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The patellofemoral (PF) is a challenging location to repair cartilage. While both osteochondral allograft transplantation (OCA) and autologous chondrocyte implantation (ACI) are established as standard therapies for cartilage repair, most treatment algorithms continue to favor ACI for the PF joint, which shows a high rate of success. Today, however, OCA is a treatment of choice to revise prior failed PF cartilage repair. The positive outcomes in this setting encourage indicating OCA for select primary cartilage repair patients, namely those with defects that are uncontained or osteochondral. An advantage of OCA over ACI is that the tissue is more robust, and there may be less need for osteotomy to unload the PF joint. Even for ACI, TTO is reserved for those with abnormal patellar tracking and/or patella height. In terms of return to sports, realistic expectations are required. Return rates have been reported as 67% for NFL players, and 54% for a general population with an average age of 32. Both ACI and OCA are valuable treatment options for PF cartilage defects.
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Purpose: The aim of the present study is to define the minimal clinically important difference (MCID) for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) for patients undergoing tibial tubercle osteotomy (TTO) for either (1) patellofemoral pain or (2) patellar instability. Methods: Patients undergoing TTO for either patellofemoral pain or patellar instability by one of two sports medicine fellowship-trained surgeons at a single institution between September 2014 and May 2023 were included in the study. IKDC and KOOS scores were collected preoperatively and minimum 1 year postoperatively. Distribution-based methods were used to calculate the MCID. Results: Seventy-seven patients (82 knees) were included, with a median age of 29.3 years (interquartile range [IQR]: 22.2-36.3 years) and a median BMI of 24.5 kg/m2 [IQR: 22.3-28.3 kg/m2]. Fifty-seven patients (74%) were female, and there were 40 right knees (49%). The median time to IKDC and KOOS score was 1.8 and 1.7 years, respectively. Forty-five patients (46 knees) underwent TTO for patellofemoral instability, and 32 patients (36 knees) underwent TTO for patellofemoral pain. The MCID was 11.5 for IKDC, 10.2 for KOOS pain, 10.1 for KOOS symptoms, 9.9 for KOOS ADL, 14.2 for KOOS sport and 14.2 for KOOS QoL for patients undergoing TTO for patellofemoral pain. The MCID was 11.2 for IKDC, 10.1 for KOOS pain, 10.6 for KOOS symptoms, 10.2 for KOOS ADL, 16.0 for KOOS sport and 13.2 for KOOS QoL for patients undergoing TTO for patellar instability. Conclusion: We define the MCIDs for commonly used patient-reported outcome measures for patients undergoing TTO for either patellofemoral pain or patellar instability. Level of Evidence: Level II.
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Although several prior studies have described the outcomes of osteochondral allograft (OCA) transplantation for single osteochondral lesions, there is a paucity of comparative data on outcomes of single versus multiple OCA transplants. We aimed to describe the initial outcomes of single-plug versus multiple-plug knee OCA transplants at a minimum of 1 year of follow-up. We hypothesized that there would be no difference in patient-reported outcome measures (PROMs) between patients undergoing single-plug and multiple-plug OCA transplants at a minimum of 1 year of follow-up. We retrospectively reviewed the prospectively collected data of patients undergoing OCA transplantation for large (>2 cm2) osteochondral defects of the knee. Thirty patients who underwent multiple-plug (2 + ) OCA transplants (either single surface using the snowman technique or multi-surface) were 1:1 age, sex, and body mass index (BMI) matched with 30 patients who underwent single-plug OCA transplants. PROMs, including the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores, were obtained both preoperatively and at a minimum of 1 year postoperatively. Failure was defined as a revision OCA or conversion to unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). The cohort comprised 30 females (31 affected left knees), with an average age of 37 ± 10.3 years and median follow-up of 2.0 years (interquartile range: 1.7-2.5 years). There was a significant increase in PROMs from the preoperative to the postoperative period for the entire cohort and the single-plug versus multiple-plug subgroups (p < 0.01). There was no difference between the groups with respect to the percentage of patients who achieved the minimal clinically important difference (MCID) for each PROM (p > 0.05). There were two failures, both in the single-plug group, with a mean time to failure of 3.5 years. There was no difference in the initial outcomes between patients undergoing single-plug versus multiple-plug OCA transplant at the short-term follow-up. LEVEL OF EVIDENCE:: Level IV, case series.
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Background: Medial patellar facet lesions have been well-described in the setting of patellar instability. However, relatively little is known about risk factors for atraumatic medial patellar facet lesions. Purpose/Hypothesis: To identify clinical and radiographic risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability. It was hypothesized that a posterior tibial tubercle relative to the trochlear groove would be a risk factor for atraumatic medial patellar facet lesions. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 37 patients with atraumatic medial patellar facet lesions were matched by age, sex, and body mass index with 37 control patients without a history of patellofemoral dysplasia. Demographic and imaging characteristics were compared between groups. Plain radiography was used to evaluate Wiberg type, and magnetic resonance imaging was used to calculate Caton-Deschamps index, tibial tubercle-trochlear groove distance, trochlear facet asymmetry ratio, patellotrochlear index, sulcus depth, patellar bisect ratio, and tibial tubercle height. Statistically significant variables from univariate analysis were used as inputs to the multivariate regression model to assess independent risk factors. Results: There were no differences between groups with respect to Wiberg type, Caton-Deschamps index, tibial tubercle-trochlear groove distance, sulcus depth, or patellotrochlear index (P > .05 for all). The medial facet lesion group had a larger medial trochlear facet (trochlear facet asymmetry ratio, 0.72 ± 0.11 vs 0.60 ± 0.09; P < .001), a more medial-lying patella in the trochlear groove (patellar bisect ratio, 0.57 ± 0.06 vs 0.55 ± 0.07; P = .035), and a more posterior tibial tubercle relative to the trochlear groove (tibial tubercle height, -3.13 ± 5.21 vs -0.23 ± 5.93 mm; P = .030) compared with the control group. Multivariate regression analysis identified trochlear facet asymmetry and tibial tubercle height as independent risk factors for medial patellar facet lesions (relative risk = 97.3 [95% CI, 14.9-635.1], P < .001 and relative risk = 0.95 [95% CI, 0.92-0.98], P = .004, respectively). Conclusion: A relatively larger medial trochlear facet and a more posterior tibial tubercle relative to the trochlear groove were found to be risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability.
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BACKGROUND: Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patellofemoral instability and pain. TTO with distalization (TTO-D) is indicated for patients with patellofemoral instability, patellar malalignment, and patella alta. The current literature demonstrates several complications that may be associated with TTO, with reportedly higher rates of complications associated with TTO-D. PURPOSE: To analyze and compare complication rates after TTO without distalization (TTO-ND) and TTO-D and assess risk factors associated with complications. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All skeletally mature patients who underwent TTO with or without distalization by a single surgeon between September 2014 and May 2023 with a minimum of 6 months of clinical follow-up were retrospectively reviewed. Patient factors, surgical indications, perioperative data, and complications were collected via a retrospective review of electronic medical records. Concomitant procedures were categorized as intra-articular, extra-articular, and osteotomies. RESULTS: A total of 251 TTOs (117 TTO-D, 134 TTO-ND) were included in the study group. Postoperative complications were observed in 15 operations (6%), with arthrofibrosis as the most common complication (10 operations [4%]). TTO-D and TTO-ND had similar rates of complication (5% vs 7%; P = .793). Clinical nonunion was observed in 3 operations (3%) in the TTO-D cohort and 1 operation (1%) in the TTO-ND cohort. In the TTO-D cohort, concomitant intra-articular procedures were significantly associated with an increased likelihood of complications in a univariate model. In the TTO-ND cohort, an increased tourniquet time was significantly associated with an increased likelihood of complications in a univariate model. For all TTOs as well as the TTO-D and TTO-ND cohorts, there were no significant associations between patient or surgical variables in a multivariate model. CONCLUSION: TTO with and without distalization is a safe procedure with low rates of complication. TTO-D was not associated with a higher rate of complications compared with TTO-ND. There was no association between complications and surgical variables for TTO procedures.
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Instabilidade Articular , Luxação Patelar , Articulação Patelofemoral , Humanos , Estudos Retrospectivos , Estudos de Coortes , Incidência , Osteotomia/efeitos adversos , Osteotomia/métodos , Luxação Patelar/cirurgia , Tíbia/cirurgia , Instabilidade Articular/cirurgia , Articulação Patelofemoral/cirurgiaRESUMO
Background: Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses. Purpose: To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis. Study Design: Case series; Level of evidence, 4. Methods: Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle-trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores. Results: The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P < .001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P < .020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P < .001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P≤ .024 for all ). There were 4 (20%) complications-2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union. Conclusion: Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta.
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BACKGROUND: Cell-based cartilage repair procedures of the patellofemoral joint have less reliable outcomes than those of the tibiofemoral joint. No previous studies have evaluated the influence of patellar shape on cell-based cartilage repair outcomes. Patellar dysplasia may predispose patients to worse outcomes after cell-based cartilage repair. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the relationship between Wiberg patellar type and outcomes after cell-based cartilage repair (autologous chondrocyte implantation or particulated juvenile allograft cartilage transplantation) for the treatment of patellar chondral lesions at a minimum 2-year follow-up. It was hypothesized that Wiberg classification of patellar shape would have no effect on patient-reported outcome measures (PROMs) or graft survival. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing autologous chondrocyte implantation or particulated juvenile allograft cartilage transplantation for full-thickness patellar chondral defects between 2016 and 2020 were retrospectively reviewed after institutional review board approval. The change in PROMs, including International Knee Documentation Committee (IKDC), Kujala, and Veterans RAND 12-item Health Survey Mental and Physical scores, from pre- to postoperatively and the percentage of patients who achieved the minimal clinically important difference (MCID) for IKDC and Kujala scores were compared for the Wiberg type A versus Wiberg type B versus Wiberg type C groups. The log-rank test was used to evaluate for differences in survival between subgroups. RESULTS: A total of 59 patients (63 knees) were included, with a mean age of 33.3 ± 8.6 years, median body mass index of 26.0 (IQR, 21.8-30.2), and median follow-up time of 3.5 years (IQR, 2.6-4.2 years). In total, 26 (41%) patellae were Wiberg type A, 29 (46%) were Wiberg type B, and 8 (13%) were Wiberg type C. There were no differences between Wiberg type A versus Wiberg type B versus Wiberg type C groups with respect to change in PROMs from pre- to postoperatively or the percentage of patients who achieved the MCID for IKDC or Kujala scores (P > .05 for all). There were no differences in survival between groups (P = .45). CONCLUSION: Wiberg patellar type has no effect on patient-reported outcomes or graft survival at midterm follow-up. Patellar dysplasia should not be seen as a contraindication for cell-based cartilage repair procedures.
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Cartilagem Articular , Humanos , Adulto Jovem , Adulto , Cartilagem Articular/cirurgia , Estudos de Coortes , Seguimentos , Estudos Retrospectivos , Condrócitos/transplante , Transplante AutólogoRESUMO
BACKGROUND: Previous biomechanical studies evaluating medial meniscus posterior root tears (MMPRTs) are limited to low loads applied at specified loading angles, which cannot capture the effects of MMPRTs during the multidirectional forces and moments placed across the knee during physiological activities. PURPOSE: To quantify the effects of MMPRTs on knee joint contact mechanics during simulated gait. STUDY DESIGN: Controlled laboratory study. METHODS: Six human cadaveric knees were mounted on a robotic simulator programmed to apply dynamic forces, moments, and flexion angles to mimic level walking. Twelve cycles of multidirectional and dynamic standard gait input waveforms, normalized to specimen-specific body weight, were applied to the following conditions: (1) native, intact meniscus and (2) MMPRT. Peak contact stress, contact area, and the position of the weighted center of contact across the medial tibial plateau throughout the stance phase of gait were quantified using an electronic sensor placed across the medial tibial plateau. The difference between the intact state and MMPRT condition was calculated for each metric, and then the means and 95% CIs were computed. RESULTS: Despite heterogeneity in knee contact forces, MMPRTs significantly increased peak contact stress by a mean of 2 MPa across 20% to 37% of the simulated gait cycle and significantly decreased the contact area by a mean of 200 mm2 across 16% to 60% of the simulated gait cycle in comparison with the native state. There was no significant difference in the position of the weighted center of contact, in either the anterior-posterior or medial-lateral directions, after MMPRT. CONCLUSION: MMPRTs led to both a significant increase in peak contact stress and decreased contact areas for a portion of the simulated gait cycle ranging from 20% to 37% of gait, during which time the femur was flexed <15°. CLINICAL RELEVANCE: Contact mechanics are significantly affected after MMPRTs during early to midstance and at knee flexion angles lower than demonstrated previously. These data provide further biomechanical justification for treating MMPRTs.
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Meniscos Tibiais , Lesões do Menisco Tibial , Humanos , Fenômenos Biomecânicos , Cadáver , Articulação do Joelho/fisiologia , MarchaRESUMO
The purpose of this study was to evaluate the efficacy of combined patellofemoral arthroplasty (PFA) and medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral arthritis in the setting of concomitant patellar instability. Patients who underwent single-stage, combined PFA and MPFL reconstruction by a single surgeon at a tertiary-care orthopaedic center between 2016 and 2021 were identified. Postoperative radiographic and clinical outcomes at a minimum of 6 months were recorded using patient-reported outcome measures, including International Knee Documentation Committee (IKDC), Kujala, and VR-12. Early complications and rates of recurrent instability were also recorded. Of the 16 patients who met inclusion and exclusion criteria, 13 patients were available for final follow-up (81%; 51.7 ± 7.2 years, 11 females, 2 males) with a mean clinical follow-up of 1.3 ± 0.5 years (range: 0.5-2.3 years). Patients experienced significant improvements in patellar tilt and multiple patient-reported outcome metrics postoperatively, including IKDC, Kujala, VR-12 Mental Health, and VR-12 Physical Health. At the time of the most recent follow-up, no patient had experienced a postoperative dislocation or subluxation event. The findings suggest that concurrent PFA and MPFL reconstruction are associated with significant improvements in multiple patient-reported outcomes. Further studies are needed to evaluate the duration of clinical benefits achieved with this combined intervention.
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Luxações Articulares , Instabilidade Articular , Luxação Patelar , Articulação Patelofemoral , Masculino , Feminino , Humanos , Instabilidade Articular/cirurgia , Articulação Patelofemoral/cirurgia , Estudos Retrospectivos , Ligamentos Articulares/cirurgia , Luxações Articulares/cirurgia , Artroplastia/efeitos adversos , Luxação Patelar/cirurgiaRESUMO
It is important to highlight the use of patient-specific cutting guides for knee joint osteotomies. Rationale, pitfalls, and planning of conventional osteotomy techniques are examined. The benefits of using patient-specific guides focusing on the potential for improved accuracy, efficiency, and safety are reviewed. The versatility of guides to manipulate the slope in both the coronal and sagittal planes, as well as its ability to accommodate concomitant procedures, is discussed. The time and cost differentials between standard cutting guides and three-dimensional-guided templating are also discussed.
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Articulação do Joelho , Cirurgia Assistida por Computador , Humanos , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/cirurgia , Osteotomia/métodos , Cirurgia Assistida por Computador/métodosRESUMO
Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.
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Traumatismos do Tornozelo , Cartilagem Articular , Instabilidade Articular , Articulação Patelofemoral , Humanos , Criança , Instabilidade Articular/diagnóstico , Instabilidade Articular/cirurgia , Técnica Delphi , Traumatismos do Tornozelo/cirurgia , Articulação do Tornozelo/cirurgia , Cartilagem Articular/cirurgiaRESUMO
Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.
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Instabilidade Articular , Luxação Patelar , Articulação Patelofemoral , Humanos , Criança , Instabilidade Articular/cirurgia , Luxação Patelar/cirurgia , Articulação Patelofemoral/cirurgia , Técnica Delphi , Articulação do Joelho/cirurgia , Ligamentos Articulares/cirurgiaRESUMO
OBJECTIVE: We aimed to evaluate the outcomes, survivorship, and complications following multi-surface cartilage procedures at minimum 2-year follow-up. DESIGN: Patients with either (1) single-surface osteochondral allograft transplantation (OCAT) with third-generation matrix-induced autologous cultured chondrocyte implantation (MACI) or particulated juvenile cartilage implantation (DeNovo), or (2) multiple-surface OCAT ± associated MACI/DeNovo procedures for grade IV chondral or osteochondral defects about the knee with minimum 2-year follow-up were analyzed. Patient-reported outcome measures (PROMs), including International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, were obtained preoperatively and at minimum 2 years postoperatively. The percentage of patients who met the minimal clinically important difference (MCID) for each PROM was reported. Failure was defined as revision OCAT, conversion to patellofemoral/total/unicompartmental joint arthroplasty, or Arthrosurface HemiCAP placement. RESULTS: Of 257 patients identified, 35 were included. There was a significant increase in IKDC, KOOS-pain, KOOS-symptom, KOOS-sport, and KOOS-quality of life scores from preoperative to postoperative evaluation (P < 0.03 for all). More than 50% of patients met the MCID for each PROM. There were 2 failures, 1 of the patella and 1 of the medial femoral condyle, at 39.7 and 38.6 months postoperatively, respectively. DISCUSSION: Multi-surface cartilage procedures are a safe, efficacious treatment option for multifocal cartilage defects about the knee at short-term follow-up.
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OBJECTIVE: The present study aims to compare the presence and severity of patellofemoral osteoarthritis between patients with root lesions and non-root lesions. DESIGN: A total of 102 patients were included in this study (51 root lesions and 51 non-root lesions). The root lesion cohort was matched to a non-root lesion cohort based on sex, body mass index, and age at the time of surgery. Radiographic evaluation with modified Outerbridge scoring of MRI of the knee was performed to determine the severity of degeneration of the knee joint preoperatively. Mann-Whitney and Independent t tests were used to compare the groups. RESULTS: The root lesion group had statistically greater Outerbridge patella scores (M = 2.45 ± 1.12) and trochlear scores (M = 2.27 ± 1.37) than the non-root lesion patients (M = 1.78 ± 1.30, P = 0.006, and M = 1.55 ± 1.40, P = 0.010, respectively). When using a new scale for grading patellofemoral arthritis, the root lesion group had statistically greater scores (M = 8.33 ± 3.38) than the non-root lesion patients (M = 5.67 ± 3.07) (P < 0.001). CONCLUSION: Patients with root lesions have a greater degree of patellofemoral cartilage lesions than patients without root lesions. The presence of cartilage lesions preoperatively in root lesion patients has presented the question of whether repair is worthwhile or if one should delay surgery until arthroplasty is indicated. Future research should be carried out on outcomes of root repair surgery in patients with patellofemoral cartilage lesions, in addition to considering the patient's age, activity level, and other risk factors.
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Articulação do Joelho , Osteoartrite do Joelho , Humanos , Articulação do Joelho/cirurgia , Meniscos Tibiais/cirurgia , Osteoartrite do Joelho/diagnóstico por imagem , Osteoartrite do Joelho/patologia , Joelho/patologia , Imageamento por Ressonância MagnéticaRESUMO
PURPOSE: The purpose of this study was to quantify differences in mechanical stability of a wedge-shaped distalization tibial tubercle osteotomy (TTO) with a standard technique, versus a modified technique with use of a proximal bone block and distally angled screw trajectory. METHODS: Ten fresh-frozen cadaver lower extremity specimens (five matched pairs) were utilized. Within each specimen pair, one specimen was randomly assigned to undergo a standard distalization osteotomy fixed with two bicortical 4.5-mm screws oriented perpendicular to the long axis of the tibia, and the other to undergo a distalization osteotomy with modified fixation utilizing a proximal bone block and distally angled screw trajectory. Each specimen's patella and tibia were mounted on a servo-hydraulic load frame using custom fixtures (MTS Instron). The patellar tendon was dynamically loaded to 400 N at a rate of 200 N/second for 500 cycles. Following the cyclic loading, loading to failure was done at 25 mm/min. RESULTS: The modified distalization TTO technique demonstrated significantly higher average load to failure compared to the standard distalization TTO technique (1339 N vs. 844.1 N, p < 0.001). Average maximum tibial tubercle displacement during cyclic loading was significantly smaller in the modified TTO technique group compared to the standard TTO technique (1.1 mm vs. 4.7 mm, p < 0.001). CONCLUSION: This study demonstrates that distalization TTO utilizing a modified technique with a proximal bone block and distally aimed screws is biomechanically superior to standard distalization TTO without proximal bone block and screw trajectory perpendicular to the long axis of the tibia. This increased stability may aid in reducing the reported higher complication rates (including loss of fixation, delayed union and nonunion) following distalization TTO, although future clinical outcome studies are warranted.
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Patela , Tíbia , Humanos , Tíbia/cirurgia , Patela/cirurgia , Osteotomia/métodos , Extremidade Inferior , Parafusos Ósseos , Fenômenos BiomecânicosRESUMO
OBJECTIVE: Subchondral insufficiency fracture of the knee (SIFK) is associated with high rates of osteoarthritis (OA) and arthroplasty. The implantable shock absorber (ISA) is an extra-capsular implant that unloads the medial knee compartment. This study compared the 2-year freedom from arthroplasty rates in subjects with medial knee OA and SIFK when treated with an ISA versus a matched cohort of patients treated non-surgically. DESIGN: This retrospective case-control study compared 2-year conversion rates to arthroplasty in SIFK score-, age-, and body mass index (BMI)-matched control subjects without prior surgical history with ISA-implanted subjects from an ongoing prospective study. Baseline and final radiographs, and MRIs were reviewed for evaluation of meniscus or ligament injuries, insufficiency fractures, and subchondral edema. Kaplan-Meier analysis assessed survival. RESULTS: Forty-two patients (21 Control: 21 ISA), mean age = 52.3 ± 8.7 years, BMI = 29.5 ± 3.9 kg/m2, 40% female were evaluated. Both ISA and Control arms had the same numbers of low (n = 4), medium (n = 11), and high-risk (n = 6) SIFK scores. One- and 2-year freedom-from-arthroplasty rates were both 100% for ISA subjects, and 76% and 55%, respectively, for Controls (P = 0.001 for cross-group comparison). Control knees with low, medium, and high-risk SIFK scores had respective 1- and 2-year survival rates of 100% and 100%, 90% and 68% (P = 0.07 vs. ISA), and 33% and 0% (P = 0.002 vs. ISA). CONCLUSIONS: ISA intervention was strongly associated with avoidance of arthroplasty at a minimum 2 years, especially in patients with high-risk SIFK scores. SIFK severity scoring predicted relative risk of conversion to arthroplasty through at least 2 years in non-surgically treated subjects.
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Artroplastia do Joelho , Fraturas de Estresse , Fraturas do Joelho , Osteoartrite do Joelho , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Masculino , Osteoartrite do Joelho/diagnóstico por imagem , Osteoartrite do Joelho/cirurgia , Osteoartrite do Joelho/etiologia , Fraturas de Estresse/cirurgia , Estudos Retrospectivos , Estudos de Casos e Controles , Estudos Prospectivos , Artroplastia do Joelho/efeitos adversosRESUMO
BACKGROUND: A prior retrieval analysis found high rates of infection after conversion of PFA to TKA, but was limited by a small sample size. The purpose of this study is to perform a retrieval analysis with clinical correlation on an expanded group of patients to better understand conversion of PFA to TKA. METHOD: A retrospective review of an implant retrieval registry identified 62 conversions of PFA to TKA between 2004-2021. Implants were analyzed for wear pattern and cement fixation. Patient charts were reviewed for demographic information, perioperative data, prior and subsequent surgical procedures, complications and outcomes. Radiographs performed prior to index PFA and conversion procedures were assessed for KL grading. RESULTS: Cement fixation was present on 86% of retrieved components and wear was more pronounced on the lateral side. The most common indication for conversion to TKA was progression of OA in 46.8% of patients, followed by unexplained pain in the absence of radiographic or clinical changes (37.1%), loosening (8.1%), mechanical symptoms (4.8%), traumatic (3.2%). Thirteen patient experienced complications requiring additional procedures including arthrofibrosis (n = 4, 7.3%), PJI (n = 3, 5.5%), instability (n = 3, 5.5%), hematoma (n = 2, 3.6%) and loosening (n = 1, 1.8%). Revision components were used in 1.8% of cases and average post-conversion arc of motion was 119 degrees. CONCLUSIONS: The most common reason for PFA conversion to TKA was progression of osteoarthritis. PFA conversion to TKA is technically similar to primary TKA, but complication rates are more consistent with revision TKA in this study.
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PURPOSE: To define the minimal detectable change (MDC) for the international knee documentation committee (IKDC) and Kujala scores one and two years after patellofemoral joint arthroplasty (PFA). METHODS: A distribution-based method (one-half the standard deviation of the mean difference between postoperative and preoperative outcome scores) was applied to establish MDC thresholds among 225 patients undergoing primary PFA at a single high-volume musculoskeletal-care center. Stability of change in MDC achievement was explored by quantifying the proportion of achievement at one- and two-year postoperative timepoints. Multivariable logistic regression analysis was performed to explore the association between sociodemographic and operative features on MDC achievement. RESULTS: MDC thresholds for the Kujala score were 10.3 (71.1% achievement) and 10.6 (70.4% achievement) at one- and two years, respectively. The MDC thresholds for the IKDC score were 11.2 (78.1% achievement) and 12.3 (69.0% achievement) at one- and two years, respectively. Predictors of achieving the MDC for the Kujala and IKDC scores at both time points were lower preoperative Kujala and IKDC scores, respectively. Preoperative thresholds of ≤ 24.1 and 7.6 for the Kujala and IKDC scores, respectively, were associated with a 90% MDC achievement probability. When preoperative thresholds approached 64.3 and 48.3 for the Kujala and IKDC, respectively, MDC achievement probability reduced to 50%. CONCLUSION: The MDC thresholds for the Kujala and IKDC scores two years after PFA were 10.6 and 12.3, respectively. Clinically significant health status changes were maintained overall, with a slight decrease in achievement rates between one and two years. MDC achievement was associated with disability at presentation, and several probability-based preoperative thresholds were defined. These findings may assist knee surgeons with patient selection and the decision to proceed with PFA by better understanding the patient-specific propensity for MDC achievement. LEVEL OF EVIDENCE: IV, retrospective case series.
Assuntos
Articulação Patelofemoral , Humanos , Articulação Patelofemoral/cirurgia , Estudos Retrospectivos , Articulação do Joelho/cirurgia , Artroplastia/métodos , Período Pós-Operatório , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the 5-year rate of survival without undergoing arthroplasty or high tibial osteotomy (HTO) in subjects with mild-to-moderate medial compartment knee osteoarthritis (OA) who were treated with an implantable shock absorber (ISA) system. METHODS: Three prospective, sequential, multicenter, international, single-arm clinical trials were conducted comprising subjects who received an ISA for symptomatic medial knee OA after failing ≥ 6 months of conservative therapy. Study outcomes were analyzed cumulatively and by enrollment group when all subjects' follow-up data exceeded the 2-year threshold after ISA implantation. Primary outcome was survival rate without conversion to arthroplasty/HTO. Secondary outcomes were changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores after ISA implantation. RESULTS: All 171 enrolled subjects (age 51 ± 9 years, body-mass index 28.5 ± 3.5 kg/m2, 38% female; study knee Kellgren-Lawrence score 2.7 ± 0.9 points) were followed for a minimum of 2, and up to 5, years after device implantation. Overall, 90.6% (155/171) of subjects survived without requiring arthroplasty/HTO at last follow-up (mean 3.2 ± 1.6 years). The Kaplan-Meyer median 3- and 5-year survival-without-arthroplasty point estimates were 89.8% (95% CI 86.5â95.7%) and 84.9% (95% CI 75.1â91.1%), respectively. The median 3-year estimated survival rate for the most recent study (n = 81) was 97.3%. The mean WOMAC Pain score decreased 71% from baseline to last follow-up after ISA implantation, from 58 ± 13 to 16 ± 17 points (p < 0.0001). The Function score improved 69%, decreasing from 56 ± 18 to 17 ± 17 points (p < 0.0001). CONCLUSIONS: In younger patients with mild-to-moderate symptomatic medial compartment knee OA, implantation of the ISA device resulted in a 5-year survival rate of 85% from undergoing arthroplasty or HTO. The ISA system may be an effective treatment option for working-age patients with medial knee OA who are not candidates for or do not desire more invasive surgical approaches. LEVEL OF EVIDENCE: II.
Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Masculino , Osteoartrite do Joelho/cirurgia , Estudos Prospectivos , Tíbia/cirurgia , Articulação do Joelho/cirurgia , Resultado do Tratamento , Artroplastia do Joelho/métodos , Dor/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Lesions of the articular cartilage, with or without involvement of the subchondral bone, are a common cause of pain and dysfunction in the knee. Although several treatment options have been developed, the majority of previous clinical trials examined patients with isolated or focal midsized defects, which rarely represent the condition found in the general population. Rather, cartilage lesions are often associated with the presence of mild to moderate osteoarthritic changes. PURPOSE: The present multicenter randomized controlled trial compared the clinical and radiographic outcomes of an aragonite-based osteochondral implant with a control group (arthroscopic debridement/microfractures) in patients affected by joint surface lesions of the knee, including those with concurrent mild to moderate osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 251 patients were enrolled in 26 medical centers according to the following criteria: age 21 to 75 years, up to 3 cartilage defects of International Cartilage Regeneration & Joint Preservation Society grade 3a or above located on the femoral condyles and/or trochlea, total treatable area from 1 to 7 cm2, bony defect depth ≤8 mm, and knee osteoarthritis grade 0 to 3 according to Kellgren-Lawrence score. Patients were randomized to the aragonite-based implant or debridement/microfracture control arm in a 2:1 ratio. Evaluation was performed at 6, 12, 18, and 24 months based on overall Knee injury and Osteoarthritis Outcome Score (KOOS) as the primary endpoint, and the KOOS subscales (Pain, Quality of Life, Activities of Daily Living), percentage of responders, and International Knee Documentation Committee (IKDC) subjective score as the secondary endpoints. Patients also underwent magnetic resonance imaging evaluation at 12 and 24 months to assess defect fill grade. Failures (ie, need for any secondary treatment) and adverse events were also recorded. RESULTS: The implant group showed a statistically superior outcome in the primary endpoint and all secondary endpoints at each follow-up. The magnitude of improvement in the implant group was twice as large as that in the control group in terms of mean KOOS improvement at 2 years. Responder rate (defined as at least a 30-point improvement in overall KOOS) was 77.8% in the implant group as opposed to 33.6% in the control (P < .0001). Statistically superior results were seen in the IKDC score as well. At 24 months, 88.5% of the implanted group had at least 75% defect fill on magnetic resonance imaging as compared with 30.9% of controls (P < .0001). The failure rate was 7.2% for the implant group versus 21.4% for control. CONCLUSION: This aragonite-based scaffold was safe and effective in the treatment of chondral and osteochondral lesions in the knee, including patients with mild to moderate osteoarthritis, and provided superior outcomes as compared with the control group. REGISTRATION: NCT03299959 (ClinicalTrials.gov identifier).