaedics and Disaster Surgery, Moscow, Russia
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Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Purpose
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Growing interest surrounds the role of human gut microbiome in the development of degenerative pathologies such as osteoarthritis (OA), but microbes have recently been detected also in other sites previously considered to be sterile. Evidence emerged suggesting that even native and osteoarthritic knee joints may host several microbial species possibly involved in the osteoarthritic degeneration. This is the first systematic review critically collecting all the available evidence on the existence and composition of knee intra-articular microbiome.
Methods
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A systematic research on the PubMed, Cochrane and Google Scholar databases was performed. Human clinical studies investigating the presence of intra-articular microbiome in native osteoarthritic knee joints with next-generation sequencing techniques were collected.
Results
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A total of eight studies were included reporting data on 255 knees. All the included studies reported evidence supporting the existence of an intra-articular microbiome in native knee joints, with detection rates varying from 5.8% to 100%. Bacteria from the Proteobacteria phylum were found to be among the most identified followed by the Actinobacteria, Firmicutes, Fusobacteria, and Bacteroideta phyla. Proteobacteria phylum were also found to be more common in osteoarthritic knees when compared to healthy joints. Furthermore, several pathways correlating those microbes to knee OA progression have been suggested and summarized in this review.
Conclusions
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Evidence collected in this systematic review suggests that the native knee joint, previously presumed to be a sterile environment, hosts a peculiar intra-articular microbiome with a unique composition. Furthermore, its alteration may have a link with the progression of knee osteoarthritis.
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Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Università della Svizzera Italiana, Faculty of Biomedical Sciences, Lugano, Switzerland
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Purpose
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Intra-articular corticosteroid (CS) injections for knee osteoarthritis (OA) management are endorsed by several scientific societies, while the use of hyaluronic acid (HA) and platelet-rich plasma (PRP) is more controversial. Aim of the study was to quantify and compare the clinical effectiveness of CS injections with respect to HA and PRP in patients with knee OA.
Methods
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The search was conducted on PubMed, Cochrane, and Web of Science following the PRISMA guidelines. Randomized controlled trials (RCTs) on the comparison of CS injections and HA or PRP injections for the treatment of knee OA were included. The minimal clinically important difference (MCID) was used to interpret the clinical relevance of the improvements at different follow-ups up to 12 months. The study quality was assessed using the Cochrane RoB-2 tool and the GRADE guidelines.
Results
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Thirty-five RCTs were included (3348 patients). The meta-analysis comparing CS and HA revealed no difference in terms of WOMAC improvement, while HA showed superior VAS pain improvement at long-term follow-up (P = 0.011), without reaching the MCID. PRP offered a superior WOMAC improvement compared to CS at short- (P = 0.002), mid- (P < 0.001, exceeding the MCID), and long-term (P < 0.001, exceeding the MCID) follow-ups. PRP offered a superior VAS improvement at mid- (P < 0.001, exceeding the MCID) and long-term (P = 0.023) follow-ups.
Conclusion
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CS injections for knee OA offer similar results to HA and PRP only at short term, while there is an overall superiority of PRP at longer follow-ups. This difference is not only statistically significant but also clinically relevant in favour of PRP.
Department of Bone And Joint Diseases, Luoyang Orthopedic Hospital of Henan Province. Orthopedic Hospital of Henan Province, Luoyang, China
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Department of Bone And Joint Diseases, Luoyang Orthopedic Hospital of Henan Province. Orthopedic Hospital of Henan Province, Luoyang, China
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Purpose
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Although magnesium sulfate (MgSO4) is widely used as an analgesic adjuvant to peripheral analgesic cocktails, its efficacy in total knee arthroplasty (TKA) is still controversial. Therefore, we systematically reviewed and meta-analyzed the literature to assess the analgesic efficacy of MgSO4 as an adjuvant to the analgesic cocktail in TKA.
Methods
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The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched. The meta-analysis was performed according to the PRISMA guidelines. Data were qualitatively synthesized or meta-analyzed using a random-effects model.
Results
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Five randomized controlled trials involving 432 patients were included. Meta-analyses detected significant differences between the MgSO4 and control groups in the visual analog scale (VAS) pain scores (rest) at 6, 12, and 24 h postoperatively; VAS pain scores (motion) at 12, 24, and 48 h postoperatively; morphine consumption within 24 h, 24–48 h, and during the total hospitalization period; time to first rescue analgesia after TKA; and length of hospital stay. Regarding the functional recovery, the meta-analysis demonstrated significant differences between groups in terms of knee range of motion on postoperative day 1; daily mobilization distance on postoperative day 1; and daily mobilization distance. There was no significant intergroup difference in surgical complications.
Conclusion
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The findings suggest that MgSO4 is a promising adjunct to the analgesic cocktail, achieving significant improvements in pain scores and total opioid consumption during the early postoperative period after TKA.
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Purpose
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Despite the publication of several randomized controlled trials (RCTs), it is not clear which technique for the treatment of focal chondral and osteochondral defects of the knee grants the best clinical outcome. The aim of this network meta-analysis (NMA) was to compare the efficacy and safety of microfractures (MF), autologous chondrocyte implantation (ACI), autologous matrix-induced chondrogenesis (AMIC), osteochondral autograft transplantation (OCT) at short (< 1 year), intermediate (1–5 years) and long-term (> 5 years).
Methods
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We carried out an NMA with Bayesian random-effect model, according to PRISMA guidelines. The search was performed in MEDLINE, EMBASE, Web of Science, CENTRAL, CINAHL, SPORTDiscus, clinicaltrials.gov, WHO ICTRP, from inception to November 2022. The eligibilities were randomized controlled trials on patients with knee chondral and osteochondral defects, undergoing microfractures, OCT, AMIC, ACI, without restrictions for prior or concomitant surgery on ligaments, menisci or limb alignment, prior surgery for fixation or ablation of osteochondritis dissecans fragments, and prior cartilage procedures as microfractures, drilling, abrasion, or debridement.
Results
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Nineteen RCTs were included. No difference among treatments was shown in the pooled comparison of patient reported outcome measures (PROMs) at any timepoint. Safety data were not available for all trials due to the heterogeneity of reporting, but chondrospheres seemed to have lower failure and reoperation rates.
Conclusion
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This NMA showed no difference for PROMs with any technique. The lower failure and reoperation rates with chondrospheres must be interpreted with caution since adverse event data was heterogenous among trials. The standardization of the efficacy and safety outcome measures for future trials on knee cartilage repair and regeneration is necessary.
School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Department of Primary Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
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Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Master’s Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
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Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Purpose
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The combination of pharmacological and non-pharmacological interventions is strongly recommended by current guidelines for knee osteoarthritis. However, few systematic reviews have validated their combined efficacy. In this study, we investigated the effects of the combination of pharmacological agents and exercise on knee osteoarthritis.
Methods
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Randomized controlled trials that investigated the efficacy of pharmacological agents combined with exercise for knee osteoarthritis were searched in PubMed, Embase, and Cochrane Library up to February 2024. The network meta-analysis was performed within the frequentist framework. Standardized mean difference (SMD) with 95% CI was estimated for pain and function. Grading of recommendations, assessment, development, and evaluations were used to evaluate the certainty of evidence.
Results
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In total, 71 studies were included. The combination therapy outperformed pharmacological or exercise therapy alone. Among the various pharmacological agents combined with exercise, mesenchymal stem cell injection was ranked the best for short-term pain reduction (SMD: −1.53, 95% CI: −1.92 to −1.13, high certainty), followed by botulinum toxin A, dextrose, and platelet-rich plasma. For long-term pain relief, dextrose prolotherapy was the optimal (SMD: −1.76, 95% CI: −2.65 to −0.88, moderate certainty), followed by mesenchymal stem cells, platelet rich in growth factor, and platelet-rich plasma.
Conclusion
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Exercise programs should be incorporated into clinical practice and trial design. For patients undergoing exercise therapies, mesenchymal stem cell, dextrose, platelet-rich plasma, platelet rich in growth factor, and botulinum toxin A may be the optimal agents.
Personalized Arthroplasty Society, Atlanta, Georgia, USA
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Personalized Arthroplasty Society, Atlanta, Georgia, USA
Clinique Orthopédique Duval, Laval, Quebec, Canada
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Personalized Arthroplasty Society, Atlanta, Georgia, USA
Clinique Orthopédique Duval, Laval, Quebec, Canada
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Department of Knee Surgery, Casa di Cura Solatrix, Rovereto, TN, Italy
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Personalized Arthroplasty Society, Atlanta, Georgia, USA
Clinique Orthopédique Duval, Laval, Quebec, Canada
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Over the years, with a better understanding of knee anatomy and biomechanics, superior implant designs, advanced surgical techniques, and the availability of precision tools such as robotics and navigation, a more personalized approach to total knee arthroplasty (TKA) has emerged.
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In the presence of extra-articular deformities, performing personalized TKA can be more challenging and specific considerations are required, since one has to deal with an acquired pathological anatomy.
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Performing personalized TKA surgery in patients with extra-articular deformities, the surgeon can: (1) resurface the joint, omitting the extra-articular deformity; (2) partially compensate the extra-articular deformity with intra-articular correction (hybrid technique), or (3) correct the extra-articular deformity combined with a joint resurfacing TKA (single stage or two-stage procedure).
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Omitting the acquired lower limb malalignment by resurfacing the knee has the advantages of respecting the joint surface anatomy and preserving soft tissue laxities. On the other hand, it maintains pathological joint load and lower limb kinematics with potentially detrimental outcomes.
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The hybrid technique can be performed in most cases. It circumvents complications associated with osteotomies and brings lower limb axes closer to native alignment. On the other hand, it creates some intra-articular imbalances, which may require soft tissue releases and/or constrained implants.
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Correcting the extra-articular deformity (through an osteotomy) in conjunction with joint resurfacing TKA represents the only true kinematic alignment technique, as it aims to reproduce native knee laxity and overall lower limb axis.
