Abstract:Knee osteoarthritis (OA) remains a leading cause of pain and disability, yet few nonoperative therapies have demonstrated durable clinical benefit or potential effects on structural disease progression. Pulsed electrical stimulation (PES) was investigated extensively over two decades, but this evidence has received little attention in the contemporary era of disease-modifying OA research. A structured evidence synthesis was performed of five principal prospective clinical investigations evaluating capacitively coupled PES for symptomatic knee OA. These included two randomized double-blind placebo-controlled trials, one multicenter phase IV investigation, one long-term observational study of arthroplasty deferral, and one histologic and radiographic study assessing structural cartilage changes. Collectively, the studies included 587 patients treated over more than 20 years. Clinical outcomes, functional improvement, medication utilization, safety, arthroplasty deferral, and structural findings were systematically reviewed and synthesized. Across investigations, PES consistently improved pain, physical function, physician and patient global assessments, and overall clinical status. Randomized controlled trials demonstrated significant improvements compared with placebo, while the multicenter phase IV study confirmed effectiveness in routine practice and identified a dose-response relationship, with superior outcomes following greater cumulative treatment exposure. Approximately 45% of patients reduced nonsteroidal anti-inflammatory drug use by at least 50%, and nearly 60% of compliant patients previously advised to undergo total knee arthroplasty deferred surgery for 4 years or longer. Tissue characterization in one patient, supported by radiographic observations in five additional patients, suggested hyaline-like cartilage formation and increased compartmental joint-space width. There were no serious device-related adverse events reported. More than two decades of prospective evidence suggest that PES improves pain, function, patient-reported outcomes, and clinical status while maintaining an excellent safety profile. These findings support a contemporary reappraisal of this technology as a nonoperative joint-preservation strategy for symptomatic knee OA.
Abstract:Despite increasing evidence showing major diversity in subjective balancing approaches, soft-tissue balance during total knee arthroplasty (TKA) remains primarily based upon empirical surgeon assessment. A quantitative technique for describing knee stiffness and laxity after TKA was previously introduced: the modified pendulum knee drop (PKD) test. This study expands upon prior validation work by evaluating the reproducibility of surgeon-directed balancing assessments compared with the modified PKD test across a larger cohort of arthroplasty surgeons. Robotic-assisted TKAs were performed on an advanced knee simulator model previously validated for ligament balancing investigations. After completing blinded polyethylene insert identification trials using manual balance assessments, eight high-volume arthroplasty surgeons underwent additional testing with the modified PKD test. During several testing cycles, polyethylene inserts ranging from 9 to 14 mm were randomly assigned and assessed. For both manual and PKD-assisted evaluations, accuracy, delta error, and intra- and interobserver reliability were computed. Stiffness and laxity behavior were described using oscillatory excursion measurements and logarithmic decrement values. Surgeons correctly identified polyethylene insert thickness manually in 60% of trials and within 1 mm in 84.2% of trials. In contrast, PKD-assisted balancing resulted in 97% correct insert identification (p < 0.001). The mean delta between surgeon-estimated and actual polyethylene thickness was 0.68 mm during manual assessment versus 0.05 mm with the PKD test (p < 0.001). Intraobserver reliability improved from a kappa of 0.61 during manual balancing to 0.96 with PKD assessment, while interobserver reliability improved from 0.38 to 0.97, respectively. The PKD test maintained highly reproducible thickness-independent stiffness ranking patterns across nearly all trials. High-volume arthroplasty surgeons demonstrated substantial variability during subjective soft-tissue balancing assessments, whereas the modified PKD test provided highly reproducible, objective biomechanical characterization of stiffness and laxity during TKA. These expanded findings further validate the PKD methodology as a reproducible tool to quantify soft-tissue knee laxity during robotic-assisted TKA.
INTRODUCTION:Golf is a widely played recreational sport, but degenerative osteoarthritis in older adults can limit participation and performance. This study prospectively evaluates recreational golfers' performance metrics of play, and clinical outcomes before and after total knee arthroplasty (TKA). METHODS:A prospective cohort of 10 recreational golfers undergoing primary TKA were assessed at a professional golf performance center preoperatively and at 3 months, and 1-year postoperatively. The mean age was 72 years, 90% were men, and 50% underwent TKA on the lead leg. . Participants averaged 67 rounds in the year prior to surgery, maintained a handicap index (HCP) of 18. Golf performance metrics (driver and 7-iron), force-plate biomechanics, return-to-play timing, quality of play, and Knee Injury and Osteoarthritis Outcome Score, Junior (KOOS-JR) were analyzed using descriptive statistics. RESULTS:At 1-year postoperatively, the mean changes in driver and 7-iron swing speed (+1.3 and -1.5 miles per hour (mph), respectively, 95% CI: -5, 4.7), ball speed (+3.5 and -2.6 mph, 95% CI: -12.9, 12.3), carry distance (-0.8 and +6.2 yards, 95% CI: -17.7, 17.1), maximum torque (+43 and +85 pounds per foot (lbs/ft), 95% CI: -30, 259), and vertical force (+93 and +119 lbs/ft, 95% CI: -175, 412). All patients returned to full golf rounds playing a mean 8 (SD: +5.7) and 44 (SD: +29.7) rounds by 3- and 12-months, respectively, with no change in HCP (P = 0.9). The KOOS-JR significantly improved (57 to 80, P = 0.01). CONCLUSION:Recreational golfers safely returned to play after TKA with no significant changes in swing performance or handicap, while patient-reported outcomes improved. These findings suggest TKA enables resumption of golf without compromising performance.
Abstract:Robotic Total Knee Arthroplasties (TKAs) have gained popularity over recent years, having been shown to achieve better component alignment than conventional TKAs. However, few studies have compared the different robotic systems. This study was conducted to compare the functional outcomes and implant positioning between a computed tomography (CT) based, semi-active robotic system and a CT-free, passive robotic system. A single-centre propensity score matched retrospective study was conducted comparing 181 CT-based and 113 CT-free cases. Patient reported outcome measures including Oxford Knee Score (OKS), Knee Society Score - Function (KSS-F), Visual Analogue Scale (VAS) pain score and Passive Range of Motion (ROM) were evaluated preoperatively and at 3 months, 1 year and 2 years postoperatively. Postoperative radiographs including lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), hip knee angle (HKA), femoral flexion and posterior tibial slope (PTS) were also measured. Postoperatively, the CT-based group had better KSS-F scores at 1 year (78.2 vs. 65.9) and 2 years (78 vs. 72), exceeding previously documented MCIDs. Better OKS scores were also demonstrated at 2 years (41.7 vs. 39.8) in the CT-based group. However this does not exceed previously documented MCIDs and is likely clinically insignificant. There was no significant observable difference in VAS pain score and passive ROM. The CT-based group also demonstrate better surgical accuracy, with MPTA (90.0° vs. 87.8°) and HKA (_0.22° vs. _2.52°) closer to planned targets of mechanical alignment. Femoral flexion (3.22° ± 0.37° vs 0.15° ± 0.47°, p = 0.001) was also closer to the target of 3° of flexion. There was no significant difference in posterior tibial slope. We conclude that a CT-based, semi-active robotic system resulted in better functional outcomes and implant positioning than a CT-free passive robotic system.
Abstract:Manipulation under anesthesia (MUA) is a noninvasive intervention commonly performed after total knee arthroplasty (TKA) for persistent knee stiffness unresponsive to conservative measures. Adjunctive strategies, including periarticular injections and regional anesthesia, have been proposed to improve pain control and outcomes following MUA. This study evaluated whether adductor canal block (ACB) at the time of MUA reduces postoperative opioid use and improves range of motion (ROM). We performed a retrospective review of 83 consecutive patients undergoing MUA after TKA between October 2021 and April 2024 at a single institution. All patients after June 28, 2023, were offered ACB per an initiative set by the institution's Department of Anesthesia. Patients receiving ACB after the initiative were compared with controls prior to the initiative. Five patients were excluded (four lost to follow-up, one due to concomitant open lysis of adhesion), leaving 78 patients: 39 received ACB and 39 served as controls. Demographic variables collected included age, sex, and relevant medical comorbidities. Clinical variables comprised time to manipulation, pre- and postmanipulation ROM, and postoperative opioid prescription data. Mean time to MUA was 76.6 days after TKA; controls underwent earlier manipulation (64.2 days vs. 88.9 days). Premanipulation ROM ranged from 4.3 to 84.1 degrees in controls and 2.8 to 85.5 degrees in the ACB group. At 2 weeks, ROM improved to 2.5 to 102.7 degrees and 1.2 to 101.8 degrees, respectively (p = 0.821). Eighteen patients (23.1%) received opioid prescriptions within 30 days, most commonly oxycodone 5 mg. Opioids were prescribed to seven (17.9%) of controls and eleven (28.2%) of ACB patients (p = 0.345). Mean morphine milligram equivalents were 43.7 (SD: 115.9) and 70.6 (122.3), respectively (p = 0.225). The remaining patients did not require opioid prescriptions during the postmanipulation period. MUA resulted in short-term ROM improvement regardless of ACB use. Although the ACB group underwent later manipulation, both groups achieved comparable gains at 2 weeks. ACB was not associated with reduced opioid prescribing or improved ROM, suggesting no measurable benefit in this setting.
Abstract:Unicompartmental knee arthroplasty (UKA) is a cost-conscious, minimally invasive surgical option for patients with isolated compartment disease. Because UKA is an increasingly common and outpatient procedure, it serves as a model for evaluating the effects of hospital price transparency legislation. This study investigated the association between state-level policy and socioeconomic factors on hospital-reported UKA pricing. This cross-sectional analysis included hospital-reported gross charges for UKA (CPT 27446) from the Turquoise Health database across the 50 states in the United States. Multivariable linear regression assessed associations between UKA price and state partisanship (0-5 scale: Democrat to Republican), Certificate of Need (CON) laws, Medicaid expansion, and care setting (inpatient or outpatient). A secondary analysis of North Carolina hospitals assessed the influence of Area Deprivation Index and urbanization on within-state price variation. Among 141,541 reported UKA prices from 2,522 facilities, lower gross charges were associated with states with Republican affiliation (β = $286.9; p < 0.0001), presence of CON laws (β = - $799.8, p < 0.0001), and outpatient settings (β = - $386.0, p < 0.0001). Medicaid expansion was associated with increased pricing (β = +$468.3, p < 0.0001). In North Carolina, hospitals in high ADI counties listed significantly lower prices (β = - $2,727.4, p = 0.014); urban location was not significant. Gross charges for UKA vary by state policy environment and care setting. Lower prices were observed in states with Republican leaning, CON laws, high-deprivation regions, and outpatient settings, whereas higher prices were associated with Medicaid expansion. These findings highlight the complex role of policy in shaping equitable access to affordable orthopedic care.
Abstract:Patellar resurfacing in primary total knee arthroplasty (TKA) has been debated for decades. This study aimed to evaluate cost-effectiveness and clinical outcomes of patellar resurfacing in modern TKA at a high-volume arthroplasty center. A retrospective study was conducted on 4,534 patients who underwent unilateral, elective, primary TKA from 2021 to 2024 at an urban academic institute. Patients were stratified by patellar resurfacing: resurfaced (n = 3,753) or not (n = 781). Baseline characteristics, operative costs (implants, anesthesia, operating room time), and postoperative outcomes (revision incidence) were collected. The median follow-up was 2.0 years (1.0-4.8). The individual cost of patellar component was adjusted for implant manufacturer and cementation out of total implant cost. Multivariable regression analysis determined added operating room time (ORT) due to patellar resurfacing, controlling for body mass index, usage of robotics, navigation, and cementation. Relative costs of added ORT and the patellar component were compared with total implant and procedure costs of patellar-resurfacing operations. The patellar component accounted for an average of 7.9% of the total implant cost in patellar-resurfacing operations. Patellar-resurfacing operations had longer operative times (112.2 vs. 105.4 minutes, p < 0.001), and multivariable regression determined patellar resurfacing is associated with an added 6.3 minutes of total ORT (p < 0.001). The patellar component implant cost and the cost of added ORT due to resurfacing accounted for 4.5% of the total procedure cost in resurfaced group. Resurfaced group had an overall 5% higher total operative cost than the non-resurfaced group. No differences existed in length of stay (LOS), discharge disposition, or all-cause and patella-specific revision incidence. We found that patellar resurfacing was associated with longer operative times and greater implant and procedure costs, although there was no effect on LOS, discharge disposition, or all-cause and patella-specific revision incidence. Ultimately, the decision to resurface the patella in primary TKA should be based on patient-specific indications and clinical judgment. However, it is important to consider the additional cost associated with this procedure. Level of evidence is III.
Abstract:Contemporary anterior cruciate ligament reconstruction (ACLR) techniques have evolved, but whether these changes differ by sex remains unclear. This study evaluated sex-based temporal trends in graft selection, fixation strategy, and suture augmentation after primary ACLR. Following Institutional Review Board approval, a retrospective cohort study was performed within a large multicenter health system, which evaluated all primary ACLR procedures performed between 2014 and 2022 and were identified using Current Procedural Terminology code 29888. Adult patients (≥18 years) were included, while those with multiligamentous injuries or revision ACLR were excluded. Demographic and operative variables were analyzed by sex, and temporal trends were assessed using correlation and categorical analyses. A two-sided p-value <0.05 was considered statistically significant. Of 2,695 primary ACLR procedures identified, 1,781 met inclusion criteria, including 583 female patients (32.7%) and 1,198 male patients (67.3%), with a mean age of 31.2 ± 10.6 years. Autograft was used in 1,162 cases (65.2%). Autograft utilization was lower in females than males (58.5% vs. 68.5%, p < 0.001). Among females ≤25 years, allograft use declined from 26.3% in 2014 to 0.0% by 2022 (r = - 0.722, p = 0.015). Overall quadriceps tendon graft utilization, including both autograft and allograft sources, increased in both sexes, reaching 20.5% in females and 16.7% in males by 2022. In temporal analyses, quadriceps tendon allograft utilization increased among females (r = 0.719, p = 0.029), while quadriceps tendon autograft utilization increased among males (r = 0.772, p = 0.015). Suspensory fixation (r = 0.703, p = 0.034) and suture augmentation (r = 0.765, p = 0.016) increased significantly among female patients over time, while pin fixation declined in both females (r = - 0.692, p = 0.039) and males (r = - 0.765, p = 0.016). These findings demonstrated that contemporary ACLR technique selection evolved in a sex-specific manner, with distinct patterns in graft adoption and fixation strategy consistent with changing operative preferences over time.
Abstract:Few studies assess the impact of prior knee surgery on long-term total knee arthroplasty (TKA) outcomes. This study investigates the effect of prior ligament reconstruction on TKA revision rates, modes of failure, and patient-reported outcome measures (PROMs). All males undergoing primary TKA from January 1999 to July 2024 from the New Zealand Joint Replacement Registry were included, with a median follow-up of 7.2 years. Patients with previous knee ligament reconstruction were compared with those without. The primary outcome was all-cause revision with results stratified by age. Secondary outcome measures were modes of failure and 6-month and 5-year Oxford Knee Scores (OKS). Age, sex, American Society of Anesthesiologists (ASA) score, body mass index, fixation, bearing, patella resurfacing, and surgery year were examined as potential confounders. Revision rates with 95% confidence intervals (CI) were calculated using Poisson approximation. Multivariate Cox proportional hazards assessed the independent relationship between ligament reconstruction and revision. A total of 73,355 TKAs were performed; 1,440 (2.0%) with previous ligament reconstruction surgery and 71,915 (98.0%) without. Patients with previous ligament reconstruction were younger (58.7 [8.7] vs. 68.3 [8.8] years) and had lower ASA scores, less cemented fixation, more posterior-stabilized bearings, and more patella resurfacing (all p < 0.001). The unadjusted risk of revision was higher in those with previous ligament reconstruction (hazard ratio [HR]: 1.90 [95% CI: 1.54-2.35], p < 0.001) with 15-year cumulative percent revision (CPR) 12.9 versus 6.1%. This difference was more profound in younger patients (age < 40: 15-year CPR 33.3 vs. 10.0%; age 40-54: 15-year CPR 16.6 vs. 11.8%). Adjusted multivariate analysis showed a nonstatistical difference in revision risk (HR: 1.25 [95% CI: 0.99-1.59], p = 0.064). No statistical differences for modes of failure and no clinically significant differences in 6-month nor 5-year OKS were seen. In men with previous knee ligament reconstruction surgery undergoing TKA, revision risk appeared higher, particularly in younger patients, but the difference was attenuated and no longer statistically significant after adjustment for confounders, especially in younger patients, but PROMs remain similar.
Abstract:The incidence of periprosthetic distal femur fractures after total knee arthroplasty (TKA) is increasing in parallel with the increasing number of primary TKA procedures being performed. This number will continue to rise going forward. Treatment decisions depend on patient factors, fracture characteristics, and implant stability. It is important to have a thorough understanding of the available modalities for treatment, including their indications, advantages, and disadvantages, to effectively manage these injuries and optimize outcomes. Nonoperative treatment is indicated in select cases but is generally associated with inferior outcomes, including higher rates of nonunion, malunion, and medical complications secondary to prolonged immobility. Operative management is the gold standard, and options include open reduction internal fixation (ORIF) with plates and screws, intramedullary nailing (IMN), nail/plate combination constructs, and revision arthroplasty with distal femoral replacement (DFR). Locking plate fixation can be useful for comminuted or more complex fractures and poor bone stock, while IMN is less invasive, preserving biology and allowing for earlier mobilization in some cases, especially when combined with plating. DFR is indicated for cases of implant loosening or severe bone loss and has been associated with more reliable early weight-bearing at the expense of increased risks for infection and revision arthroplasty. Overall, each of the treatment modalities discussed is a viable option for the management of these complex injuries. Management should ultimately be tailored to the individual patient. The surgeon should consider patient factors, fracture characteristics, implant stability, and their own level of expertise when deciding on treatment.
Abstract:Conflicting findings exist regarding the association between obesity and functionality after total knee arthroplasty (TKA). We aimed to compare knee extensor mechanism function, knee function, and knee flexion range of motion between obese and nonobese patients who underwent simultaneous bilateral TKA. A total of 153 patients were divided into two groups as the obese (N = 99) and nonobese (N = 54) groups. The groups were compared for knee extensor mechanism function (chair-rise test), knee function (Hospital for Special Surgery [HSS] knee score), and knee flexion range of motion. The follow-up period was 2 years. In the chair-rise test, no statistically significant group-by-time interaction (χ2 (5) = 1.29, p = 0.93) or main effect of group (χ2 (1) = 0.02, p = 0.90) was found. For the HSS knee score, neither the group-by-time interaction (F (5, 728.17) = 0.17, p = 0.97) nor the main effect of group (F (1, 146.79) = 2.21, p = 0.14) was statistically significant. Regarding knee flexion range of motion, the group-by-time interaction was not statistically significant (F (5, 728.01) = 0.10, p = 0.99), whereas the main effect of group was statistically significant (F (1, 146.81) = 4.19, p = 0.04), with the obese group exhibiting lower knee flexion range of motion than the nonobese group. Obese and nonobese patients show similar improvements in knee extensor mechanism function, knee function, and knee flexion range of motion during the 2 years following simultaneous bilateral TKA. Obese patients have lower knee flexion range of motion compared with nonobese patients over the 2-year period after TKA. At the end of 2 years after TKA, both obese and nonobese patients achieve satisfactory results in all outcomes.
Abstract:Radiofrequency ablation (RFA) has been shown to be effective in relieving pain in patients with osteoarthritis of the knee. There is a paucity of literature on the effectiveness of RFA in patients with persistent pain following total knee arthroplasty. A prospective observational trial of 20 patients with pain lasting greater than 12 months following a total knee arthroplasty. Patients were treated with a single session of cooled RFA to the genicular nerves under ultrasound guidance. Outcome measures were the numeric rating scale (NRS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and patient perceived effect. Patients were followed at 13, 26, and 52 weeks following treatment. Patients showed a significant improvement in NRS pain at 13 (median: 4, interquartile range [IQR]: 3.5), 26 (median: 3, IQR: 4.5), and 52 (median: 5, IQR: 5.5) weeks when compared with baseline (median: 8, IQR: 1.75; p < 0.05). Patients also demonstrated significant improvements in WOMAC pain, function, and overall scores from 13 to 52 weeks and WOMAC stiffness from 26 to 52 weeks (p < 0.05). This study found that cooled RFA led to decreases in patient-reported pain and increases in patient-reported function through 12 months. Future studies should look to evaluate cooled RFA against a control group and provide longer follow-up to determine the total duration of effect.
Abstract:The incidence of periprosthetic and native distal femoral fractures is rising with the increasing utilization of total knee arthroplasty and an aging global population. These injuries present significant clinical challenges, most commonly affecting elderly patients. While fixation-based strategies remain widely employed, distal femoral replacement has emerged as an increasingly utilized alternative. The purpose of this narrative review is to examine the current indications, implant considerations, and clinical evidence supporting the use of distal femoral replacement in the management of both periprosthetic and native distal femoral fractures. Distal femoral replacement demonstrates broadly equivalent outcomes to conventional fixation and allows for immediate full weight-bearing and expedited rehabilitation, which is particularly important in elderly patients. Surgeon expertise, familiarity with available implant systems, and a coordinated multidisciplinary perioperative approach are important contributors to optimizing outcomes. Distal femoral replacement is a safe, reliable, and increasingly relevant treatment strategy for carefully selected patients presenting with periprosthetic or native distal femoral fractures. It is most appropriately indicated in elderly or low-demand patients with severe metaphyseal comminution, significant osteoporosis, preexisting osteoarthritis, a loose or malrotated femoral component, or fractures not amenable to stable internal fixation. Future prospective studies and randomized controlled trials are needed to better define patient selection criteria, standardize outcome reporting, and formally evaluate cost-effectiveness.
Abstract:The purpose of this study was to determine the percentage of implants successfully deployed during arthroscopic all-inside meniscal repair. A data query of meniscus repair (Current Procedural Terminology [CPT] codes: 29882 and 29883) procedures was performed at a single institution. The query was limited to include procedures performed between June 1, 2020, and June 1, 2023. Multiple different manufacturer implants were used by five sports medicine fellowship-trained orthopaedic surgeons. The number of implants successfully used and the number of implants wasted due to intraoperative failure during meniscal repair were found on EPIC and documented for each procedure. The success rate of meniscal implants was determined by dividing the number of implants wasted by the total number of implants used. The query identified 1,026 patients who underwent meniscus repair. From this cohort, 3,867 total meniscal implants were utilized for an average of 3.77 implants per case. Overall, all-inside meniscus repair was found to have a low implant failure or waste rate (1.03% [n = 40]). The highest failure rates were found with JuggerStitch Curved (9.38%), NOVOSTITCH Cartridge 0 Suture (2.44%), and TRUESPAN 12 Degrees (2.11%) implants. The most important finding was that the overall failure rate of meniscal implants is low. Implants with higher waste rates should be addressed by the industry and considered by surgeons when selecting surgical implants. These preliminary findings establish the necessity to further examine the implant failure rate and the associated costs of meniscus repair.
Abstract:Bone tunnel widening following anterior cruciate ligament reconstruction (ACLR) is a well-recognized radiological phenomenon with multifactorial etiology. While concerns have been raised regarding potentially greater tunnel enlargement with allografts due to immune-mediated responses, evidence remains inconsistent. This study compared long-term femoral and tibial tunnel widening between hamstring autograft and allograft reconstruction at a mean follow-up exceeding 10 years. A retrospective analysis was conducted on 60 patients who underwent primary ACLR between 2011 and 2016 by a single surgeon. Group I consisted of 29 patients receiving soft tissue allografts (Achilles, tibialis anterior, or peroneus longus tendons), while Group II included 31 patients with four-strand hamstring autografts. All procedures utilized identical fixation: adjustable-loop suspension device (femur) and bioabsorbable interference screw with tibial staple. Patients with previous knee surgery, re-rupture, clinical graft failure, concomitant ligament procedures, or significant chondral lesions were excluded. Computed tomography scans at final follow-up (mean: 10.7 years) were analyzed using standardized oblique reformatted sections perpendicular to tunnel axes. Six measurements per tunnel (three levels × two planes) were averaged. Tunnel widening was expressed as absolute change (Δmm) and percentage relative to intraoperative drill bit diameter. Two blinded orthopedic surgeons performed independent measurements. Statistical analysis included Mann-Whitney U test, analysis of covariance adjusted for body mass index (BMI) and follow-up duration, categorical threshold analysis, and correlation analysis with Bonferroni correction. No significant differences were observed between groups for tibial widening (allograft 2.07 ± 1.75 mm vs. autograft 2.31 ± 1.72 mm, p = 0.500) or femoral widening (1.73 ± 1.48 mm vs. 2.30 ± 1.63 mm, p = 0.157). After adjustment for BMI and follow-up duration, between-group differences remained nonsignificant (all adjusted p > 0.0125 after Bonferroni correction). Categorical distribution across predefined thresholds showed similar patterns. Initial tunnel diameter inversely correlated with tibial percentage widening (r =-0.373, p = 0.003). Interobserver reliability was excellent (intraclass correlation coefficient: 0.89-0.92). At long-term follow-up, allograft and hamstring autograft demonstrated comparable tunnel widening patterns, suggesting graft selection should prioritize clinical factors beyond tunnel enlargement concerns.
Abstract:Tunnel malposition is a frequent complication of anterior cruciate ligament (ACL) reconstruction. We evaluated whether the tibial tunnel location of patients who underwent anatomical single-bundle ACL reconstruction with hamstring tendons affected knee stability, muscle strength, and clinical outcomes. We retrospectively evaluated operated and normal knee magnetic resonance imaging (MRI) scans of 34 patients who underwent anatomical single-bundle ACL reconstruction technique with hamstring tendons. Tibial tunnel location was measured according to two techniques: anatomical landmarks of the tibial footprint and contralateral normal knee ACL anatomical scans. The effect of tibial tunnel location on knee stability, isokinetic and single-leg hop test (SLHT) results, and Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC-2000) scores was evaluated. For tunnel position evaluated by anatomical landmark methods, patients were defined as regular footprint in 23 patients, anterior in 5, and posterior in 6. Similarly, tibial tunnel positions evaluated by contralateral footprint: 20 patients were grouped as regular, 4 as anterior, 6 as posterior, and 4 as medial tibial tunnel position. Groups were compared according to both techniques. KOOS pain scores were significantly different in posterior tunnel position patients compared to patients with regular position (p = 0.023). No significant difference was found between the pivot shift, Kneelax 3 anterior translation, and SLHT, and leg symmetry index (LSI). Isokinetic test results and IKDC and other KOOS scores of all groups were similar. The kappa value between two measurement techniques was 0.681, and the agreement between techniques was 82% (p < 0.001). Tibial tunnel position may not be optimal because of technical reasons. Tunnel malposition does not significantly affect the stability and clinical outcomes of the patients in mid-term results. We can evaluate the tibial tunnel only with the operated knee's routine control MRI scans.
Abstract:Despite increasing evidence supporting the efficacy of repair for most meniscus tear types, research assessing the outcomes of repair of complex tears is limited. The purpose of this study is to analyze failure risk and postoperative complications following repair of complex meniscus tears. A retrospective review of medical records was performed for patients who underwent meniscus surgery between 2011 and 2022 at a single academic medical center. Only patients with a complex meniscus tear treated through repair with a minimum follow-up period of 2 years were included. Patients were evaluated for demographic information (age, sex, BMI, race, smoking status), surgical information (type of tear), failure of meniscus repair, and postoperative complications. Failure of meniscus repair was defined as repeat surgery on the index meniscus (including meniscectomy or revision repair) or total knee arthroplasty. A total of 77 patients underwent repair of a complex meniscus tear during the study period (mean age, 32.6 ± 13.9 years; BMI, 28.5 ± 6.5 kg/m2) with an average follow-up time of 4.6 years. Overall, 17 (22.1%) patients had a failure of their meniscus repair, of which 14 underwent partial meniscectomy, 2 underwent a total knee arthroplasty, and 1 had a revision repair. On univariate analysis, previous knee surgery was the only significant predictor of postoperative failure when considering lateral meniscus repairs (p = 0.036) in isolation. All other demographic and surgical variables were statistically insignificant. The only postoperative complication seen acutely after surgery was a surgical site infection (1/77, 1.3%) managed by oral antibiotics. Patients with complex meniscus tears who underwent repair demonstrated a 22.1% failure rate at 4.6 years after surgery and demonstrated a low incidence of acute postoperative complications. Level of evidence is IV.
Abstract:Cyclops lesions are a common postoperative complication that occurs in up to 47% of patients after anterior cruciate ligament reconstruction (ACLR), often resulting in painful extension loss. While risk factors for cyclops lesions have been identified, the influence of graft fixation technique on the development of symptomatic cyclops lesions remains unknown. A retrospective cohort study was conducted on 1,245 patients who underwent primary ACLR between January 1, 2015 and December 31, 2021. Patient demographics, pre-/postoperative metrics, graft type, and fixation methods were collected. The primary outcome was development of symptomatic cyclops lesions, confirmed by clinical exam and magnetic resonance imaging or surgical debridement. Statistical analysis included Kaplan-Meier survival analysis and mixed-effects logistic regression to determine predictors of lesion development. All-suspension fixation showed a significantly higher cyclops lesion rate (12.34%) compared with the other methods (4.2%, p < 0.01) and was the strongest predictor of cyclops lesion development (odds ratio [OR]: 9.208, 95% CI [1.773, 47.836]). Female sex and Black race were also significant predictors. Graft type did not significantly affect lesion risk in multivariable analysis. The all-suspension tibial-sided fixation technique significantly increases the risk of symptomatic cyclops lesion development, independent of graft type, or patient-specific factors. Biomechanical factors such as sagittal plane micro-motion and local tissue response may contribute to this increased risk. Recognition of fixation-related risk may inform surgical decision-making and postoperative management.
Abstract:Restoring knee joint range of motion is a key objective after total knee arthroplasty (TKA), as it strongly influences functional outcomes. This study evaluated the efficacy of repeated knee flexion maneuvers performed after wound closure on clinical outcomes following one-stage simultaneous bilateral TKA. In this prospective, double-blinded, randomized controlled trial, 46 patients (92 knees) were randomized to determine the intervention side, which involved 15 repetitions of deep knee flexion and full extension after wound closure. The contralateral knee served as the control. Outcomes included active knee flexion angles, extension lag (EL), and pain intensity measured by the visual analog scale (VAS). Active knee flexion angles were significantly greater in the intervention group on postoperative day 1 (mean difference of 6.9 degrees, 95% confidence interval [CI]: 3.8-10.0, p < 0.001), day 2 (mean difference of 4.8 degrees, 95% CI: 1.7-8.0, p = 0.003), day 3 (mean difference of 6.3 degrees, 95% CI: 3.1-9.4, p < 0.001), and at 2 weeks (mean difference of 5.4 degrees, 95% CI: 2.3-8.6, p < 0.001). The EL was lower in the intervention knee, with statistical significance observed on postoperative day 1. VAS pain scores were also significantly lower in the intervention knee at 2 weeks postoperatively, although the difference remained below the clinically meaningful threshold. Repeated knee flexion maneuvers after wound closure improved active knee flexion during the first 2 weeks after TKA. However, these differences did not persist beyond the early postoperative period, and final knee flexion outcomes were similar between groups. This study was registered in the Thai Clinical Trials Registry database (no. TCTR20230314002).
Abstract:Structural cartilage restoration strategies provide mechanical solutions for focal knee chondral defects in which biologic repair alone is unlikely to withstand load-bearing demands. These approaches are most applicable to discrete lesions in otherwise preserved joints where restoration of articular congruity and immediate mechanical stability are required. This review evaluates focal resurfacing implants and osteochondral autograft transfer system procedures as structural joint-preserving interventions. Contemporary metal and polymer-based focal implants demonstrate meaningful short- to mid-term improvements in pain and function. However, registry data and meta-analyses reveal variable survivorship and revision risk, frequently related to progressive osteoarthritis or implant-related complications. Outcomes are highly dependent on appropriate patient selection and precise implant positioning. Osteochondral autograft transfer system procedures and mosaicplasty restore mature hyaline cartilage and subchondral bone using autologous osteochondral plugs. Long-term series extending beyond a decade support durable outcomes in small, contained lesions. Donor-site morbidity, graft contouring limitations, and size constraints, however, restrict broader applicability. Comparative data highlight trade-offs between mechanical resurfacing and cartilage transfer. Implants avoid donor harvest, but introduce device survivorship concerns and complex revision pathways. Autograft transfer offers established durability with native tissue, but carries technical constraints and harvest-related morbidity. Structural restoration strategies occupy a defined position within the cartilage preservation continuum. Their success depends on alignment between defect characteristics, patient activity demands, and the surrounding joint environment. When applied within appropriate indications, these techniques can provide durable symptom relief, though none of them eliminates the risk of progression to arthroplasty.
