The Journal of Knee Surgery

Journal Information
ISSN / EISSN: 15388506 / 19382480
Total articles ≅ 2,258

Latest articles in this journal

Zhongming Chen, Sandeep S. Bains, Daniel Hameed, Jeremy A. Dubin, Jonathan M. Stern, Michael A. Mont
Published: 25 November 2022
The Journal of Knee Surgery; https://doi.org/10.1055/s-0042-1758550

Abstract:
Introduction: Randomized controlled trials (RCTs)are regarded as highest level of scientific evidence. There is belief that while prospective randomized control trials (PRCTs) are the gold standard for evaluating efficacy of interventions, there are very few conducted on lower extremity joint arthroplasty. However, there was a more than adequate amount (n=197) of published RCTs in knee arthroplasty during the 2021 calendar year. Therefore, we studied RCTs on knee arthroplasties for 2021 and assessed them for overall study topic reasons (i.e., devices as well as prostheses, rehabilitation, pain control, blood loss [tranexamic acid], and other), which were then subcategorized by: (1) country of origin; (2) sample size; and (3)whether or not they were follow-up studies. After this, we specifically focused on the studies (n=26) concerning devices or prostheses. Methods: A search of PubMed on “knee arthroplasty” specifying “RCT” using their search function and dates between January 1, 2021 to December 24, 2021 resulted in the analyzed reports. A total of 17.3% reports analyzed rehabilitation methods while 28.4% studied pain control. A total of 20.3% examined blood loss topics and 20.8% investigated other topics. Results: We found that 26 studies (13.2%) involved prosthetic design and implantation. Overall, only 15% knee arthroplasty RCTs were conducted in the United States, the mean total final sample size was 133±146 patients, and 7% were follow-up studies. None of the prostheses studies were performed in the United States, and the mean total final sample size of all of these studies was 86±54 patients, and 23% were follow-up studies. Total knee arthroplasty prospective RCTs were not performed in the United States. Conclusion: The authors believe that other study designs, such as database or registry analyses, are also appropriate in this rapidly advancing field of joint arthroplasty for the continuing evaluation and approval of new prostheses and techniques, while we await more PRCTs in our field.
Ayoosh Pareek, Chad Parkes, Konrad Slynarski, Jacek Walawski, Robert Smigielski, Willem van der Merwe,
Published: 23 November 2022
The Journal of Knee Surgery; https://doi.org/10.1055/a-1984-9980

Abstract:
Introduction: Subchondral insufficiency fractures of the knee (SIFK) can result in high rates of osteoarthritis and arthroplasty. The Implantable Shock Absorber (ISA) implant is a titanium and polycarbonate urethane device which reduces load on the medial compartment of the knee by acting as an extra-articular load absorber while preserving the joint. The purpose of this study was to evaluate whether partially unloading the knee with the ISA altered the likelihood of progression to arthroplasty utilizing validated predictive risk model (SIFK score). Methods: A retrospective case-control (2:1) study was performed on patients with SIFK without any previous surgery and those implanted with the ISA with outcome being progression to arthroplasty compared to non-operative treatment at 2 years. Baseline and final radiographs, as well as MRIs, were reviewed for evaluation of meniscus or ligament injuries, insufficiency fractures and subchondral edema. Patients from a prospective study were matched using the exact SIFK Score, a validated predictive score for progression to arthroplasty in patients with SIFK, to those with the ISA implant. Kaplan-Meier analysis was conducted to assess survival. Results: Total of 57 patients (38 controls:19 ISA) with mean age of 60.6 years were included. The SIFK score was matched exactly between cases and controls. The 2-year survival rate of 100% for the ISA group was significantly higher than corresponding rate of 61% for the control group (p<0.01). In ISA, 0% of the patients converted to arthroplasty at 2 years, and 5% (1 patient) had hardware removal at 1 year. When stratified by risk, the ISA group did not have a significantly higher survival compared to low-risk (p=0.3) or medium-risk (p=0.2) controls, though it had a significantly higher survival for high-risk groups at 2-years (100% vs 15%, p<0.01). Conclusion: SIFK of the medial knee can lead to significant functional limitation and high rates of conversion to arthroplasty. Implants such as the Implantable Shock Absorber have the potential to alter progression to arthroplasty in these patients, especially those at high-risk.
Oliver C. Sax, Sandeep S. Bains, Zhongming Chen, Christopher G. Salib, James Nace,
Published: 17 November 2022
The Journal of Knee Surgery; https://doi.org/10.1055/s-0042-1757595

Abstract:
Mechanical knee symptoms secondary to knee osteoarthritis (OA) may warrant knee arthroscopy (KA). Degenerative changes may progress and require a subsequent total knee arthroplasty (TKA). Recent studies have evaluated the timing of KA prior to TKA, associated a narrow interval with increased post-TKA complications. However, an updated analysis is required. We compared surgical outcomes in recipients of KA prior to TKA as stratified by four, time-dependent cohorts (< 12, 12 to 16, 16 to 20, and 20 to 24 weeks prior to TKA). We specifically compared: 90-day (1) manipulations under anesthesia (MUAs); (2) septic revisions at 90 days, 1 year, and 2 years; as well as (3) how various independent risk factors influenced the manipulations or revisions. We queried a national database for patients undergoing TKA. Patients who underwent KA with the following intervals: < 12 (n = 1,023), 12 to 16 (n = 816), 16 to 20 (n = 1,957), and 20 to 24 weeks (1,727) prior to TKA were compared with those patients who did not have a history of KA (n = 5,000). Bivariate analyses were utilized to assess 90 days through 2 years surgical outcomes. Afterwards, multivariate regression models were utilized to assess for independent risk factors. The unadjusted analyses showed an increase in MUA through 2 years among all the KA recipients (p < 0.001). Septic revisions and surgical site infections at all time points were not associated with any of the four arthroscopy time intervals (p > 0.476). The adjusted analyses showed an increased risk for 90-day MUA among all TKA cohorts (p < 0.001). Risk for septic revisions did not reach significance. Delaying TKA by 24 weeks in KA recipients was not associated with a decreased risk in septic revisions. However, there was an apparent risk of MUA at 90 days for all KA cohorts suggesting that waiting after KA before TKA makes no difference in MUA rates. These results update existing literature, may serve as an adjunct to current practice guidelines, and can contribute to shared decision making in the preoperative setting.
Ibin Varughese, Sarah L Whitehouse, William J Donnelly,
Published: 25 October 2022
The Journal of Knee Surgery; https://doi.org/10.1055/a-1967-2346

Abstract:
Purpose: This study examines the potential cost savings for the health system and the community in a broadly accessible model through the increased utilization of UKA using robotic arm-assisted UKA vs conventional TKA. Methods: We retrospectively reviewed 240 patients where the first 120 consecutive robotic arm-assisted UKA performed during this period were matched to 120 conventional TKAs. Clinical data from the medical records and costs for procedure for each component were collected. Bivariate analyses were performed on the data to determine if there were statistically significant differences by surgery type in clinical outcomes and financial costs. Results: There was a significantly lower cost incurred for robotic arm-assisted UKA vs TKA with an average saving of AU$7179 per case. The operating time (86.0 min vs 75.9 min; p=0.004) was significantly higher for UKA but the length of stay was significantly lower (1.8 vs 4.8 days; p<0.001). There was a significant difference in the use of opioids between UKA compared to TKA (125.0 morphine equivalent (ME) vs 522.1 ME, p<0.001). Conclusion: This study demonstrated that the use of robotic arm-assisted UKA rather than TKA in suitably indicated patients may realize significant cost savings.
Kyoung Ho Yoon, Sang Jun Song, Sung Hyun Hwang, Cheol Hyun Jung,
Published: 21 October 2022
The Journal of Knee Surgery; https://doi.org/10.1055/a-1965-5631

Abstract:
One-week staged bilateral open-wedge high tibial osteotomies (OWHTOs) can be a safe procedure, with the added advantage of fast functional recovery, cost saving, and reduced hospital stay. However, there can be concerns about correction loss after one-week staged OWHTOs because high loading is inevitably applied to osteotomy sites during postoperative weight bearing. Although leaving the osteotomy site with no grafts is possible in OWHTOs, use of grafts can provide additional stability to the osteotomy site and prevent correction loss. We compared the amount and incidence of correction loss between one-week staged bilateral OWHTOs with and without allogenic bone grafts. Seventy-five patients who underwent one-week staged bilateral OWHTOs with a locking spacer plate (Nowmedipia, Seoul, Korea) by a single surgeon were retrospectively reviewed. Allogenic cancellous bone grafts were applied in 53 patients (Group G; 106 knees, operated consecutively between 2012 and 2017), but not in 22 patients (Group N; 44 knees, operated consecutively between 2017 and 2019). Demographics were similar between the groups. Radiographically, the mechanical axis (MA), medial proximal tibial angle (MPTA), and posterior tibial slope (PTS) were evaluated preoperatively and within 1 year postoperatively. Unstable hinge fracture was investigated using computer tomography in all cases. The incidence of correction loss (MPTA loss ≥ 3°) was determined. There were no significant differences in the MA, MPTA, and PTS between the groups preoperatively and 2 weeks postoperatively. The incidence of unstable hinge fractures did not differ. The losses in MA, MPTA, and PTS during the first postoperative year were significantly greater in group N than in group G (MA, -5.5° vs. -2.3°; MPTA, -3.0° vs. 0°; PTS, -2.0° vs. -0.7°; p < 0.05° on all parameters). The correction loss incidence was 6.6% (7/106) and 31.8% (14/44) in groups G and N, respectively (p < 0.001). Appropriate treatment is necessary to prevent correction loss in one-week staged bilateral OWHTOs. Grafting, which provides additional stability to the osteotomy site, is a recommended method.
, Dylan Matthews, Amanda Kumar
Published: 21 October 2022
The Journal of Knee Surgery; https://doi.org/10.1055/a-1965-4283

Abstract:
To the Editor, We read the article “Integrating IPACK (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) Block in an Enhanced Recovery after Surgery Pathway for Total Knee Arthroplasty—A Prospective Triple-Blinded Randomized Controlled Trial” by Pai et al in the Journal for Knee Surgery (2022) with great interest1. We applaud the authors in finding that when added to an enhanced recovery after surgery pathway consisting of a spinal anesthetic, adductor canal nerve catheter, and surgeon-administered periarticular joint infiltration (PAI), the IPACK block did not significantly impact postoperative opioid consumption or measured functional outcomes on postoperative day 1. Interestingly, the authors found that addition of the IPACK block did significantly decrease posterior knee pain. We found this notable as both the IPACK block and PAI target the posterior knee capsule. Innervation of the posterior knee capsule is complex and includes branches of the obturator, sciatic, common fibular, and tibial nerves2. PAI has variable effectiveness in this anatomical area3. Prior studies have shown that addition of the IPACK and adductor canal blocks to PAI provides superior analgesia and decreases opioid consumption in TKA4. This study found that the IPACK block resulted in improved posterior knee analgesia compared to PAI. This could signify that an ultrasound-guided approach may be more consistent in targeting the posterior knee capsule. The authors also astutely mention concern for local anesthetic toxicity (LAST). Peripheral nerve blocks, especially in the lower extremity, have a decreased risk of LAST compared to PAI5. Further study of the effectiveness of the IPACK block compared to PAI may show that the IPACK is a reasonable replacement of PAI, while also potentially decreasing the risk of LAST. We greatly appreciate the work Dr. Pai and team performed to further our understanding of posterior knee analgesia and its contribution toward the creation of patient care pathways that target analgesia and prioritize patient safety.
, William Fm Jackson, Yoshihito Suda, Tomoyuki Kamenaga, Shotaro Araki, Takaaki Fujishiro, Motoki Koide, Koji Okamoto
Published: 21 October 2022
The Journal of Knee Surgery; https://doi.org/10.1055/a-1965-4361

Abstract:
In restricted kinematic alignment total knee arthroplasty, bone resection is performed to within a safe range to help protect against failure from extreme alignments. Patient-specific instrumentation, navigations and robotics, are often required for restricting bone cuts to within a specified safe zone. We hypothesized that the lateral malleolus could be used as a landmark for restricting the tibial osteotomy using a mechanical jig. Here, we examine its feasibility in anatomical and clinical settings. We studied long-leg standing radiographs of 114 consecutive patients (228 knees) who underwent knee arthroplasty in our institution. We measured the lateral malleolus angle, the angle between the tibial axis and the line between the centre of the knee and the lateral surface of the lateral malleolus. The medial proximal tibial angle was also measured before and after restricted kinematic alignment total knee arthroplasty under restriction with reference to the lateral malleolus. Mean lateral malleolus angle was 5.5° ± 0.5°. This was relatively consistent and independent of patient height, weight and BMI. The lateral malleolus is a reliable bone landmark that can be used to recognize approximately 5.5° of varus intraoperatively. A surgeon can use this as a restriction of the tibial varus cut up to 6° without the requirement for expensive assistive technologies.
, Andrew J. Sheean, Justin W. Arner, DeVaughn Wilkerson, James P. Bradley
Published: 26 September 2022
The Journal of Knee Surgery; https://doi.org/10.1055/s-0042-1757701

Abstract:
Although the majority of patients with patellar tendinopathy (PT) can be treated nonoperatively, operative management may be indicated for recalcitrant cases. While several surgical techniques have been described, there is limited understanding of postoperative outcomes and expectations regarding return to activity and sport. The purpose of this study was to characterize the clinical outcomes associated with the surgical management of PT with an emphasis on return to sport (RTS) rates. We hypothesized that surgical management would lead to clinically important improvements in patient-reported outcomes (PROs) with high rates of RTS and RTS at the same level. A comprehensive search of the PubMed, Medline, and Embase databases was performed in December 2020. Level of evidence studies I through IV, investigating results of surgical management for PT (PRO, functional outcomes, pain, and/or RTS), were included. The search was performed in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Forty clinical studies reporting on surgery for PT satisfied inclusion criteria, with 1,238 total knees undergoing surgery for PT. A comparison of pre- and postoperative Victorian Institute of Sport Assessment, patellar tendon (VISA-P) scores (mean difference: 41.89, p < 0.00001), Lysholm scores (mean difference: 41.52, p < 0.00001), and visual analogue scale (VAS) pain scores (mean difference: 5, p < 0.00001) demonstrated clinically and statistically significant improvements after surgery. The overall RTS rate following operative management was 89.8% (95% confidence interval [CI]: 86.4–92.8, I 2 = 56.5%) with 76.1% (95% CI: 69.7.5–81.9, I 2 = 76.4%) of athletes returning to the same level of activity. Surgery for PT provides meaningful improvement in patient reported outcomes and pain while allowing athletes to RTS at high rates with levels of participation similar to that of preinjury. Comparative studies of open and/or arthroscopic surgery are still limited but current evidence suggests better rates of RTS for arthroscopic surgery compared with open surgery. This is a systematic review of level-I to -IV studies. Received: 15 November 2021 Accepted: 26 April 2022 Article published online: 26 September 2022 © 2022. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
Yoshinori Takashima, Naoki Nakano, Kazunari Ishida, Tomoyuki Kamenaga, , Yuichi Kuroda, Shinya Hayashi, Ryosuke Kuroda,
Published: 23 September 2022
The Journal of Knee Surgery; https://doi.org/10.1055/s-0042-1756502

Abstract:
The aim of the study is to explore and compare the differences in trochlear shape and knee anatomy between four types of prostheses and preoperative native knee matched with preoperative computed tomography (CT). Thirty patients were scheduled for primary kinematically aligned total knee arthroplasty (TKA) for varus knee osteoarthritis at our hospital and the region between their pelvis to ankle joint was simulated using a CT-based three-dimensional planning software. The axial plane containing the transepicondylar axis was set as Slice A, and the 10-mm distal plane from Slice A was set as Slice B. The distances to the deepest trochlear groove between the native knee and each prosthesis and the medial and lateral facet heights were compared among the four groups. The deepest femoral trochlear groove of the prostheses was located 1.6 to 3.0 mm more medial than that of the native knee, and in the Persona group, it was significantly more medial than in the e-motion or Triathlon groups on both Slices A and B. The native knee and the medial and lateral facet heights of the four prostheses on both Slices A and B were significantly lower than those of preoperative native knees when femoral prostheses were set in the kinematically aligned (KA)-TKA position. The deepest point of the trochlear groove of the Persona group was the most medial among the four prostheses studied, and the deepest points differed depending on the prosthesis design in KA-TKA. Thus, surgeons should carefully select the type of prostheses used in KA-TKA.
Pedro J. Rullán, Daniel Grits, Ajay Potluri, Ahmed K. Emara, Alison K. Klika, Michael A. Mont,
Published: 22 September 2022
The Journal of Knee Surgery; https://doi.org/10.1055/s-0042-1756503

Abstract:
Technological innovation is the key for surgical progress in knee arthroplasty and improvement in patient outcomes. Exploring patented technologies can help elucidate trends and growth for numerous innovative technologies. However, patent databases, which contain millions of patents, remain underused in arthroplasty research. Therefore, the present study aimed to: (1) quantify patent activity; (2) group patents related to similar technologies into well-defined clusters; and (3) compare growth between technologies in the field of knee arthroplasty over a 30-year period. An open-source international patent database was queried from January 1990 to January 2020 for all patents related to knee arthroplasty A search strategy identified 70,154 patents, of which 24,425 were unique and included analysis. Patents were grouped into 14 independent technology clusters using Cooperative Patent Classification (CPC) codes. Patent activity was normalized via a validated formula adjusting for exponential growth. Compound annual growth rates (CAGR) were calculated (5-year, 10-year, and 30-year CAGR) and compared for each cluster. Overall yearly patent activity increased by 2,023%, from 104 patents in 1990 to 2,208 patents in 2020. The largest technology clusters were “drugs” (n = 5,347; 23.8%), “components” (n = 4,343; 19.0%), “instruments” (n = 3,130; 13.7%), and “materials” (n = 2,378; 10.4%). The fastest growing technologies with their 5-year CAGR were: “user interfaces for surgical systems” (58.1%); “robotics” (28.6%); “modularity” (21.1%); “navigation” (15.7%); and “computer modeling” (12.5%). Since 1990, overall patent growth rate has been greatest for “computer modeling” (8.4%), “robotics” (8.0%), “navigation” (7.9%), and “patient-specific instrumentation” (6.4%). Most patents in knee arthroplasty for the last 30 years have focused on drugs, components, instruments, and materials. Recent exponential growth was mainly observed for user interfaces for surgical systems, robotics, modularity, navigation, and computer-assisted technologies. Innovation theory would suggest that these rapidly growing technologies are experiencing high innovation output, increased resource investments, growing adoption by providers, and significant clinical impact. Periodic monitoring of technological innovation via patent databases can be useful to establish trends and future directions in the field of knee arthroplasty.
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