Knee
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Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science (LIROMS), Luxembourg, Luxembourg
Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d’Eich, Luxembourg, Luxembourg
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Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland
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This review explores the intricate relationship between knee osteotomy and frontal plane joint line orientation, emphasizing the dynamic nature of the joint line’s influence on knee forces and kinematics.
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Consideration of coronal alignments, knee phenotypes, and associated angles (medial proximal tibial angle (MTPA), lateral distal femoral angle (LDFA), joint line convergence angle (JLCA)) becomes crucial in surgical planning to avoid joint line deformities.
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The double-level osteotomy is to be considered a valid option, especially for severe deformities; however, the target patient cannot be selected solely based on high predicted postoperative joint line obliquity (JLO) and MPTA.
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Major amputations of the lower extremity may be required after trauma and a variety of underlying diseases such as peripheral vascular disease, diabetes, and malignancies.
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The goal of any major amputation is an optimal functional result with a maximum limb length in combination with optimal wound healing. The preservation of the knee joint is essential for successful rehabilitation, and this is best achieved by the Burgess below-knee amputation (BKA).
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Whenever a BKA is not possible, the Gritti–Stokes amputation is our first choice.
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This technique mainly consists of a through-knee amputation with the creation of a pedicled patella flap consisting of the patella, patellar ligament, and overlying soft tissue. After osteotomy of the distal femur and resection of the articular surface of the patella, the anterior flap is rotated in order to cover the femur defect while performing a patellofemoral arthrodesis.
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The aim of this paper is to describe our surgical technique and experience with GSA and to point out the important steps of this procedure.
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In conclusion, GSA is an excellent surgical option for patients requiring major lower limb amputations where BKA cannot be considered. Particular attention must be paid to careful preoperative evaluation and optimization of comorbidities. A meticulous surgical technique is warranted, including atraumatic tissue handling and an optimal patellofemoral arthrodesis technique.
Institut du mouvement et de l’appareil locomoteur, Marseille, France
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Varus knees with associated cartilage pathologies are not uncommon scenarios that present to orthopaedic surgeons.
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There is no agreement on the ideal management of varus knees with concomitant cartilage pathology.
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Through a literature review, the authors tried to answer three main questions:
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On October 2022, OVID MEDLINE, EMBASE, and COCHRANE databases were searched. Clinical studies reporting on clinical, radiologic, or macroscopic cartilage regeneration following either isolated knee osteotomy or concomitant osteotomy and a cartilage procedure were reviewed.
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Despite controversies, the literature demonstrated favourable outcomes of combined knee osteotomy and a cartilage procedure in patients with substantial deformity and cartilage defects.
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Isolated high tibial osteotomy may induce cartilage regeneration in several scenarios and severities of concomitant malalignment and cartilage defects.
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There are recommendations that knee osteotomy should be added to a cartilage procedure when an extra-articular deformity of > 5° is detected.
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Some studies report good outcomes for combining a knee osteotomy with cartilage grafting, but they lack a control group of isolated osteotomy.
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There is still scarce of evidence on the influence of osteotomies on cartilage regeneration and the outcomes of concomitant osteotomy and different cartilage procedures vs isolated osteotomies.
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With advanced statistical evaluation (artificial intelligence, machine learning) of big datasets, more answers and better results will be delivered.
Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Objective
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This study aimed to provide the evidence of the role of addition hyaluronic acid immediate after arthroscopy in pain relief and functional recovery.
Methods
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A multiple databases search of the PubMed, the Cochrane Library, and Embase was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to identify randomized controlled trials that evaluate the effect the hyaluronic acid compared with placebo addition immediately after arthroscopy for degenerative arthropathy. Data related to postoperative pain using the visual analog scale, and functional scores, were extracted and analyzed using the RevMan software.
Results
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A total of five randomized controlled trials were included in this study. All patients showed significant pain relief after surgery at 2 weeks and 2 months, but no statistically significant differences between the hyaluronic group and control group were observed at 2 weeks and 2 months, respectively. This meta-analysis did not find a difference of WOMAC score between the two groups at 2 weeks (MD: 3.07; 95% CI: −0.66 to 6.81; I2 =39%; P = 0.11) and 2 months (MD: 5.47; 95% CI: −0.69 to 11.62; I2 =57%; P = 0.08), respectively.
Conclusion
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For patients with symptomatic degenerative arthropathy, adding hyaluronic acid immediately after arthroscopic surgery did not appear to provide patients with more pain relief and better functional recovery.
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Surgical intervention is the treatment of choice for recurrent lateral patellar instability.
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Surgery should be considered for first time lateral patella dislocations with osteochondral fractures or underlying anatomical risk factors.
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Primary repair and nonanatomical imbrications/reconstructions have fallen out of favor due to abnormal biomechanics and high rates of recurrence. Anatomical reconstruction of the MPFL using a variety of auto and allograft tissues have yielded good outcomes and low redislocation rates.
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Physeal sparing MPFL reconstruction techniques under radiological control are safe and do not cause growth disturbance. Allografts may be indicated for hyperlax patients.
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Although no clear cutoff points exist, correction of valgus and excessive femoral anteversion should be considered when indicated.
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Osteochondral and chondral injuries are common and should be addressed during surgery for instability.
Department of Orthopaedics, University Hospital of Ghent, Ghent, Belgium
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Department of Electromechanics, InViLab research group, University of Antwerp, Antwerp, Belgium
Department of Trauma and Orthopedics, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Purpose
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Emerging reports suggest an important involvement of the ankle/hindfoot alignment in the outcome of knee osteotomy; however, a comprehensive overview is currently not available. Therefore, we systematically reviewed all studies investigating biomechanical and clinical outcomes related to the ankle/hindfoot following knee osteotomies.
Methods
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A systematic literature search was conducted on PubMed, Web of Science, EMBASE and Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered on international prospective register of systematic reviews (PROSPERO) (CRD42021277189). Combining knee osteotomy and ankle/hindfoot alignment, all biomechanical and clinical studies were included. Studies investigating knee osteotomy in conjunction with total knee arthroplasty and case reports were excluded. The QUality Appraisal for Cadaveric Studies (QUACS) scale and Methodological Index for Non-Randomized Studies (MINORS) scores were used for quality assessment.
Results
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Out of 3554 hits, 18 studies were confirmed eligible, including 770 subjects. The minority of studies (n = 3) assessed both high tibial- and distal femoral osteotomy. Following knee osteotomy, the mean tibiotalar contact pressure decreased (n = 4) except in the presence of a rigid subtalar joint (n = 1) or a talar tilt deformity (n = 1). Patient symptoms and/or radiographic alignment at the level of the ankle/hindfoot improved after knee osteotomy (n = 13). However, factors interfering with an optimal outcome were a small preoperative lateral distal tibia angle, a small hip–knee–ankle axis (HKA) angle, a large HKA correction (>14.5°) and a preexistent hindfoot deformity (>15.9°).
Conclusions
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Osteotomies to correct knee deformity alter biomechanical and clinical outcomes at the level of the ankle/hindfoot. In general, these changes were beneficial, but several parameters were identified in association with deterioration of ankle/hindfoot symptoms following knee osteotomy.
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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Personalized Arthroplasty Society, Atlanta, Georgia, USA
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Advanced hemophilic knee arthropathy is a frequent and devastating manifestation of severe hemophilia with significant implications for activities of daily living.
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Hemophilic arthropathy is caused by repeated bleeding, resulting in joint degeneration, pain, deformity and disability.
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In patients with hemophilia and advanced disease, total knee arthroplasty (TKA) has proven to be the most successful intervention, improves physical function and reduces knee pain.
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Hemophilic patients carry additional risks for complications and required specific pre/postoperative considerations. Expert treatment center should be used to improve patient outcome.
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Hemophilic patients present significant surgical challenges such as joint destruction, bone loss, severe ankylosis and oligoarticular involvement. The surgeon performing the arthroplasty must be experienced to manage such problems.
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Purpose
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To systematically review and analyze the data available in the literature to evaluate the role of patellofemoral overstuffing in affecting clinical outcomes following primary total knee arthroplasty.
Methods
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A systematic literature review was conducted following the PRISMA guidelines. Only studies including primary total knee arthroplasty in the setting of osteoarthritis with a quantifiable method of measuring patellofemoral overstuffing using pre- and post-operative x-rays or advanced imaging, as well as reported subjective and/or objective patient outcomes in relation to patellofemoral overstuffing were included. Extracted data included patellofemoral overstuffing quantitative measurement method, outcome measurements, follow-up, patient demographics, author, and publication details. Descriptive analysis was provided for the available literature.
Results
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There were six included articles with a total of 2325 TKAs assessed. All papers found no significant effect on clinical outcomes when the amount of PFJ overstuffing was within reason.
Conclusion
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The amount of overstuffing that routinely takes place seems to be within tolerable limits and does not create a significant difference in clinical outcomes. Nevertheless, it is recommended to recreate the anatomic dimensions of the PFJ in order to best obtain a joint that is within this safe margin of error.
Hospital Militar de Santiago, Santiago, Chile
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Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
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Lateral hinge fractures (LHF) are one of the most common complications of medial opening wedge high tibial osteotomy (MOWHTO), and are the leading cause of construct instability displacement, non-union, and varus recurrence after this procedure.
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To date, Takeuchi’s classification is the most popular classification to describe this complication, and it can help surgeons to make intra and postoperative decisions.
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Opening medial gap width is the most recognized factor related to LHF occurrence.
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Recognizing the implications of LHF in patients’ clinical and radiographic results has led many authors to propose surgical tips and the use of osteosynthesis materials such as K-wires and screws for its prevention, which should be considered when identifying risk factors for LHF during preoperative planning.
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The evidence for determining the optimal management of LHF is scarce and mostly supported by experts’ opinions and recommendations; therefore, studies are still needed to identify the most appropriate behavior when dealing with such a complication.
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Despite the general success of anterior cruciate ligament reconstructions (ACL-R), there are still studies reporting a high failure rate. Orthopedic surgeons are therefore increasingly confronted with the treatment of ACL retears, which are often accompanied by other lesions, such as meniscus tears and cartilage damage and which, if overlooked, can lead to poor postoperative clinical outcomes.
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The literature shows a wide variety of causes for ACL-R failure. Main causes are further trauma and possible technical errors during surgery, among which the position of the femoral tunnel is thought to be one of the most important.
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A successful postoperative outcome after ACL-revision surgery requires good preoperative planning, including a thorough evaluation of patient's medical history, e.g. instability during daily or sports activity, increased general joint laxity, and hints for a low-grade infection. A careful clinical examination should be performed. Additionally, comprehensive imaging is necessary. Besides a magnetic resonance imaging, a CT scan is helpful to determine location of tunnel apertures and to analyze for tunnel enlargement. A lateral knee radiograph is helpful to determine the tibial slope.
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The range of surgical options for the treatment of ACL-R failure is broad today. Orthopedic surgeons and experts in Sports Medicine must deal with various possible associated injuries of the knee or unfavorable anatomical conditions for ACL-R.
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The aim of this review was to highlight predictors and reasons of failures of ACL-R as well as describe diagnostic procedures to individualize treatment strategies for improved outcome after revision ACL-R.
