Knee Surgery, Sports Traumatology, Arthroscopy

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  1. Abstract

    Purpose

    The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar instability.

    Methods

    Using PRISMA guidelines, a systematic review of studies reporting outcomes following surgical intervention for patellar instability was conducted using Pubmed, Cochrane, OVID Medline, and Google Scholar. Subgroup analysis of articles reporting at least two PROs with baseline and follow-up data were used to evaluate responsiveness of instruments using relative efficiency and effect size.

    Results

    From the search, 2,848 unique articles were found, of which 178 were included in final analysis (7,122 patients, mean age 22.6, 63.6% female). The most commonly used PRO was the Kujala score (79.2%), followed by the Lysholm (34.8%), and Tegner (30.9%). Seventy-nine articles were eligible for subgroup analysis. The Kujala had a higher relative efficiency than ten of the 14 instruments to which it was compared but had lower relative efficiency compared to the IKDC and Lysholm scores. The Banff Patella Instability Instrument (BPII) and the Norwich score, condition-specific tools, were unable to be fully assessed due to rarity of use and lack of comparisons.

    Conclusion

    The hypothesis that the Kujala score is the most commonly used PRO for patellar instability, although other instruments offer greater efficiency was supported by our results. The IKDC and Lysholm scores had similar effect sizes but higher relative efficiencies than the Kujala, thus suggesting better responsiveness. This analysis adds useful information for surgeons on the effectiveness of the most common PRO’s for evaluating patellofemoral instability outcomes.

    Level of evidence

    Level III.

  2. Abstract

    Purpose

    The aim of this study is to evaluate the return to sport after surgical treatment of shoulder injuries in professional goalkeepers in relationship with the mechanism of injury and the pattern of related shoulder lesions.

    Methods

    Twenty-six shoulders in nineteen elite male professional soccer goalkeepers were retrospectively analyzed considering multiple diseases (instability, rotator cuff, biceps or other tendon injuries). Data was collected for injury modality and context, pathological findings, surgical procedures, time, level of return to sport, and complications.

    Results

    The mechanism of injury was “mild trauma without contact” in 46% of the cases and 54% of injuries happened during training. 11 patients (42%) reported multiple pattern lesions and 9 patients (35%) classic anterior instability lesions. The mean time for return to differentiated training and unrestricted sport activity was 14 and 20.2 weeks, respectively. 15 athletes (62.5%) reported 100% return to sport, 4 (16.7%) to 90%, 1 (4.2%) to 85%, 3 (12.5%) to 80% and 1 athlete to 50%, stopping professional activity. 21% of the cases reported the persistence of some shoulder symptoms. 3 cases experienced a new injury. Patients with classic anterior instability had significantly lower age (30.7 vs 19.8 years, P = 0.001), experienced injury in different context and reported symptoms more frequently compared to multiple lesion patients (4/8 vs 0/10, P = 0.011).

    Conclusion

    Professional elite goalkeepers which required shoulder surgery for different causes demonstrated high-rate level of return to play despite the persistence of mild symptoms. The high frequency of multiple lesions, patients’ characteristics, injury context and mechanism, increase the concern for injuries in overstressed shoulder for this category of sport.

    Level of evidence

    IV.

  3. Abstract

    Purpose

    The purpose of the study was to determine the long-term survivorship, functional outcomes of a single-design condylar constrained (CCK) TKA in primary and revision cases as well as to assess specific risk factors for failure. It was hypothesized that primary CCK TKA had a better survival than revision knees.

    Methods

    One hundred and forty three patients who underwent revision TKA (n = 119) or complex primary TKA (n = 24) using a single-design condylar constrained knee system (Genesis CCK, Smith & Nephew) performed at a single institution between 1999 and 2008 were retrospectively included. The median follow-up amounted to 11.8 years (IQR 10.3–14.4). Implant survivorship was analyzed using Kaplan–Meier survival estimates and multivariate Cox regression analysis to identify risk factors for failure. Function was determined using the Oxford Knee Score (OKS).

    Results

    The implant survival was 86.4% after five, 85.5% after ten and 79.8% at 15 years. A reduced implant survivorship was found in males (HR 5.16, p = 0.001), smokers (HR 6.53, p = 0.004) and in obese patients (HR 2.26, p = 0.095). Patients who underwent primary TKA had a higher revision-free implant survivorship compared to revision TKA at 15 years (100% vs. 76%, p = 0.036). The main cause for re-revision was infection in 10% of all revision TKA performed with the CCK design included, while no case was revised for instability.

    The median OKS was 39 (IQR 35–44) in 102 patients available for long-term functional outcome.

    Conclusion

    CCK implants are associated with excellent long-term survival when used in primary TKA; however, survival was worse when used during revision TKA. Males, smokers, obese patients and are at higher risk for revision. While instability and aseptic loosening were rare, infection remains a major concern.

    Level of evidence

    Level IV, retrospective observational study.

  4. Abstract

    Purpose

    Alignment errors in medial unicompartmental knee arthroplasty (UKA) predispose to premature implant loosening and polyethylene wear. The purpose of this study was to determine whether a novel CT-free robotic surgical assistant improves the accuracy and reproducibility of bone resections in UKA compared to conventional manual instrumentation.

    Methods

    Sixty matched cadaveric limbs received medial UKA with either the ROSA® Partial Knee System or conventional instrumentation. Fifteen board-certified orthopaedic surgeons with no prior experience with this robotic application performed the procedures with the same implant system. Bone resection angles in the coronal, sagittal and transverse planes were determined using optical navigation while resection depth was obtained using calliper measurements. Group comparison was performed using Student’s t test (mean absolute error), F test (variance) and Fisher's exact test (% within a value), with significance at p < 0.05.

    Results

    Compared to conventional instrumentation, the accuracy of bone resections with CT-free robotic assistance was significantly improved for all bone resection parameters (p < 0.05), other than distal femoral resection depth, which did not differ significantly. Moreover, the variance was significantly lower (i.e. fewer chances of outliers) for five of seven parameters in the robotic group (p < 0.05). All values in the robotic group had a higher percentage of cases within 2° and 3° of the intraoperative plan. No re-cuts of the proximal tibia were required in the robotic group compared with 40% of cases in the conventional group.

    Conclusion

    The ROSA® Partial Knee System was significantly more accurate, with fewer outliers, compared to conventional instrumentation. The data reported in our current study are comparable to other semiautonomous robotic devices and support the use of this robotic technology for medial UKA.

    Level of evidence

    Cadaveric study, Level V.

  5. Abstract

    Purpose

    Ultrasound with superb microvascular imaging (SMI) is a novel microvascular imaging technology which may be useful to assess the vascularity of the torn anterior cruciate ligament (ACL) as a potential measure of healing potential following surgery. This study aimed to quantify the vascularity of the torn and intact ACL using ultrasound with SMI.

    Methods

    23 patients (mean age ± standard deviation, 27.1 ± 12.8 years), who were diagnosed with an ACL tear with an intact contralateral ACL were enrolled (ACL injury group). Ten healthy volunteers (36.1 ± 4.9 years) who had intact ACLs in both knees were also recruited (ACL healthy controls). The vascularity of the ACL was assessed using SMI within 15 mm from the tibial insertion in both knees. The amount of the vascular signal was assessed using a semi-quantitative grading scale (vascularity grade: grade 0–3) and a quantified ratio of vascularized area with respect to total area of the region of interest (vascularity ratio).

    Results

    In the ACL injury group, a significantly higher vascularity grade and ratio were observed in the torn ACL (vascularity grade 0–3: 1, 8, 7, and 7 patients, respectively; vascularity ratio: 1.3 ± 1.4%) than the contralateral intact ACL (vascularity grade 0–3: 21, 1, 1, and 0 patients, respectively; vascularity ratio: 0.1 ± 0.5%) (P < 0.001), whereas no significant difference was observed between both ACLs in the ACL healthy control group.

    Conclusions

    SMI was useful to assess the increased vascularity in torn ACL, which may reflect the potential for, or state of, ACL maturation following reconstruction or repair.

    Level of evidence

    Level III.

  6. Abstract

    Purpose

    To assess the recovery of extension and improvement in functional scores after an arthroscopic or open posterior knee capsulotomy in the setting of an extension deficit.

    Methods

    A systematic search of articles published between 1980 and 2020 was performed in the MEDLINE/PubMed database, EMBASE/Ovid database and Web of Science database. The inclusion criteria consisted of patients with primary extension deficits > 5° who underwent an arthroscopic or open posterior knee capsulotomy. The assessed outcomes were preoperative and postoperative range of motion and functional outcome scores. Randomized controlled trials, cohort studies and case series with a follow-up longer than 6 months were included. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for case series. The certainty of evidence was assessed using the GRADE approach.

    Results

    Of 226 records identified through database searching, 7 studies were included in the final analysis. The outcomes of 107 patients with a mean age of 34.1 (range 15–63) years were available. In all the included studies, a posterior capsulotomy resulted in the restoration of knee extension to normal or nearly normal values (mean postoperative extension deficit: 0.4–4.2 degrees) with a significant increase in functional outcome scores. No neurovascular complications were reported within the studies. Due to the diverse methodology of studies, the direct comparison of arthroscopic versus open approaches was not possible. Concerning the risk of bias assessment, the greatest concerns raised the selection of participants among the included studies and the methods of outcome measurement. The certainty of evidence was very low according to the GRADE.

    Conclusions

    Both arthroscopic and open posterior capsulotomy of the knee results in restoration of normal or nearly normal knee extension and significant improvement in functional outcomes.

    Level of evidence

    IV.

  7. Abstract

    Purpose

    The aim of the present study was to compare the in vivo under weight-bearing kinematic behavior of a posterior-stabilized (PS) and an ultra-congruent (UC) total knee arthroplasty (TKA) model during a sit-to-stand motor task, a common activity of daily life.

    Methods

    A cohort of 16 randomly selected patients (8 PS Persona Zimmer, 8 UC Persona Zimmer) was evaluated through dynamic radiostereometric analysis (RSA) at a minimum of 9 months after TKA, during the execution of a sit-to-stand. The anteroposterior (AP) translation of the femoral component and the AP translation of the low point of medial and lateral femoral compartments were compared through Student’s t test (p < 0.05).

    Results

    A significantly greater anterior translation of the femoral component was found for the PS group compared to the UC group. The flexion interval where statistical significance was found was between 30° and 0° (p = 0.017). Both groups showed a significantly greater anterior translation of the low point of the lateral compartment with respect to the medial one (PS: p = 0.012, UC: p = 0.018). This was consistent with a medial-pivot pattern. Furthermore, a significantly greater anterior translation of the medial compartment was found in the PS group compared to the UC group (p = 0.001). The same pattern was observed for the lateral compartment (p = 0.006).

    Conclusions

    The TKA designs evaluated in the present study showed comparable in-vivo kinematics with regards to medial pivot pattern but differences in absolute AP translation. Specifically, the UC design showed greater AP stability than the PS design. This finding could be positive in terms of implant stability, but negative in terms of premature polyethylene wear and thus implant failure. This remains to be verified in studies with a larger sample size and longer follow-up.

    Level of evidence

    IV.

  8. Abstract

    Background

    No previous study has evaluated the MCID for revision total knee arthroplasty (TKA). This study aimed to identify the MCID for the Knee Society Score (KSS), for revision TKA.

    Methods

    Prospectively collected data from 270 patients who underwent revision TKA at a single institution was analysed. Clinical assessment was performed preoperatively, at 6 months and 2 years using Knee Society Function Score (KSFS) and Knee (KSKS) Scores, and Oxford Knee Score (OKS). MCID was evaluated with a three-pronged methodology, using (1) anchor-based method with linear regression, (2) anchor-based method with receiver operating characteristic (ROC) and area under curve (AUC), (3) distribution-based method with standard deviation (SD). The anchors used were improvement in OKS ≥ 5, patient satisfaction, and implant survivorship following revision TKA.

    Results

    The cohort comprised 70% females, with mean age of 69.0 years, that underwent unilateral revision TKA. The MCID determined by anchor-based linear regression method using OKS was 6.3 for KSFS, and 6.6 for KSKS. The MCID determined by anchor-based ROC was between 15 and 20 for KSFS (AUC: satisfaction = 71.8%, survivorship = 61.4%) and between 33 and 34 for KSKS (AUC: satisfaction = 76.3%, survivorship = 67.1%). The MCID determined by distribution-based method of 0.5 SD was 11.7 for KSFS and 11.9 for KSKS.

    Conclusion

    The MCID of 6.3 points for KSFS, and 6.6 points for KSKS, is a useful benchmark for future studies looking to compare revision against primary TKA outcomes. Clinically, the MCID between 15 and 20 for KSFS and between 33 and 34 for KSKS is a powerful tool for discriminating patients with successful outcomes after revision TKA. Implant survivorship is an objective and naturally dichotomous outcome measure that complements the subjective measure of patient satisfaction, which future MCID studies could consider utilizing as anchors in ROC.

    Level of evidence

    II.

  9. Abstract

    Purpose

    Discoid meniscus is a congenital abnormality of the lateral meniscus and is seen more frequently in East Asia. The purpose of this study was to retrospectively assess the relationship between discoid lateral meniscus (DLM) types and tear patterns and causes of age-specific clinical symptom onset.

    Methods

    Of 1650 arthroscopic surgeries over a 20-year period, 138 (105 patients) were performed for DLM and were evaluated in this study. The mean age at surgery was 21.5 ± 15.8 years. The DLM type was classified by Watanabe’s classification, and tear patterns were classified by the modified Bin’s classification as simple horizontal, complicated horizontal, longitudinal, radial, complex, and no tear. Additionally, patients were divided by age group (< 10, 10–19, 20–39, 40–59, and ≥ 60 years) and classified according to the causes of clinical symptom onset as follows: sports activities, minor trauma in daily living, and no traumatic episode.

    Results

    The DLM was complete in 78 (56.5%) knees and incomplete in 60 (43.5%); no Wrisberg type DLM was observed. Simple horizontal and complicated horizontal tears were significantly more frequent in complete DLM, whereas radial tears and no tears were significantly more frequent in incomplete DLM (p < 0.0001). When classified by age group, 74 (53.6%) knees with DLMs were found in teenagers. Sports activities caused symptom onset significantly more often in teenagers, no traumatic episode caused symptom onset in patients aged < 10 years, and minor trauma in daily living caused symptom onset in patients aged 40–59 years and ≥ 60 years (p < 0.0001). No relationship was found between the age distribution and tear patterns; however, the absence of tears tended to be more common in teenaged patients, and complicated horizontal tears were more common in patients over 20 years of age.

    Conclusion

    Symptomatic DLM occurred most often in teenagers. A relationship was identified between the DLM types and tear patterns, which could be helpful in preoperative planning. Causes of clinical symptom onset in patients with DLM were characterised by age group, which might help clinicians to suspect the presence of DLM.

    Level of evidence

    Level IV.

  10. Abstract

    Purpose

    Meniscectomy results in poor knee function and increased risk for osteoarthritis. Meniscal allograft transplantation is not widely used due to costs and availability. The semitendinosus tendon (ST) has the potential to remodel and revascularize in an intraarticular environment, such as ACL reconstruction. The objective for this pilot study was to investigate whether the ST graft could function as a meniscal transplant.

    Methods

    The ST was doubled and sutured with running sutures and pull-out sutures in each end. Bone tunnels were used for root anchorage and the graft was sutured with allinside, inside-out and outside-in technique. The pull-out sutures were fixed over a button. Partial weight bearing was allowed with limited range of motion in a brace for the first 6 weeks. Evaluation was assessed using clinical examination, radiology and patient reported outcome.

    Results

    A total of seven patients have been included between January 2018 and June 2020. Six medial transplants and one lateral transplant were performed. Mean age was 29 years. Four patients had completed the 12-month follow-up. Improvements were noted for IKDC Global Score, KOOS pain subscale and Lysholm. MRI indicated that the transplant become more wedge-like with visible roots and minor protrusion.

    Conclusions

    Even though this is primarily a technical report the follow-up data indicate that the transplant survives and adapts in shape and capabilities to an original meniscus. There were no adverse events and the patients seem to improve in terms of pain and quality of life.

  11. Abstract

    Purpose

    This study aimed to evaluate the outcomes of arthroscopic type 2 superior labrum anterior–posterior (SLAP) lesion repair in the general population and compare clinical outcomes according to patient age and repair site.

    Methods

    Between 2005 and 2018, patients who underwent arthroscopic repair for isolated type 2 SLAP lesions were retrospectively reviewed. Baseline characteristics, pre- and postoperative [1-year and > 2-year (final)] shoulder range-of-motion, and functional scores, comprising the pain visual analogue scale (PVAS), functional VAS, and American Shoulder and Elbow Surgeons (ASES) score, were evaluated. Return to overhead activities and subjective satisfaction were assessed at the final follow-up, and patients were divided by age [group YB (< 40 years] and group OB (≥ 40 years)] and repair site [group P (only posterior labrum repair) and group AP (anterior and posterior labrum repair)]. Overall patient outcomes were analysed and compared between groups.

    Results

    This study included 54 patients (45 men) with a mean age of 37.1 ± 8.3 years. The mean follow-up was 90.8 ± 51.3 months. Two patients experienced early failure, and one patient had a ruptured biceps tendon during the follow-up period. Final functional scores improved compared to their preoperative scores in all patients, except three (all p < 0.001). Fifty patients (98.0%) were satisfied, and 39 patients (76.5%) were able to perform overhead sports without restriction. In 25 patients who attended more than 7 years of follow-up (mean, 11.3 ± 2.7 years), 21 patients (84%) had an ASES score ≥ 80, and all patients had PVAS ≤ 2. There was no significant difference in clinical outcomes between groups YB and OB. The final median external rotation was significantly more restricted in group AP than in group P (40 [25–65] vs. 60 [50–70], p = 0.002).

    Conclusion

    Arthroscopic type 2 SLAP repair induced good short- and long-term clinical outcomes, return to overhead activities, and subjective satisfaction in the general population, regardless of age, due to the careful evaluation of patient history, physical examination, and imaging studies. However, performing only posterior repair seems sufficient since anterior labral SLAP lesion repair can limit ER. Isolated type 2 SLAP lesion posterior repair only is, thus, recommended to reduce external rotation deficit risk and increase satisfaction, regardless of patient age.

    Study design

    Case series.

    Level of evidence

    Level IV.

  12. Abstract

    Purpose

    Current treatment recommendations emphasize early loading, with preservation of tendon length and physiologic tension. The objective of this systematic review and network meta-analysis was to compare failure load and elongation after cyclic loading of Achilles tendon repair techniques at time-zero.

    Methods

    The databases PubMed, CENTRAL and Web of Science were searched for all published in-vitro studies comparing Achilles tendon repair techniques, or augmentation with autografts/biomaterials, and reports of failure load or elongation after cyclic loading. Only studies using human cadaveric Achilles tendons and matched pairs, or randomized specimen allocation, were selected for quantitative synthesis. A network meta-analysis per primary outcome was performed. Results were summarized as P score rankings and their validity was assessed using statistical methods.

    Results

    Sixteen studies, comprising 367 tendon repairs, were included. The following repair techniques were used (n = number of studies): Krackow (n = 8), Achillon (n = 4), double Krackow (n = 3), Bunnell (n = 3), Percutaneous Achilles Repair System (n = 3), Percutaneous Achilles Repair System Midsubstance (n = 2), Kessler (n = 3), double Kessler (n = 1), modified triple Kessler (n = 1), triple bundle (n = 1), a multifilament stainless steel cable-crimp technique (n = 1) and a double loop knot stitch (n = 1). Five studies assessed augmentation with autografts/biomaterials. Regarding the failure load, biomaterial augmented Krackow repairs occupied the first four positions in the ranking, followed by the multifilament stainless steel cable-crimp and Percutaneous Achilles Repair System Midsubstance techniques. Concerning elongation after cyclic loading, the triple Kessler was ranked first, followed by the Achillon and Percutaneous Achilles Repair System Midsubstance techniques. A negligible correlation between ranks was found (rs = 0.11; p = 0.75n.s.), meaning that a higher repair tensile strength is not necessarily related to improved performance in regard to avoidance of elongation.

    Conclusion

    In the failure load network meta-analysis, biomaterial augmented Krackow repairs ranked highest, but noticeable statistical heterogeneity was found. Regarding elongation with cyclic loading, the modified triple Kessler stitch showed the highest probability of ranking first.

    Level of evidence

    Level IV.

  13. A correction to this paper has been published: https://doi.org/10.1007/s00167-021-06622-8

  14. Abstract

    Purpose

    The purpose of this study was to evaluate the current status of education of polish surgeons in the subject of meniscus repair possibilities. The analysis of the possible correlations between the number of knee arthroscopy procedures performed by polish surgeons and their decision whether to remove or to repair the damaged meniscus has been performed.

    Methods

    Two-hundred and five registered orthopedic surgeons took part in surveys. The questionnaire contained the description of 20 patients with different types of meniscus damage and three questions concerning the experience in knee arthroscopy (two questions) and a choice of the treatment method (one question). Comparisons were made between knee arthroscopy experts (> 100 arthroscopies performed per year) and non-experts (≤ 100 cases).

    Results

    The questionnaire was completed by 194 knee surgeons from Poland with different levels in knee arthroscopy experience. For most cases, experts and non-experts agreed on the meniscus treatment method. Statistically significant differences in the recommended treatment between experts and non-experts were observed in 4 cases, where experts decided to repair the damage rather than to perform the meniscectomy.

    Conclusions

    Meniscectomy remains a frequent orthopedic procedure, despite meniscal sparing having been advocated for several decades now and despite the existence of meniscus repair technique which gives good clinical outcomes—augmentation of the damaged meniscus with a collagen membrane. Polish surgeons still need education on the meniscus treatment possibilities.

    Level of evidence

    V.

  15. Abstract

    Purpose

    Intra-articular pathologies, such as labral and chondral lesions, are common in patients with frozen shoulder. This study evaluated the correlations between the range of motion and labral and chondral lesions in patients with frozen shoulder and investigated their pathophysiologies.

    Methods

    In total, 125 individuals (53 men and 72 women) who underwent arthroscopic pan-capsular release between 2014 and 2020 were included in the study. The range of motion was measured using scapular fixation and true glenohumeral motion under general anaesthesia. The American Shoulder and Elbow Surgeons Shoulder score and the Shoulder Rating Scale score of the University of California, Los Angeles were used to compare intra-articular pathologies.

    Results

    More than 80% of patients with frozen shoulder had labral pathologies, and nearly half of them had chondral pathologies. Labral lesions extending to the anterior rim of the glenoid had a greater range of motion and the greatest total American Shoulder and Elbow Surgeons Shoulder score. More severe chondral lesions had a lesser range of motion, but presented the greatest function scores and the lowest strength scores according to the Shoulder Rating Scale of the University of California, Los Angeles. The pain scores of the American Shoulder and Elbow Surgeons Shoulder score and the Shoulder Rating Scale of the University of California, Los Angeles were not correlated with the degree of these pathologies. The traction force affected the labrum during true range of motion, and the compression force occurred on the articular cartilage during internal rotation at 90° of forward flexion during diagnostic arthroscopy.

    Conclusion

    Labral and chondral lesions are common in patients with frozen shoulder. Adherence to the capsulolabral complex induced a limited range of motion and labral and chondral pathologies. Diagnostic arthroscopy with motion is an important method of reproducing the pathogenesis of intra-articular structures for patients with frozen shoulder.

    Level of evidence

    Level III.