Medial opening wedge high tibial osteotomy performs similarly irrespective of body mass index.

PURPOSE: This study investigates the effect of the body mass index (BMI) on the early (2 years) to midterm (5 years) results of medial opening wedge high tibial osteotomy (MOWHTO). METHODS: A prospectively maintained single-centre database of 1138 knee osteotomies, between 2002 and 2022, was retrospectively reviewed. Adult patients who underwent MOWHTO for symptomatic unicompartmental medial knee osteoarthritis (OA), with varus knee malalignment, having failed conservative management, were included. Patients were categorized into three groups according to their BMI as per the classification from the National Institute for Health and Care Excellence (NICE): the healthy weight (HW) group (BMI of 18.5-24.9 kg/m2), the overweight (OW) (BMI of 25-29.9 kg/m2), and the obesity (OB) group (BMI ≥ 30 kg/m2). Multiple patient-reported outcome measures (n = 6) were recorded preoperatively and at 2 and 5 years postoperatively. Deformity analysis was undertaken preoperatively and postoperatively. The relative risk (RR) of the complications between the HW, OW and OB groups was calculated. The rate of conversion to arthroplasty, and 5 and 10 years survivorship were recorded, as well as the hazard ratio (HR) of BMI on survivorship. RESULTS: A total of 574 cases were included in the study: the HW group (n = 96), the OW group (n = 233) and the OB group (n = 245), with a mean BMI of 23 ± 1.5 kg/m2, 27.4 ± 1.4 kg/m2 and 34.4 ± 3.8 kg/m2, respectively. The mean follow-up was 13.3 years (4.8-20.3). The mean mechanical tibiofemoral angle corrections were in the HW group: 7.1 ± 3°, OW group: 6.6 ± 3.5° and OB group: 7.1 ± 3.8°, with no intergroup significant difference (p = n.s.). Clinically, despite lower preoperative scores in the OW and OB groups, no difference was observed postoperatively amongst the three groups. The overall complication rate was 12.5% in the HW group, 6.8% in the OW group, and 9.8% in the OB group. There was no significant difference in the RR of complications between the HW and OW groups (RR = 0.6, 95% confidence interval [CI] = 0.3-1.3) (p = 0.2), and the HW and OB groups (RR = 0.8; 95% CI = 0.3-2.2) (p = 0.7). There was no overall significant difference in survival outcomes based on the BMI between the three groups (p = 0.4). The HR of conversion to arthroplasty between the HW and OW groups was 1.4 [95% CI = 0.6-3.5](p = 0.5) and between the HW and OB groups was 1.8 [95% CI = 0.8-4.4] (p = 0.2). CONCLUSION: BMI has no significant effect on either the radiological corrections, clinical outcomes, complications or survivorship of MOWHTO at short- to medium-term follow-up. No specific cutoff point for BMI can be recommended as a contraindication to MOWHTO. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

Osteotomy around the painful degenerative varus knee has broader indications than conventionally described but must follow a strict planning process: ESSKA Formal Consensus Part I.

PURPOSE: The European consensus was designed with the objective of combining science and expertise to produce recommendations that would educate and provide guidance in the treatment of the painful degenerative varus knee. Part I focused on indications and planning. METHODS: Ninety-four orthopaedic surgeons from 24 European countries were involved in the consensus, which focused on the most common indications for osteotomy around the knee. The consensus was performed according to an established ESSKA methodology. The questions and recommendations made were initially designed by the consensus steering group. And 'best possible' answers were provided based upon the scientific evidence available and the experience of the experts. The statements produced were further evaluated by ratings and peer review groups before a final consensus was reached. RESULTS: There is no reliable evidence to exclude patients based on age, gender or body weight. An individualised approach is advised; however, cessation of smoking is recommended. The same applies to lesser degrees of patellofemoral and lateral compartment arthritis, which may be accepted in certain situations. Good-quality limb alignment and knee radiographs are a mandatory requirement for planning of osteotomies, and Paley's angles and normal ranges are recommended when undertaking deformity analysis. Emphasis is placed upon the correct level at which correction of varus malalignment is performed, which may involve double-level osteotomy. This includes recognition of the importance of individual bone morphology and the maintenance of a physiologically appropriate joint line orientation. CONCLUSION: The indications of knee osteotomies for painful degenerative varus knees are broad. Part I of the consensus highlights the versatility of the procedure to address multiple scenarios with bespoke planning for each case. Deformity analysis is mandatory for defining the bone morphology, the site of the deformity and planning the correct procedure. LEVEL OF EVIDENCE: Level II, consensus.

Surgical strategy and complication management of osteotomy around the painful degenerative varus knee: ESSKA Formal Consensus Part II.

PURPOSE: The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy. METHODS: Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released. RESULTS: The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months. CONCLUSION: Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research. LEVEL OF EVIDENCE: Level II, consensus.

Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies.

PURPOSE: This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO). METHODS: A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests. RESULTS: An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees. CONCLUSION: In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered. LEVEL OF EVIDENCE: Level Ⅳ, retrospective case-control study.

The tipping point in medial opening wedge high tibial osteotomy relates to the shape of the proximal tibia more than to lower limb alignment correction.

PURPOSE: The tipping point (TP) of the knee joint is the centre of rotation of the joint in the coronal plane. This study aimed to define the TP in medial opening wedge high tibial osteotomy (MOWHTO). METHODS: Data from 154 consecutive patients with varus knee malalignment, who underwent MOWHTO between 2017 and 2021, was retrospectively reviewed. The degree of preoperative osteoarthritis (OA), using the Kellgren-Lawrence (KL) grading system, was recorded. Long-leg standing radiographs were used to record the alignment parameters, including the hip-knee-ankle angle (HKA), the mechanical lateral distal femoral angle (mLDFA), the medial proximal tibial angle (MPTA), the joint line convergence angle (JLCA) and the joint line obliquity (JLO) angle. Postoperative Tegner activity scores, Western Ontario and McMaster University Scores and patients' satisfaction were recorded. To define the TP, the relationship of all variables to Δ JLCA (absolute difference between preoperative to postoperative JLCA values) was analysed. Linear regression was employed for Δ JLCA to preoperative JLCA and postoperative and Δ MPTA (absolute difference between preoperative and postoperative values). K-means clustering was used to partition observations into clusters, in which each observation belongs to the cluster with the nearest mean serving as a prototype of the cluster, and analysed if there was any specific threshold influencing Δ JLCA. After defining the TP, further subanalysis of the TP based on the preoperative KL OA grade and analysis of variance of this TP to the KL OA grade was performed. RESULTS: A total of 154 patients (77.9% males and 22.1% females) were included. The mean age was 48.2 ± 11 years, and the mean body mass index was 27.1 ± 4 kg/m2. Preoperatively, 26 (16.9%) patients had KL grade IV OA. The mean preoperative and postoperative JLCA and the significance of their relation to Δ JLCA were 2.6° ± 1.8° (p < 0.0001) and 1.9° ± 1.8° (p = 0.6), respectively. The mean Δ JLCA was 1.4° ± 1.5°. The mean pre- and postoperative MPTA and the significance of their relation to Δ JLCA were 84.6 ± 2.2 (p = 0.005) and 91.8 ± 2.5 (p < 0.0007), respectively. The mean Δ MPTA was 7.2 ± 2.3 (p = 0.3). The mean preoperative and postoperative HKA and the significance of their relation to Δ JLCA were 174.6 ± 2.5 (p = 0.2) and 181.9 ± 2.4 (p = 0.7), respectively. The overall linear regression for Δ JLCA was statistically significant for preoperative JLCA (R2 = 0.3, p < 0.0001) and postoperative MPTA (R2 = 0.09, p = 0.0001) and statistically insignificant for Δ MPTA (R2 = 0.01, p = 0.2) and postoperative HKA (R2 = 0.04, p = 0.7). MPTA > 91.5° was the optimal threshold dividing this series data set between substantial and nonsignificant Δ JLCA. CONCLUSION: In this study, the main predictive factors for intra-articular correction (Δ JLCA) after MOWHTO were the preoperative value of JLCA and the postoperative value of MPTA. A value of 92° for postoperative MPTA is potentially the optimal threshold to predict intra-articular correction. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

High survivorship and low complication rate in a single-centre series of 651 medial opening wedge high tibial osteotomy cases with a mean follow-up of 13 years.

PURPOSE: This study aimed to report the early to midterm results of medial opening wedge high tibial osteotomy (MOWHTO) from the largest single-centre osteotomy database. The primary outcomes were reporting the radiological corrections and the functional outcomes represented by multiple patient-reported outcome measures (PROMs). The secondary outcomes were to report the complications, revisions and survivorship up to 10 years postoperatively. METHODS: A prospectively maintained single-centre database of 1138 knee osteotomies was retrospectively reviewed. Patients who underwent MOWHTO and met the inclusion criteria were included. Those inclusion criteria were moderate to severe knee pain that failed conservative management; varus knee malalignment; and isolated medial osteoarthritis of the knee. A total of 651 cases, with a mean age of 46.7 ± 9 years and a mean body mass index of 29.6 ± 5.2 kg/m2 , were included. This comprised 71% males (n = 462) and 29% females (n = 189). The mean follow-up was 158.1 ± 45.4 months. Multiple PROMs were recorded preoperatively and serially postoperatively. This included the Knee injury and Osteoarthritis Outcome Scores, the Oxford Knee Score, the Oxford Knee Score-Activity and Participation Questionnaire, the Western Ontario and McMaster University Scores, the Visual Analogue Scale for health and pain, and the EQ-5D, which is a standardised measure of health-related quality of life. All lower limb alignment measurements were recorded pre- and postoperatively. The rates of osteotomy revision, conversion to arthroplasty, complications, and 5- and 10-year survivorship were recorded. RESULTS: A total of 651 cases were followed up to a mean of 158.1 ± 45.4 months. The mean planned correction angle was 7.6° ± 2.9°. The mean planned opening wedge distance was 8.1 ± 3.1 mm. The mean intraoperative anterior and posterior osteotomy gaps opening were 7.7 ± 3.4 and 8.9 ± 3.8 mm, respectively. Postoperatively, the mean mechanical tibiofemoral angle improved from -5.7° ± 2.9° varus to 1.3° ± 2.5° valgus, the mean medial proximal tibial angle improved from preoperative 85.5° ± 2.3° to postoperative 91.6° ± 2.7° and the mean Mikulicz point improved from 21.7 ± 12.6% to 54.8 ± 11% (all p values < 0.001). All PROMs significantly improved at 24 months follow-up (all p values < 0.001). The rate of osteotomy revision was 1.1% at a mean of 2 ± 2.5 years postoperatively. The overall rate of arthroplasty conversion was 9.1%. This comprised 5.8% total knee arthroplasty conversion at a mean of 6.9 ± 3.5 years postoperatively and 3.2% unicompartmental knee arthroplasty conversion at a mean of 5.7 ± 2.5 years postoperatively. An overall 10.3% complication rate was recorded. The 5 and 10-year survivorship was 97.2% and 91.9%, respectively. CONCLUSION: MOWHTO is a radiologically and clinically rewarding procedure with a high survival rate at 5 and 10 years and a low complication rate in experienced hands. MOWHTO should be considered in patients presenting with medial unicompartmental knee pain with an evidence of overload and a varus mechanical coronal plane axis. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Using a patient-specific cutting guide enables identical knee osteotomies: An evaluation of accuracy on sawbones.

PURPOSE: It was hypothesized that using a Patient-Specific Cutting Guide (PSCG) would allow the creation of sawbones model osteotomies, identical in the 3 planes and the hinge parameters, that can be used for biomechanical studies. The aim of the study was to evaluate the accuracy of the PSCG system and to introduce and assess the new hinge parameter; the hinge area. METHODS: Six identical sawbones tibia models were identically set up for identical osteotomy cuts by the same surgeon in the same session and with identical instruments. A medical scanner was used to evaluate the 3D configuration of all the specimens. The analyzed parameters included the cutting angles in both the coronal and sagittal planes (degrees) and the hinge and the slicing areas (cm2), and the hinge thickness (mm). The values were statistically evaluated for average, standard deviation, 95% confidence index, and delta to the expected values were calculated. RESULTS: The mean values for the coronal and sagittal angles were 110.5̊±1̊ and 89.8̊±0.8̊, respectively. The 95% confidence index level ranged between 0.1̊, and 0.8̊ in both the coronal & the sagittal planes. The mean values for the hinge thickness, the hinge area, and the slicing area were 12.7±1.5mm, 4.2±0.9 cm2, and 18.3±1.2 cm2, respectively. CONCLUSION: In the presented study, it can be demonstrated that mechanically identical osteotomy specimens, with regard to the cutting planes and hinge parameters, can be reliably created using the PSCG. The identical specimens can be used for biomechanical research purposes to further expand our knowledge of the factors affecting osteotomy outcomes. LEVEL OF EVIDENCE: IV.

Protective effect of tomato pomace extract encapsulated in combination with probiotics against indomethacin induced enterocolitis.

Tomato pomace (TP), an antioxidant-rich byproduct, may be suitable for noble applications. The regulation of ROS generation and the anti-inflammatory response can help to prevent ulceration. The purpose of this study was to examine TP for antioxidants, in silico anti-inflammatory properties, and its potential to protect against ulceration and erosion triggered by indomethacin. Tomato pomace extract (TPE) was encapsulated either alone or with probiotics to maximize its potential effect. These microcapsules were investigated in indomethacin-treated rats. TPE demonstrated antioxidant activity as well as high levels of carotenoids (15 mg/g extract) and polyphenols. Because of their binding affinity as well as hydrophobic and hydrogen bond interactions with the active sites of TNF-α and IL-1ß inflammatory cytokines, ellagic acid and rutin may be implicated in the anti-inflammatory effect of TPE, according to the docking study. TPE microcapsules, either alone or in combination with probiotics, demonstrated a protective effect against enterocolitis by reducing oxidative stress and inflammation, as evidenced by the decrease in stomach and intestinal MDA, NO, IL-1ß, IL-6, and TNF-α levels and the increase in CAT, SOD, and GSH activities. The produced microcapsules are suggested to be promising candidates for protection against gastric ulcers and erosion.

Ameliorative effects of vitamins-loaded flavoured nanophytosomes fortified with star anise volatile oil against CsA-Induced liver and kidney injury in rats: Application in functional ice cream.

This study investigated the effect of flavoured nanophytosomes loaded with vitamins A, E, D, B complex, folic acid, and C, as well as zinc on the immunosuppressive cyclosporin A (CsA)-induced liver and kidney injury in male rats. The vitamins flavoured nanophytosomes (VFnPs) were characterized in terms of particle size, zeta potential, encapsulation efficiency. Ice cream was flavoured with star anise volatile oil to mask the VFnPs' flavour and unacceptable taste. The study found that treatment with CsA alone resulted in increased (P > 0.05) levels of creatinine, urea, and MDA, as well as the activities of AST and ALT, while the levels of SOD, CAT, GST, proteins, CD4, INF-ᵧ, IL-6, IL-1ß, and TLR4 decreased (P > 0.05). However, the group that received CsA simultaneously with VFnPs showed a significant (P > 0.05) decrease in the levels of creatinine, urea, and MDA, as well as the activities of AST and ALT, and increased (P > 0.05) levels of SOD, CAT, GST, proteins, CD4, INF-ᵧ, IL-6, IL-1ß, and TLR4. The increase in the ratio of VFnPs had little effect on the physiochemical and sensory evaluation of the ice cream. Finally, the study suggests that VFnPs could potentially protect against CsA-induced liver and kidney injury and serve as a promising natural therapy for treating such conditions.

Systematic Review and Meta-Analysis of Studies Comparing the Rate of Post-operative Periprosthetic Fracture Following Hip Arthroplasty With a Polished Taper Slip versus Composite Beam Stem.

BACKGROUND: We compared the incidence of postoperative periprosthetic femoral fractures (POPFF) following hip arthroplasty with either a cemented polished taper slip (PTS) stem or a cemented composite beam (CB) stem in comparative studies. METHODS: A systematic review of comparative studies, written in English and published in peer-reviewed journals since the year 2000, was conducted. Study quality was assessed using the Newcastle-Ottawa scale.The overall study qualities were good. There were 913,021 patients from 18 cohorts included in the meta-analysis. There were 294,540 patients who received a CB stem and 618,481 received a PTS stem. Cohorts were classified as high- or low-risk for POPFF based on patient risk factors. A metanalysis was performed using a random effects model, and the relative incidence with 95% confidence intervals (CIs) was reported. RESULTS: The patients at low risk of POPFF had an incidence rate ratio of 3.14 (CI: 2.48, 3.98) for the PTS group versus the CB group. Whereas, the patients at high risk of POPFF had an incidence rate ratio of 9.87 (CI: 3.63, 26.80) for the PTS group versus the CB group. CONCLUSIONS: The risk of POPFF is lower when hip arthroplasty was performed using a CB stem versus a PTS stem. This protective effect was greatest in patients who had a higher risk of POPFF. Surgeons should consider the effect of cemented stem choice on the risk of subsequent periprosthetic femur fracture, particularly in frail or elderly patients who are at a higher risk of postoperative periprosthetic femoral fracture.

Maintaining Posterior Tibial Slope and Patellar Height During Medial Opening Wedge High Tibial Osteotomy.

Background: Increased posterior tibial slope (PTS) and decreased patellar height (PH) after medial opening wedge high tibial osteotomy (MOWHTO) have been repeatedly reported in the literature. However, this has been disputed in more recent biomechanical studies. Hypothesis: No change in PTS or PH would result after MOWHTO with the freehand technique, regardless of the degree of the coronal plane correction. Study Design: Case series. Methods: A total of 62 patients who underwent MOWHTO between 2018 and 2020 were included. Surgery was performed using a dedicated step-by-step protocol to reduce the risk of unintentional slope changes. All patients were evaluated preoperatively and at a 2-year follow-up with the Knee injury and Osteoarthritis Outcome Score and the University of California, Los Angeles physical activity scale. Pre- and postoperative radiographic lower limb alignment parameters-including hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle, proximal posterior tibial angle (PPTA), joint line convergence angle, and joint line obliquity-were measured on full-length lower limb radiographs. PH measurements assessed on lateral and anteroposterior knee radiographs included the Caton-Deschamps, Insall-Salvati, and Schröter indices. Results: A significant change was observed in the coronal plane alignment, with an increase in the MPTA from 84.38° to 90.39° (P < .001) and a consequent increase in the HKA from 172.19° to 180.15° (P < .001). No significant changes were observed in the PTS, as evidenced by a postoperative PPTA of 80.6° versus a preoperative value of 80.4° (P = .2). No significant changes were detected in the mean PH on all 3 indices used-pre- versus postoperative Caton-Deschamps, Insall-Salvati, and Schröter indices measured 0.95 versus 0.93 (P = .2), 1.03 versus 1.03 (P = .5), and 1.56 versus 1.54 (P = .3), respectively. Conclusion: In this study, MOWHTO did not result in significant changes in the PTS or PH when accurate preoperative planning and precise intraoperative freehand technique were adopted..

Inconsistent Return to Sport Despite Improved Outcomes After Re-revision Anterior Cruciate Ligament Reconstruction: An Updated Systematic Review.

PURPOSE: The primary objective was to systematically review the literature evaluating patient-reported outcomes and return to sport after re-revision anterior cruciate ligament reconstruction (ACLR) procedures. The secondary objectives were 2-fold: to identify the risk factors that lead to revision ACLR failure and to assess the secondary knee structure injuries after the initial revision ACLR. METHODS: A systematic review of the literature was performed using the MEDLINE/PubMed and Cochrane databases. The inclusion criteria were outcomes of re-revision ACLR, minimum of 2 years' follow-up, human studies, and English language. Basic science articles, epidemiologic studies, editorials, surgical technique articles, surveys, cadaveric studies, and animal studies were excluded. RESULTS: Fifteen studies met the inclusion criteria and were considered for review. There were 6 Level III and 9 Level IV studies that included 399 patients undergoing re-revision ACLR. The rate of concomitant meniscal lesions at the time of re-revision ranged from 35% to 90%. The prevalence of concomitant cartilaginous lesions at the time of re-revision ranged from 13.6% to 90%. Compared with preoperative scores, patient-reported outcomes overall improved after re-revision ACLR, with mean preoperative Lysholm scores ranging from 38.4 to 73.15 that improved to postoperative scores ranging from 68 to 87.8. However, return to sport at preinjury levels was inconsistent, with rates ranging from 12.5% to 80%. CONCLUSIONS: Re-revision ACLR was found to restore knee stability and improve functional outcomes. Despite this improvement, there was a low rate of return to sport at the preinjury level. Functional outcomes were also inferior when compared with primary ACLR. In addition, concomitant knee pathologies were found to rise in prevalence compared with revision and primary ACLR cases. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Reference standards for stress radiography measurements in knee ligament injury and instability: a systematic review.

PURPOSE: Stress radiographs are an easily accessible, cost-effective tool in the evaluation of acute and chronic ligament knee injuries. Stress radiographs provide an objective, quantifiable, and functional assessment of the injured ligament and can be a useful adjunct when planning surgical management and to objectively assess postoperative outcomes. This study aimed to review the literature reporting on stress radiographic techniques in evaluating knee ligament injury and instability and propose thresholds for interpreting stress radiography techniques. METHODS: The following three databases, OVID MEDLINE, the EMBASE library, and the Cochrane Controlled Trials Register, were systematically searched on January 23, 2023, for studies published from January 1970 to January 2023. The search extended to the reference lists of all relevant studies and orthopedic journals. Included studies were those that described a stress technique for the diagnosis of knee ligament injury; studies that reported a description or comparison of the accuracy and/or reliability of one or several stress radiography techniques, or studies that reported a comparison with alternative diagnostic modalities. RESULTS: Sixteen stress radiography techniques were reported for assessing the ACL with stress applied in the anterior plane, 10 techniques for assessing the PCL with stress applied in the posterior plane, 3 techniques for valgus stress, and 4 techniques for varus stress. The Telos device was the most commonly used stress device in the ACL and PCL studies. There was no consensus on the accuracy and reliability of stress radiography techniques for the diagnosis of any knee ligament injury. Stress radiography techniques were compared with alternative diagnostic techniques including instrumented arthrometry, MRI, and physical examination in 18 studies, with variability in the advantages and disadvantages of stress radiography techniques and alternatives. Analysis of results pooled from different studies demonstrated average delta gapping in knees with a completely injured ligament compared to the normal contralateral knee as per the following: for the ACL 4.9 ± 1.4 mm; PCL 8.1 ± 2.5 mm; MCL 2.3 ± 0.05 mm; and the FCL 3.4 ± 0.2 mm. CONCLUSION: Despite heterogeneity in the available literature with regard to stress examination techniques and device utilization, the data support that stress radiography techniques were accurate and reliable when compared to numerous alternatives in the diagnosis of acute and chronic knee ligament injuries. The present study also provides average increased ipsilateral compartment gapping/translation for specific knee ligament injuries based on the best available data. These values provide a reference standard for the interpretation of stress radiography techniques, help to guide surgical decision-making, and provide benchmark values for future investigations. LEVEL OF EVIDENCE: III.

The joint line convergence angle (JLCA) correlates with intra-articular arthritis.

PURPOSE: Knees with unicompartmental varus osteoarthritis (OA) usually display a combination of tibiofemoral bony deformity and increased joint line convergence angle (JLCA). The JLCA is a product of intra-articular deformity and lateral soft tissue laxity. This study aims to define the correlation between the JLCA and progression of OA. METHODS: A retrospective radiological analysis of 501 patients, who underwent either high tibial osteotomy (HTO) or unicompartmental knee arthroplasty (UKA), was performed. The preoperative OA grade was reported based on the Ahlbäck and the Kellgren-Lawrence (KL). The hip-knee-ankle angle (HKA), the medial proximal tibial angle (MPTA), the mechanical lateral distal femoral angle (mLDFA) and the joint line convergence angle (JLCA) were recorded. The primary outcome was the relationship between the JLCA values and the OA grade. The secondary outcomes were comparing the JLCA and other alignment parameter values between HTO and UKA groups. RESULTS: A total of 501 (59.3% females n = 297) cases were included, comprising 293 cases of HTO and 208 cases of UKA. Patients had a mean age of 57.63 ± 8.97 years, a mean BMI of 28.37 ± 7.39 kg/m2. Patients with Ahlbäck grade 2 represented 49.3% of all patients (n = 247) and patients with KL grade 3 represented 54.7% of all patients (n = 274). A high JLCA was observed in both groups. The reported mean JLCA in the UKA group was 3.69 ± 2.1°, and in the HTO group was 2.93 ± 1.82. There was a significant association between the increase in the JLCA and the progression of OA based on both the Ahlbäck and KL grades (both p values < 0.001). The mean JLCA in patients with Ahlbäck grades 1 and 4 was 1.48 ± 1.32°, and 7 ± 0.93°, respectively. The mean JLCA in patients with KL grades 1 and 4 was 1.77 ± 1.42°, and 4.89 ± 1.73°, respectively. The mean recorded preoperative HKA angle in the UKA group was 175.06 ± 3.08°, and in the HTO group was 173.26 ± 3.02°, whereas the mean MPTA was 88.63 ± 1.72° for the UKA group and 89.31 ± 2.29° for the HTO group. CONCLUSION: The JLCA progressively increases with osteoarthritis progression in patients with unicompartmental varus knee osteoarthritis. The JLCA can potentially be used as a grading parameter for osteoarthritis progression akin to Ahlbäck and Kellgren-Lawrence grading systems.

National variation in prophylactic antibiotic use for elective primary total joint replacement.

Aims: Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance. Methods: The guidelines for the primary and alternative recommended prophylactic antibiotic regimens in clean orthopaedic surgery (primary arthroplasty) for 109 hospitals and trusts across the UK were sought by searching each trust and hospital's website (intranet webpages), and by using the MicroGuide app. The mean cost of each antibiotic regimen was calculated using price data from the British National Formulary (BNF). Regimens were then compared to the 2018 Philadelphia Consensus Guidance, to evaluate adherence to international guidance. Results: The primary choice and dosing of the prophylactic antimicrobial regimens varied widely. The two most used regimens were combined teicoplanin and gentamicin, and cefuroxime followed by two or three doses of cefuroxime eight-hourly, recommended by 24 centres (22.02%) each. The alternative choice and dosing of the prophylactic antimicrobial regimen also varied widely across the 83 centres with data available. Prophylaxis regimens across some centres fail to cover the likeliest causes of surgical site infection (SSI). Five centres (4.59%) recommend co-amoxiclav, which confers no Staphylococcus coverage, while 33 centres (30.28%) recommend cefuroxime, which confers no Enterococcus coverage. Limited adherence to 2018 Philadelphia Consensus Guidance was observed, with 67 centres (61.50%) not including a cephalosporin in their guidance. Conclusion: This analysis of guidance on antimicrobial prophylaxis in primary arthroplasty across 109 hospitals and trusts in the UK has identified widespread variation in primary and alternative antimicrobial regimens currently recommended.

Assessment of return to sport and functional outcomes following distal femoral, double level and high tibial osteotomies for active patients with symptomatic varus malalignment.

PURPOSE: This study indicated the outcomes of three surgical techniques for the treatment of symptomatic unicompartmental knee osteoarthritis (UKOA) with varus malalignment in younger, active patients: distal femoral osteotomy (DFO), double-level osteotomy (DLO) and high tibial osteotomy (HTO). The outcomes measured included the return to sport, sport activity and functional scores. METHODS: A total of 103 patients (19 DFO, 43 DLO, 41 HTO) were enrolled in the study and were divided into three groups based on their oriented deformity, each undergoing one of the three surgical techniques. All patients underwent pre- and post-operative evaluations including X-rays, physical exams and functional assessments. RESULTS: All three surgical techniques were effective in treating UKOA with constitutional malalignment. The average time to return to sport was similar among the three groups (DFO: 6.4 ± 0.3 [5.8-7] months, DLO: 4.9 ± 0.2 [4.5-5.3] months, HTO: 5.6 ± 0.2 [5.2-6] months). The sport activity and functional scores improved significantly for all three groups, with no significant differences observed among the groups. CONCLUSION: Various knee osteotomy procedures, DFO, DLO, and HTO, result in high RTS rates and quick RTS times with satisfactory functional scores. Despite pre- to post-operative improvements in sport activities following DFO and DLO, pre-symptom levels were not reached following all evaluated procedures. LEVEL OF EVIDENCE: Retrospective case-control study, Level III.

High tibial osteotomy is equally effective for varus malaligned knees with either virgin or wrecked medial meniscus: An age and gender-matched secondary analysis of a Francophone Arthroscopy Society Symposium.

INTRODUCTION: Despite the growing concept of meniscal preservation, partial meniscectomy could be the definitive procedure in specific scenarios. And total meniscectomy was once before a frequent procedure, with current sequelae of degenerate knees. High tibial osteotomy (HTO) is an effective treatment for patients suffering from unicompartmental degenerative changes, and substantial deformities. However, it is yet to be answered, whether HTO is similarly effective in both post-meniscectomy knees and knees with not previously operated meniscus. HYPOTHESIS: Outcomes of HTO is similar with or without previous history of total or subtotal meniscectomy. METHODS: This study compared the clinical and radiological outcomes of 41 patients who received HTO and had no previous history of surgery in the ipsilateral knee (group I), and 41 age, and gender-matched patients who had meniscectomy surgery in the ipsilateral knee (group II). Preoperatively and postoperatively, all patients were clinically evaluated; the visual analogue scale scores, Tegner activity score, and the Western Ontario and Macmaster University scores were reported. Radiographically, osteoarthritis grade and pre- and postoperative parameters were reported, including hip-knee-ankle angle, femoral mechanical angle, medial proximal tibial angle, joint line convergence angle, proximal posterior tibial angle, and limb length discrepancy. Perioperative details and complications were reported. RESULTS: A total of 82 patients were included; group I (n=41) and group II (n=41). The mean age was 51.18±8.64 (27-68) and 90.24% were male. The duration since the onset of symptoms was longer in group II vs. group I, 43.34±41.03 versus 38.07±36.11months respectively. No significant differences in the clinical evaluation between the two groups with a greater proportion of patients demonstrating moderate degenerative changes. Similar preoperative and postoperative radiographic parameters were reported, in group I, Δ HKA was 7.19±4.14 versus 7.65±3.16 in group II. Preoperative pain VAS scores were slightly higher in group II vs. group I, 79.23±26.35 vs. 76.31±24.45, respectively. However, postoperatively, the pain scores significantly improved in group I vs. group II, 22.84±3.65 vs. 41.69±17.33, respectively. Tegner activity scores and WOMAC scores were comparable between both groups preoperatively and postoperatively. Only the WOMAC function scores were better in group I when compared to group II, 26.13±25.84 versus 20.01±17.98. All patients returned to work at an average of 0.82±0.38months. CONCLUSION: Knee preservation with high tibial osteotomy is equally effective in managing unicompartmental degenerative changes in varus malaligned knees with either no previous history of meniscal surgeries or where a meniscal sacrifice was inevitable, either with subtotal or total meniscectomy. LEVEL OF EVIDENCE: III, retrospective case-control study.

MCID and PASS in Knee Surgeries. Theoretical Aspects and Clinical Relevance References.

The application and interpretation of patient-reported outcome measures (PROM), following knee injuries, pathologies, and interventions, can be challenging. In recent years, the literature has been enriched with metrics to facilitate our understanding and interpretation of these outcome measures. Two commonly utilized tools include the minimal clinically important difference (MCID) and the patient acceptable symptoms state (PASS). These measures have demonstrated clinical value, however, they have often been under- or mis-reported. It is paramount to use them to understand the clinical significance of any statistically significant results. Still, it remains important to know their caveats and limitations. In this focused report on MCID and PASS, their definitions, methods of calculations, clinical relevance, interpretations, and limitations are reviewed and presented in a simple approach.

Double-level knee osteotomy accurately corrects lower limb deformity and provides satisfactory functional outcomes in bifocal (femur and tibia) valgus malaligned knees.

PURPOSE: Double-level knee osteotomy (DLO) is a challenging procedure that requires precision in preoperative planning and intraoperative execution to achieve the desired correction. It is indicated in cases of severe varus or valgus deformities where a single-level osteotomy would yield significantly tilted joint line obliquity (JLO). This study aimed to evaluate the effectiveness of DLO in achieving accurate correction without compromising JLO, using patient-specific cutting guides (PSCGs), in cases of bifocal valgus maligned knees. METHODS: A single-centre, retrospective analysis of prospectively collected data for a total of 26 patients, who underwent DLO by PSCGs for valgus malaligned knees, between 2015 and 2020. Post-operative alignment was evaluated and the delta for different lower limb0.05, not statistically significant (ns)). All KOOS subs alignment parameters was calculated; the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), and lateral distal femoral angle (ΔLDFA). At the two-year follow-up, changes in the KOOS sub-scores, UCLA scores, lower limb discrepancy (LLD), and mean time to return to work and sport were recorded. All intraoperative and postoperative complications were recorded. The Mann-Whitney U test with a 95% confidence interval (95% CI) was used to evaluate the differences between two variables; one-way ANOVA between more than two variables and the paired Student's t-test was used to estimate the evolution of functional outcomes. RESULTS: The postoperative mean ΔHKA was 0.9 ± 0.9°, the mean ΔMPTA was 0.7 ± 0.7°, and the mean ΔLDFA was 0.7 ± 0.8° (all values with p > 0.05, not statistically significant (ns)). All KOOS subscore's mean values were improved to an extent two-fold superior to the reported minimal clinically important difference (MCID) (all with p < 0.0001). There was a significant increase in the UCLA score at the final follow-up (5.4 ± 1.5 preoperatively versus 7.7 ± 1.4, p < 0.01). The mean time to return to sport and work was 4.7 ± 1.1 and 4.3 ± 2.1 months, respectively. There was an improvement in Lower-limb discrepancy preoperative (LLD = 1.3 ± 2 cm) to postoperative measures (LLD = 0.3 ± 0.4 cm), ns. Complications were 2 femoral hinge fractures, 2 deep vein thromboses, 1 delayed tibial healing, and 1 hardware removal for hamstring irritation syndrome. CONCLUSION: DLO is effective and safe in achieving accurate correction in bifocal valgus malaligned knees with maintained lower limb length and low complication rate with no compromise of JLO. LEVEL OF EVIDENCE: III.