Non-surgical correction of knee flexion deformity in persons with haemophilia: A staged multidisciplinary approach.

INTRODUCTION: Flexion deformity of the knee is a common complication following recurrent haemarthrosis in persons with haemophilia (PWH) on episodic factor replacement therapy, restricting independent mobility. There is limited literature on the comprehensive management of this condition. This report provides the outcome of a staged multidisciplinary approach for the correction of knee flexion deformity (KFD) even in limited resource settings. PATIENTS AND METHODS: The data of 49 consecutive PWH who were treated for KFD were analysed. The approach included graded physical therapy (PT), followed by serial casting and/or mobilisation under anaesthesia (MUA). MUA was done in carefully selected knees. Surgical correction was opted when non-surgical methods failed. RESULTS: Of the 49 patients (55 knees), with a median KFD of 40 degrees (range: 10-90), 26/55 (47%) were corrected by graded PT. With serial casting, 9/19 (47%) knees had their KFD corrected. MUA was done for 11 knees of which five achieved correction (45%). Surgical correction was required for only seven knees (12.7%). Following this approach, KFD improved from 40 degrees (range: 10-90) to 15 degrees (range: 0-40), with only minor loss of flexion from 105 (range: 60-155) to 90 degrees (range: 30-150). Out of 55 KFD, 46 (83.6%) KFD were corrected; non-surgical, 39 (70.9%) and surgery, seven (12.7%). The remaining patients (nine KFD; 16.4%) were able to achieve their functional goal despite not meeting the correction criteria. CONCLUSION: This study shows that in PWH, functionally significant KFD correction can be achieved in about 71%, through non-surgical methods, even without prophylactic factor replacement.

Deformed Popliteal Artery Due to Highly Flexed Knee Position Can Cause Kinks, Creating an Unfavorable Hemodynamic State.

BACKGROUND: Endovascular treatment devices of the femoropopliteal artery have evolved, improving clinical results. However, the effects of dynamic changes in the popliteal artery during knee flexion have not been sufficiently investigated. In this study we performed a 3-dimensional analysis to clarify the dynamic changes in the popliteal artery during knee flexion and their effects on hemodynamics.Methods and Results: To analyze dynamic changes in the popliteal artery in the knee flexion position, a computed tomography protocol was developed in the right-angled and maximum flexion knee positions. Thirty patients with lower extremity artery disease were recruited. V-Modeler software was used for anatomical and hemodynamic analyses. Various types of deformations of the popliteal artery were revealed, including hinge points and accessory flexions. Kinks can occur in the maximum flexion position; however, they rarely occur in the right-angled flexion position. In addition, hemodynamic analysis revealed a tendency for lower minimum wall shear stress and a higher maximum oscillatory shear index at the maximum curvature of the popliteal artery. CONCLUSIONS: Kinks in the maximum flexion position suggested that the outcome of endovascular treatment may change in areas such as Japan, where knee flexion is customary. Hemodynamics at the maximum curvature of the popliteal artery indicated that the luminal condition was unfavorable for endovascular treatment.

The Influence of Sports-Related Concussion on Cognition and Landing Biomechanics in Collegiate Athletes.

Injury surveillance data indicate that collegiate athletes are at greater risk for lower extremity (LE) injuries following sports-related concussion (SRC). While the association between SRC and LE injury appears to be clinically relevant up to 1-year post-SRC, little evidence has been provided to determine possible mechanistic rationales. Thus, we aimed to compare collegiate athletes with a history of SRC to matched controls on biomechanical and cognitive performance measures associated with LE injury risk. Athletes with a history of SRC (n = 20) and matched controls (n = 20) performed unanticipated bilateral land-and-cut tasks and cognitive assessments. Group-based analyses (ANOVA) and predictive modeling (C5.0 decision tree algorithm) were used to compare group differences on biomechanical and cognitive measures. Collegiate athletes with a history of SRC demonstrated approximately six degrees less peak knee flexion on both dominant (p = 0.03, d = 0.71) and nondominant (p = 0.02, d = 0.78) limbs during the land-and-cut tasks compared to controls. Verbal Memory, knee flexion, and Go/No Go total score (C5.0 decision tree algorithm) were identified as the strongest indicators of previous SRC injury history. Reduced knee flexion during sport-specific land-and-cut tasks may be a mechanism for increased LE injury risk in athletes with a history of SRC. There appears to be multiple biomechanical and cognitive predictors for identifying previous SRC in collegiate athletes, providing evidence to support a multifactorial SRC management strategy to reduce future injury risk.

Myoelectric interface for neurorehabilitation conditioning to reduce abnormal leg co-activation after stroke: a pilot study.

BACKGROUND: The ability to walk is an important factor in quality of life after stroke. Co-activation of hip adductors and knee extensors has been shown to correlate with gait impairment. We have shown previously that training with a myoelectric interface for neurorehabilitation (MINT) can reduce abnormal muscle co-activation in the arms of stroke survivors. METHODS: Here, we extend MINT conditioning to stroke survivors with leg impairment. The aim of this pilot study was to assess the safety and feasibility of using MINT to reduce abnormal co-activation between hip adductors and knee extensors and assess any effects on gait. Nine stroke survivors with moderate to severe gait impairment received 6 h of MINT conditioning over six sessions, either in the laboratory or at home. RESULTS: MINT participants completed a mean of 159 repetitions per session without any adverse events. Further, participants learned to isolate their muscles effectively, resulting in a mean reduction of co-activation of 70% compared to baseline. Moreover, gait speed increased by a mean of 0.15 m/s, more than the minimum clinically important difference. Knee flexion angle increased substantially, and hip circumduction decreased. CONCLUSION: MINT conditioning is safe, feasible at home, and enables reduction of co-activation in the leg. Further investigation of MINT's potential to improve leg movement and function after stroke is warranted. Abnormal co-activation of hip adductors and knee extensors may contribute to impaired gait after stroke. Trial registration This study was registered at ClinicalTrials.gov (NCT03401762, Registered 15 January 2018, https://clinicaltrials.gov/study/NCT03401762?tab=history&a=4 ).

Restricted kinematically aligned total knee arthroplasty with an anatomically designed implant can restore constitutional coronal lower limb alignment.

PURPOSE: Restricted kinematically aligned total knee arthroplasty (rKA-TKA) may not restore the constitutional varus alignment in most patients with knee osteoarthritis. This study aimed to investigate (1) the extent to which constitutional lower limb alignment can be restored by rKA-TKA using an anatomically designed implant and (2) which lower limb alignment parameters are associated with patient-reported outcome measures (PROMs). METHODS: This study included 60 patients who underwent rKA-TKA using an anatomically designed implant. Radiographic alignment parameters, including mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), coronal hip-knee-ankle angle (HKA), coronal joint line obliquity (JLO), posterior tibial slope (PTS), single-leg standing knee flexion angle (KFA), sagittal JLO, and arithmetic HKA (aHKA), were evaluated preoperatively and postoperatively. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used for clinical evaluation. RESULTS: The mLDFA, MPTA, and aHKA showed no significant differences before and after surgery. Coronal HKA and PTS have significantly changed from 8.1 ± 8.7° and 9.9 ± 8.6° preoperatively to 3.5 ± 3.1° and 2.5 ± 2.0° postoperatively, respectively (p < 0.001 for each comparison). The postoperative WOMAC total score was significantly correlated with the KFA (r = 0.4063, p = 0.0034) and sagittal JLO (r = -0.3435, p = 0.0157). Postoperative KFA is a causal factor for the increased postoperative WOMAC total score (r = 1.416, 95% confidence interval: 0.491-2.342, p = 0.003). CONCLUSION: rKA-TKA using an anatomically designed implant can restore constitutional coronal lower limb alignment, while postoperative KFA and sagittal JLO were associated with poor PROMs. Care should be taken for the postoperative KFA because it is a risk factor for poor PROMs. LEVEL OF EVIDENCE: Level III, case-control study.

Association Between Overhang of the Posterior Femoral Condyle and Restricted Postoperative Knee Flexion Related to Patient-Reported Stiffness in Medial-Pivot Total Knee Arthroplasty.

BACKGROUND: The primary aim of this study was to investigate the association between the posterior longitudinal overhang in the femoral condyle (PLOF) in medial-pivot total knee arthroplasty (TKA) and a change in knee flexion angle (change in flexion). METHODS: This retrospective cohort study included 148 knees undergoing medial-pivot TKA for medial knee osteoarthritis. The primary outcome was the change in flexion (c-flexion) preoperatively and 1 year postoperatively. The component positions were evaluated using three-dimensional measurements, where the PLOF was measured for each medial and lateral femoral condyle. The secondary outcome was the Western Ontario and McMaster Universities OA Index (WOMAC) scores taken preoperatively and 2 years postoperatively. A multivariate regression analysis was performed to determine predictors of c-flexion and risk factors for negative c-flexion (less than 0°). Furthermore, a receiver operating characteristic curve was utilized to determine the threshold for negative c-flexion. RESULTS: The mean c-flexion was -3.2°± 8.7, and lateral PLOF was significantly associated with c-flexion (ß = -0.52; P < 0.001). Larger preoperative flexion angles (odds ratio, 1.10; P <0.001) and larger lateral PLOF (odds ratio, 1.69; P = 0.001) were risk factors for negative c-flexion, with thresholds of 129° and 1.1 mm, respectively (sensitivity, 0.79; specificity, 0.72). Additionally, patients who had negative c-flexion (n = 91) demonstrated less improvement in preoperative and 2-year postoperative WOMAC stiffness subscores than patients who had positive c-flexion (0° or more; n = 57) (P = 0.01). CONCLUSION: A larger lateral PLOF was associated with decreased and negative c-flexion after medial-pivot TKA. Patients who had negative c-flexion demonstrated less improvement in knee stiffness. Surgical strategies aimed at minimizing lateral PLOF may enhance postoperative knee flexion and overall patient outcomes in medial-pivot TKA.

Outcomes of Early Versus Delayed Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Stiffness following total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA). However, there is debate regarding the timing of MUA, with many recommending against MUA beyond 3 months after TKA. Therefore, the purpose of this systematic review was to evaluate the functional and clinical outcomes of early versus delayed MUA for stiffness following TKA. METHODS: A search following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed in the PubMed, Embase, Scopus, and Cochrane databases in November 2023. Data regarding study characteristics, demographics, knee flexion and extension, patient-reported outcomes, complications, and revisions were collected. A quality assessment was performed using the Methodological Index for Non-randomized Studies. Included were 14 studies analyzing 13,445 knees, 72.1% of which underwent early MUA and 27.8% of which underwent delayed MUA. Of the 14 studies, 10 defined early MUA as being performed within 3 months of the index TKA. RESULTS: Pre-MUA and post-MUA knee flexion for the early/delayed groups was 71.3°/77.9° and 103.0°/96.1°, respectively. Upon meta-analysis, pre-MUA knee flexion was significantly higher in the delayed group (P = .003), whereas post-MUA flexion was similar in both groups (P = .36). The mean gain in knee flexion for the early and delayed groups was 32.0°/19.2°. The surgical complication and revision TKA rates for the early and delayed groups were 4.9%/10.3% and 5%/9%, respectively. A meta-analysis found the risk of surgical or medical complications and revision TKA to be significantly higher in the delayed MUA group (P < .00001 and = .002, respectively). CONCLUSIONS: Although post-MUA knee flexion was similar in patients undergoing early and delayed MUA following TKA, the mean gain in flexion for early patients was nearly double that of delayed patients. Delayed patients also had significantly higher risks of surgical or medical complications and revision TKA following MUA.

Comparative analysis of surgical treatment modalities for a popliteal pterygium: a meta-analysis.

INTRODUCTION: Popliteal pterygium syndrome is a rare congenital disorder characterized by orofacial, cutaneous, musculoskeletal, and genital anomalies. The popliteal pterygium (PP) affects ambulation due to severe knee flexion contracture and equinovarus deformities. Surgical treatment aims to correct these deformities while preserving limb sensibility. However, due to its rarity, surgical guidelines are lacking. MATERIALS AND METHODS: A meta-analysis according to PRISMA guidelines was conducted to summarize and compare surgical methods for PP. 183 paper were identified in PubMed and data from 32 articles were analyzed, including patient demographics, treatment modalities (Ilizarov fixator, femoral osteotomy, skin/soft tissue procedures, hamstring release, nerve surgery, and amputation), pre- and post-operative abilities to walk, knee joint parameters, complications, and recurrent contractions. RESULTS: Among 58 patients (87 limbs), Ilizarov fixator demonstrated improved knee and ankle mobility postoperatively, but showed a relatively high surgical session count and complication rates. Femoral osteotomy achieved successful knee posture correction with fewer sessions and no complications. Isolated skin/soft tissue procedures improved flexion contracture and mobility, though they required several procedures. Hamstring release achieved notable contracture reduction but also necessitated multiple interventions. Nerve surgery and amputation had limited data, warranting further investigation. CONCLUSION: The management of PP demands a comprehensive approach, considering individual patient characteristics and treatment outcomes. While different surgical modalities offer distinct benefits, a classification or guideline to treat this deformity is still lacking. Further research is essential to validate findings, refine treatment approaches, and enhance the quality of life for individuals with PP.

Increased accuracy in component positioning using an image-less robotic arm system in primary total knee arthroplasty: a retrospective study.

BACKGROUND: Robotic-assisted total knee arthroplasty (RTKA) and navigated total knee arthroplasty (NTKA) have shown improved knee alignment and reduced radiographic outliers. Recent studies have proven that conventional mechanical alignment may not be the optimal goal for every patient. The aim of this study was to compare the accuracy of the planned implant positioning of a novel image-less robotic technique with an established navigated technique (NTKA). METHOD: The study is a retrospective analysis of prospectively collected data that compared the implant positioning and lower-limb alignment of 86 image-less RTKA with 86 image-less NTKA. Radiographic analysis was performed to evaluate the lower-limb overall alignment, femoral and tibial components positioning in the coronal and sagittal planes. Outliers were evaluated with a cutoff of ± 3°. RESULTS: No difference was noted between the two groups for radiographic outliers within ± 3° from neutral (p = 0.098). The mean hip-knee-ankle angle deviation from target was 1.3° in the RTKA group compared to 1.9° in the NTKA (p < 0.001). Femoral sagittal deviation (femoral component flexion) was smaller in the RTKA group (0.9° vs 1.9°; p < 0.001). Similarly, tibial coronal deviation (0.8° vs 1.5°; p < 0.001) and tibial sagittal deviation (tibial slope) were smaller in the RTKA group compared to the NTKA group (0.9° vs 1.7°; p < 0.001). CONCLUSIONS: The RTKA group reported a substantial and significant reduced error from the planned target angles for both tibial and femoral components. No difference in terms of radiographic outliers was noted between navigation and robotic assistance.

Comparing Knee Kinetics and Kinematics in Healthy Individuals and Those With Knee Osteoarthritis, With and Without Flat Feet.

Individuals with knee osteoarthritis (KOA) and flat feet are more likely to experience increased pain and cartilage damage. This study aimed to investigate the knee kinetics, kinematics, pain, and physical function in individuals with moderate symptomatic KOA, in comparison to asymptomatic control participants. Thirty volunteers with moderate KOA (with flat feet n = 15, with normal feet n = 15) and 30 asymptomatic people (with flat feet n = 15, with normal feet n = 15) were evaluated. The knee adduction angular impulse, knee flexion moment, knee flexion angular impulse, and knee flexion angle were measured during level walking. The pain was assessed in patients with KOA. The study found that individuals with KOA had a significant increase in the knee adduction angular impulse compared with the asymptomatic people (P < .05). The KOA with flat feet group had significantly lower knee flexion moment, knee flexion angular impulse, and knee flexion angle values than the KOA with normal feet group (P < .05). Furthermore, the KOA with flat feet group had a higher pain score than the KOA with normal feet group. Individuals with osteoarthritis and flat feet had lower knee flexion moments which may indicate reduced knee force exerted through compensatory mechanisms. Despite this reduction, they reported significantly higher levels of pain compared with those without flat feet, a finding that warrants further investigation in future studies.

The Ilizarov technique in the management of haemophilic knee flexion contracture.

INTRODUCTION: The Ilizarov technique has the potential to be an attractive option for severe knee flexion contracture (KFC) patients with a high risk of bleeding. However, studies on this technique in the management of haemophilic KFC are scarce. AIM: The purpose of this study was to review and analyse the results of the Ilizarov technique in correcting haemophilic KFC and to evaluate the safety and efficacy of this technique. METHODS: Twelve male haemophilia patients with severe KFC who underwent distraction treatment using the Ilizarov technique from June 2013 to April 2019 were included in this study. The hospital day, flexion contracture, range of motion (ROM) of the knees, complications and functional outcomes were recorded and analysed. Functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) knee scores of the preoperation, end of distraction and last follow-up. RESULTS: The average preoperative flexion contracture and range of motion (ROM) of the knees were 55 ± 15° and 66 ± 18°, respectively. The average preoperative HSS knee score was 47 ± 5. The average duration of follow-up was 75.5 ± 30.1 months. All flexion contractures achieved full correction (≤5°) at the end of distraction, and the flexion contracture significantly decreased to 6 ± 5° at the last follow-up (p < .0001). The ROM of the knees was significantly increased at the last follow-up compared with that before distraction treatment (p < .0001). The HSS knee scores at the end of distraction and at the last follow-up were both significantly higher than the preoperative HSS knee score (p < .0001). No major complications were encountered. CONCLUSIONS: This study provided evidence for the safety and effectiveness of Ilizarov technique plus physical therapy in the management of haemophilic KFC and accumulated clinical experience for the proper application of this technology.

Mobilization under anaesthesia for correction of knee flexion deformity in haemophilia.

INTRODUCTION: Haemophilia patients not treated with primary or secondary prophylaxis, often present with recurrent haemarthrosis. Knee is the most frequently involved joint leading to disabling knee flexion deformity (KFD). Here, we present a retrospective study of our experience on the role of mobilization under general anaesthesia in the correction of KFD. AIM: To study the effectiveness of mobilization under anaesthesia (MUA) for correction of knee flexion deformity (KFD) in persons with haemophilia (PWH). METHODS: Outcome of all patients managed with MUA in our multidisciplinary haemophilia clinic from 2008 to 2019 were included for analysis. PWH with KFD > 20 degree who underwent MUA were included in the study. Under general anaesthesia and cover of clotting factor replacement, gentle joint mobilization was done to achieve maximal correction in flexion deformity, followed by above knee casting in this position. The outcome measures assessed were reduction in knee flexion deformity following MUA and complications, if any. RESULTS: Thirty patients (34 knees) with knee flexion deformity were included in the study. Mean age of the study population was 14.23 years ± 8.3. Study population was analysed in two groups, Group 1 included patients who underwent single MUA and Group 2, patients who underwent two or more MUA. There was significant improvement in KFD correction in both groups. [Group 1; Mean difference: 22 ± 13.7, p value -0.01, 95% CI (16.4-27.5) and Group 2; Mean difference 48.8 ± 19.8, p value -0.00, 95% CI (34.2-64.5)]. CONCLUSION: MUA can be effective in the short-term correction of KFD in PWH particularly those below 15 years of age. It should be done judiciously when target correction is not achieved with other physical methods.

The influence of varus and valgus deviation on the contact area of patellofemoral joint in healthy knees.

OBJECT: Varus-valgus lower alignment is a risk factor for patellofemoral osteoarthritis, but malalignment alone affect not only the tibiofemoral joint but also the patellofemoral joint. The aim of the present study was to analyse the contact area of patellofemoral joint in varus alignment and valgus alignment of healthy subjects using magnetic resonance imaging. METHODS: Twenty-six healthy subjects with valgus lower limb alignment (Group I, n = 26) and twenty-six volunteers with varus lower limb alignment (Group II, n = 26) was performed. An MRI scan was used to capture and measure the patellofemoral joint articular cartilage contact area at different degrees of knee flexion (20°, 40°,60°) in passive movement. All subjects were categorized on the basis of the global limb alignment and mechanical alignment of the femur and tibia. Varus alignment is hip-knee-ankle angle ≥ 3°; and valgus alignment is hip-knee-ankle angle ≥ - 3°. To obtain medial facet contact area and lateral facet contact area for each slice, the length of each respective line of contact was multiplied by the 5 mm slice thickness. RESULTS: The overall joint contact area increased from 168.0 ± 20.5 mm2 at 20° knee flexion to 334.4 ± 30.5 mm2 at 60° knee flexion in group (I) The overall joint contact area increased from 178.0 ± 18.9 mm2 at 20° knee flexion to 328.9 ± 27.2 mm2 at 60° knee flexion in group (II) There was a significant difference in lateral facet contact area between group I and group II at 40° of knee flexion. There was significantly different in medial facet contact area between group I and group II at 20° and 40° of knee flexion. CONCLUSIONS: Throughout the knee movement, the contact area on the lateral facet of the patellofemoral joint was greater in the valgus group. In the early phase of knee flexion, the contact area of the medial patellofemoral joint was larger in the varus group. Lower alignment is an important factor in patellofemoral joint degeneration.

Bicruciate-retaining total knee arthroplasty procedure reduced tensile force in the middle and posterior components of lateral collateral ligament during deep knee flexion activities with no effect on tensile force of the medial collateral ligament.

PURPOSE: To analyse the effects of bicruciate-retaining total knee arthroplasty (BCR-TKA) on the tensile force of the collateral ligaments during two deep knee flexion activities, cross-leg sitting and squatting. METHODS: Thirteen patients (15 knees) treated using bicruciate-retaining total knee arthroplasty (BCR-TKA) for knee joint osteoarthritis were analysed. Knee joint kinematics during cross-leg sitting (open-chain flexion) and squatting (closed-chain flexion) were evaluated through fluoroscopy. The tensile force was calculated in vivo based on the change in the distance between the femoral and tibial attachment areas for the anterior, middle, and posterior components of the superficial (sMCL) and deep (dMCL) medial collateral ligament and the lateral collateral ligament (LCL). Differences in the calculated tensile forces of the collateral ligaments were evaluated using repeated measures of analysis of variance, with post hoc pairwise comparison (Bonferroni test). Statistical significance was set at P ≤ 0.05. RESULTS: The correction of the coronal alignment was related to the surgical technique, not to the implant design. No significant change in the tensile force in all three components of the sMCL from pre- to post-TKA (n.s.) was observed. For dMCL, a pre- to post-TKA change in the tensile force was observed only for the anterior dMCL component (p = 0.03). No change was observed in the tensile force of the anterior LCL with increasing flexion, with no difference in pre- to post-TKA and between activities (n.s.). In contrast, tensile force in the middle LCL slightly decreased with increasing flexion during squatting, pre- and post-TKA. After surgery, lower forces were generated at 40° of flexion (p = 0.04). Tensile force in the posterior LCL was higher in extension than flexion, which remained high in the extension post-TKA. However, after surgery, lower tensile forces were generated at 10° (p = 0.04) and 40° (p = 0.04) of flexion. CONCLUSIONS: The in vivo change in tensile forces of the collateral ligaments of the knee before and after BCR-TKA can inform the development of appropriate ligament balancing strategies to facilitate recovery of deep knee flexion activities after TKA, as well as for continued improvement of BCR-TKA designs. LEVEL OF EVIDENCE: III.

Significant changes in lower limb alignment due to flexion and rotation-a systematic 3D simulation of radiographic measurements.

BACKGROUND: Many radiographic lower limb alignment  measurements are dependent on patients' position, which makes a standardised image acquisition of long-leg radiographs (LLRs) essential for valid measurements. The purpose of this study was to investigate the influence of rotation and flexion of the lower limb on common radiological alignment parameters using three-dimensional (3D) simulation. METHODS: Joint angles and alignment parameters of 3D lower limb bone models (n = 60), generated from computed tomography (CT) scans, were assessed and projected into the coronal plane to mimic radiographic imaging. Bone models were subsequently rotated around the longitudinal mechanical axis up to 15° inward/outward and additionally flexed along the femoral intercondylar axis up to 30°. This resulted in 28 combinations of rotation and flexion for each leg. The results were statistically analysed on a descriptive level and using a linear mixed effects model. RESULTS: A total of 1680 simulations were performed. Mechanical axis deviation (MAD) revealed a medial deviation with increasing internal rotation and a lateral deviation with increasing external rotation. This effect increased significantly (p < 0.05) with combined flexion up to 30° flexion (- 25.4 mm to 25.2 mm). With the knee extended, the mean deviation of hip-knee-ankle angle (HKA) was small over all rotational steps but increased toward more varus/valgus when combined with flexion (8.4° to - 8.5°). Rotation alone changed the medial proximal tibial angle (MPTA) and the mechanical lateral distal femoral angle (mLDFA) in opposite directions, and the effects increased significantly (p < 0.05) when flexion was present. CONCLUSIONS: Axial rotation and flexion of the 3D lower limb has a huge impact on the projected two-dimensional alignment measurements in the coronal plane. The observed effects were small for isolated rotation or flexion, but became pronounced and clinically relevant when there was a combination of both. This must be considered when evaluating X-ray images. Extension deficits of the knee make LLR prone to error and this calls into question direct postoperative alignment controls. LEVEL OF EVIDENCE: III (retrospective cohort study).

Improved responsiveness for JKOOS+ compared to KOOS in Japanese patients undergoing total knee arthroplasty.

BACKGROUND: Existing knee related patient reported outcome measurements (PROMs) have overwhelmingly been developed and validated in western chair-based societies, suggesting a potential for a western bias in PROMs evaluation of patients with knee conditions. We, therefore, endeavor to evaluate the responsiveness of the previously developed culturally relevant Japanese version of the knee injury and osteoarthritis outcome score (JKOOS+). METHODS: We enrolled 114 patients scheduled for total knee arthroplasty (TKA) across 8 knee clinics in Japan. Patients completed the Oxford Knee Score (OKS) and JKOOS + both at the time of enrollment and again 1-year post-TKA. Responsiveness was evaluated using effect size and standardized response mean (SRM). An effect size or SRM >0.8 is considered adequately responsive. We further tested the difference in responsiveness between the original Japanese language KOOS activities of daily living (ADL) domain and the novel Japanese ADL (JADL) domain using the modified Jacknife test. RESULTS: All domains were adequately responsive with the exception of the KOOS sports and recreation domain, which has previously been ignored by TKA researchers due to its lack of applicability to elderly patients undergoing TKA. The JADL domain outperformed the ADL domain in both effect size (1.51 v. 1.45) and SRM (1.67 v. 1.57) (p < 0.001). The novel Knee Flexion (KF) domain was adequately responsive, though less responsive than other domains except sports and recreation (p < 0.01 v. all other PROMs domains). CONCLUSIONS: The JKOOS+ JADL domain is significantly more responsive than the Europe-developed ADL domain to TKA in Japanese knee patients suffering from knee osteoarthritis (OA). The KF domain, unique to the JKOOS+ and intended to assess difficulty with knee flexion, is adequately responsive to TKA in Japanese patients suffering from OA.

Stress and strain changes of the anterior cruciate ligament at different knee flexion angles: A three-dimensional finite element study.

OBJECTIVE: This study aimed to analyze the stress and strain changes of the anterior cruciate ligament (ACL) at different knee flexion angles using a three-dimensional finite element model. METHODS: Computed tomography and magnetic resonance imaging scans were performed on the right knee of 30 healthy adult volunteers. The imaging data were used to construct a three-dimensional finite element model of the knee joint. The magnitude and concentration area of stress and strain of ACL at knee flexion angles 0°, 30°, 60° and 90° were assessed. RESULTS: The magnitude of stress remained consistent at 0-30° (P > 0.999) and decreased at 30-90° (P < 0.001, P = 0.005, respectively), while the magnitude of strain increased between 0° and 30° (P = 0.004) and decreased between 30° and 90° (P < 0.001, P = 0.004, respectively). The stress concentration area remained consistent at the proximal end, midsubstance, and distal end between 0° and 60° (P > 0.05). The concentration area of strain increased at the proximal end, decreased at the midsubstance between 0° and 30°, and remained consistent between 30° and 90° (P < 0.001). CONCLUSION: At the low knee flexion angle, ACL's magnitude of stress and strain reached the peak, and the concentration area of ACL strain gradually shifted from midsubstance to the proximal end.

Running-Related Achilles Tendon Injury: A Prospective Biomechanical Study in Recreational Runners.

There are relatively few running studies that have attempted to prospectively identify biomechanical risk factors associated with Achilles tendon (AT) injuries. Therefore, the aim was to prospectively determine potential running biomechanical risk factors associated with the development of AT injuries in recreational, healthy runners. At study entry, 108 participants completed a set of questionnaires. They underwent an analysis of their running biomechanics at self-selected running speed. The incidence of AT running-related injuries (RRI) was assessed after 1-year using a weekly questionnaire standardized for RRI. Potential biomechanical risk factors for the development of AT RRI injury were identified using multivariable logistic regression. Of the 103 participants, 25% of the sample (15 males and 11 females) reported an AT RRI on the right lower limb during the 1-year evaluation period. A more flexed knee at initial contact (odds ratio = 1.146, P = .034) and at the midstance phase (odds ratio = 1.143, P = .037) were significant predictors for developing AT RRI. The results suggested that a 1-degree increase in knee flexion at initial contact and midstance was associated with a 15% increase in the risk of an AT RRI, thus causing a limitation of training or a stoppage of running in runners.

Mechanics of guided growth of the distal femur for correction of fixed knee flexion deformities: an extra-articular technique.

INTRODUCTION: Anterior distal femoral hemiepiphysiodesis using intra-articular plates for correction of pediatric fixed knee flexion deformities (FKFD) has two documented complications: postoperative knee pain and implant loosening. The aim of this study is to investigate the mechanical properties of a novel extra-articular technique for anterior distal femoral hemiepiphysiodesis in patients with FKFD and to compare them to the conventional technique. MATERIALS AND METHODS: Sixteen femoral sawbones were osteotomized at the level of the distal femoral physis and fixed by rail frames to allow linear distraction simulating longitudinal growth. Each sawbone was tested twice: first using the conventional technique with eight plates placed anteriorly just medial and lateral to the femoral sulcus (group A) and then with plates inserted in the proposed novel location at the most anterior part of the medial and lateral surfaces of the femoral condyles with screws in the coronal plane (group B). Gradual linear distraction was performed, and the resulting angular correction was measured. Strain gauges were attached to the plates, and the amount of strain (and equivalent stress) over the plates in response to linear distraction was recorded. The two groups were compared using the Wilcoxon signed-rank test. RESULTS: The amount of angular correction was statistically higher in group B (extra-articular plates) at 5, 10-, and 15-mm of distraction (p < 0.001). As regards stress over the plates, the maximum stress and the area under the curve (sum of all stresses measured throughout the distraction process) were significantly higher when the plates were inserted at the conventional position (group A) (p < 0.001). CONCLUSIONS: During anterior distal femoral hemiepiphysiodesis, the fixation of the eight plates in the coronal plane at the anterior part of the femoral condyles may produce a greater amount of correction and a lower degree of stress over the implants as compared to the conventional technique.

The effect of native knee rotation on the tibial-tubercle-trochlear-groove distance in patients with patellar instability: an analysis of MRI and CT measurements.

BACKGROUND: This study aimed to quantify the effect of lower limb rotational parameters on the difference in the tibial-tubercle-trochlear-groove (TTTG) distance when assessed with magnetic resonance imaging (MRI) and computed tomography (CT) in patients with patellar instability. It was hypothesized that an increased native knee rotation angle significantly contributes to an underestimation of TTTG by MRI. METHODS: Forty patients with patellar instability who had undergone standard radiographs, MRI and CT scans were included in this retrospective study. A musculoskeletal radiologist assessed all imaging for TTTG, femoral and tibial rotation, knee rotation and flexion angle, and trochlear dysplasia. ΔTTTG was defined as the TTTG measured on MRI subtracted from the TTTG measured on CT. Statistical analysis determined the effect of these parameters on the calculated difference between TTTG when measured on CT and MRI. RESULTS: Equal knee flexion in MRI and CT resulted in a ΔTTTG of 0.1 ± 0.3 mm compared to 4.0 ± 3.3 mm in patients with different knee flexion angles in both imaging acquisitions (p = 0.036). The knee rotation angle measured on CT (native knee rotation angle) was negatively correlated with ΔTTTG (r = - 0.365; p = 0.002), while neither tibial nor femoral rotation showed any associations with TTTG (n.s.). Trochlear dysplasia did not show any significant correlation with ΔTTTG, regardless of classification by Dejour or Lippacher (n.s.). Both the native knee rotation angle and the MRI knee flexion angle were independent predictors of ΔTTTG, yet with an opposing effect (knee rotation: 95% Confidence Interval [CI] for ß - 0.468 to - 0.154, p < 0.001; knee flexion 95% CI for ß 0.292 to 0.587, p < 0.001). Patients with a native knee rotation angle > 20° showed a ΔTTTG of - 5.8 ± 4.0 mm (MRI rather overestimates TTTG) compared to 0.9 ± 4.1 mm Δ TTTG (MRI rather underestimates TTTG) in patients with < 20° native knee rotation angle. CONCLUSION: The native knee rotation angle is an independent, inversely correlated predictor of ΔTTTG, thus opposing the effect of knee flexion during MRI acquisition. Consequently, these results suggest that not only knee flexion but also knee rotation should be appreciated when assessing TTTG during patellar instability diagnostic evaluation as it can potentially lead to a false estimation of the TTTG distance on MRI. LEVEL OF EVIDENCE: Level III.