A study regarding the anterior cruciate ligament remnant: Differences in balance and postural control between remnant-preserving and remnant-non-preserving patients

Introduction: The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. However, quantitative studies on evaluate the postural control influence resulted from the ACL remnant preservation or not are scarce. The aim of this study is to evaluate the postural control of patients submitted to ACL reconstruction with and without preservation of the injured remnant in pre and postoperative periods.MethodsEighteen patients underwent ACL reconstruction and separated into 2 groups according to the preservation or not of the remnant: (I) submitted to ACL reconstruction with preservation of the remnant (10 patients); (II) submitted to ACL reconstruction without preservation of the remnant (8 patients). They were assessed using the Lysholm score and force plate, which evaluated the patient's postural stability for remnant and non-remnant preservation in ACL reconstruction surgery.ResultsGroup I showed statistically significant subjective and objective improvements, both at 3 and 6 months. Additionally, improvement of the Lysholm test at 6 months in Group II was also statistically significant. Furthermore, the results of the Friedman test for the VCOP and VY variables of Group I, with support of the injured side in the force plate, showed a statistically significant difference both for pre and postoperative period at 3 months, compared to the 6-month postoperative period. The variables EAC and VX were statistically different for Group II, considering the preoperative period, 3 and 6 months postoperatively.ConclusionPreserving the ACL remnant in patients with ACL injuries has a positive impact on postural stability during recovery.(AU)

Introducción: El ligamento cruzado anterior (LCA) es el ligamento de la rodilla que se lesiona con mayor frecuencia. Sin embargo, escasean los estudios cuantitativos sobre la evaluación de la influencia del control postural derivada de la preservación, o no, del remanente del LCA. El objetivo de este estudio es evaluar el control postural de los pacientes sometidos a la reconstrucción del LCA, con y sin preservación del remanente lesionado, en los periodos previo y posterior a la cirugía.MétodosDieciocho pacientes sometidos a reconstrucción del LCA separados en 2 grupos, de acuerdo con la preservación o no preservación del remanente: I) sometidos a reconstrucción del LCA con preservación del remanente (10 pacientes), y II) sometidos a reconstrucción del LCA sin preservación del remanente (8 pacientes). Los pacientes fueron evaluados utilizando la puntuación de Lysholm y una placa de aplicación de fuerza, que evaluó la estabilidad postural del paciente para la preservación y no preservación del remanente en la cirugía de reconstrucción del LCA.ResultadosEl grupo I mostró mejoras subjetivas y objetivas estadísticamente significativas, transcurridos 3 y 6 meses. Además, la mejora de la prueba de Lysholm transcurridos 6 meses en el grupo II fue también estadísticamente significativa. Asimismo, los resultados de la prueba de Friedman para las variables VCOP y VY en el grupo I, con apoyo del lado lesionado en la placa de aplicación de fuerza, reflejaron una diferencia estadísticamente significativa en ambos períodos pre y postoperatorio transcurridos 3 meses, en comparación con el período postoperatorio transcurridos 6 meses. Las variables EAC y VX fueron estadísticamente diferentes para el grupo II, considerando el periodo preoperatorio, y los 3 y 6 meses postoperatorios.ConclusiónPreservar el remanente del LCA en los pacientes con lesiones en dicho ligamento tiene un impacto positivo en la estabilidad postural durante la recuperación.(AU)

Botox in below knee amputation for the management of post-operative contracture: a systematic review.

During the 1970s, scientists first used botulinum toxin to treat strabismus. While testing on monkeys, they noticed that the toxin could also reduce wrinkles in the glabella area. This led to its widespread use in both medical and cosmetic fields. The objective of the study was to evaluate the potential use of Botox in managing post-operative contracture after below-knee amputation. We conducted a systematic review In Pubmed, Cochrane Library, Embase, and Google Scholar using the MESH terms Botox, botulinum toxin, post-operative contracture, amputation, and below knee amputation. Our goal was to evaluate the potential use of Botox to manage post-operative contracture in patients who have undergone below-knee amputation. Our findings show evidence in the literature that Botox can effectively manage stump hyperhidrosis, phantom pain, and jumping stump, but no clinical trial has been found that discusses the use of Botox for post-operative contracture. Botox has been used in different ways to manage spasticity. Further studies and clinical trials are needed to support the use of Botox to manage this complication.

Measuring Parallelism to the Ground in Bipedal Stance Phase: Mechanical Versus Kinematic Alignment in Total Knee Arthroplasty.

Introduction The goal of total knee arthroplasty is to replace diseased cartilage and bone with an artificial implant to improve the patient's quality of life. The knee has historically been reconstructed to the patient's mechanical axis (MA). However, kinematically aligned techniques have been increasingly used. Kinematic alignment requires less soft-tissue resection and aligns the knee with what is anatomically natural to the patient, while there is concern that kinematically aligned knees will lead to earlier failure due to potential unequal weight distribution on the implant. The purpose of this study is to compare the parallelism from the floor of the joint-line cuts using kinematic and mechanical alignment and understand if the MA is a proper estimation of the tibial-ankle axis (TA). Methods A retrospective study was conducted by recruiting all high tibial osteotomy and distal femoral osteotomy recipients operated on by two surgeons in two MedStar Health hospitals from 01/2013 to 07/2020 with full-length films in preparation for restorative procedures. Baseline osteoarthritis was graded using the Kellgren-Lawrence classification system with all patients presenting as Grade 0. The TA and the joint-line orientations of the MA and kinematic axis (KA) were measured on 66 legs. The average distance from parallelism to the ground was compared between the MA and the KA and between the MA and the TA using a paired t-test. Results KA joint-line orientation (1.705° deviation) was more parallel to the floor in the bipedal stance phase than the MA (2.316° deviation, p=0.0156). The MA (2.316° deviation) was not a proper estimation of the TA (4.278° deviation, p=0.0001). Conclusion By utilizing the KA technique, the restoration of the natural joint line, as well as a joint that is more parallel to the floor in the stance phase compared to the MA, is achieved. The parallelism to the ground of the KA during the bipedal stance phase suggests an even load distribution across the knee. In addition, due to its similarity to the KA and anatomical significance in weight-bearing distribution, further investigation into the hip-to-calcaneal axis as an approximation of the joint line is warranted.

Regional Anesthesia for High-Risk Patients Undergoing Total Knee Arthroplasty: A Case Report.

Total knee arthroplasty (TKA) is a commonly performed surgery for individuals experiencing advanced knee osteoarthritis. Patients undergoing TKA can present with a variety of comorbidities, ranging from the absence of chronic illnesses to the presence of multiple health conditions. The complexity of these comorbidities can pose challenges in carrying out the desired procedure due to the elevated risk profile; this limits the anesthesia modalities that the physician can utilize. Careful consideration of patients' overall health status and personalized anesthesia approaches are crucial to ensure optimal outcomes in this diverse patient population. This case involves an eighty-year-old male with a history of multiple comorbidities who underwent a left TKA. The patient presented a high-risk profile during evaluation, classified as American Society of Anesthesiology (ASA) class IV, which made general and neuraxial anesthesia unfavorable due to high risks. Regional anesthesia was utilized as the sole modality of anesthesia and was successful. This demonstrates that regional anesthesia is a viable option when attending to patients with high risks associated with other anesthesia modalities.

Subchondral bone expansion in advanced knee osteoarthritis: Relation with radiographic severity and role in surgical decision-making.

Background: Joint space width (JSW) is a traditional imaging marker for knee osteoarthritis (OA) severity, but it lacks sensitivity in advanced cases. We propose tibial subchondral bone area (TSBA), a new CT imaging marker to explore its relationship with OA radiographic severity, and to test its performance for classifying surgical decisions between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) compared to JSW. Methods: We collected clinical, radiograph, and CT data from 182 patients who underwent primary knee arthroplasty (73 UKA, 109 TKA). The radiographic severity was scored using Kellgren-Lawrence (KL) grading system. TSBA and JSW were extracted from 3D CT-reconstruction model. We used independent t-test to investigate the relationship between TSBA and KL grade, and binary logistic regression to identify factors associated with TKA risk. The accuracy of TSBA, JSW and established classification model in differentiating between UKA and TKA was assessed using AUC. Results: All parameters exhibited inter- and intra-class coefficients greater than 0.966. Patients with KL grade 4 had significantly larger TSBA than those with KL grade 3. TSBA (0.708 of AUC) was superior to minimal/average JSW (0.547/0.554 of AUC) associated with the risk of receiving TKA. Medial TSBA, together with gender and Knee Society Knee Score, emerged as independent classification factors in multivariate analysis. The overall AUC of composite model for surgical decision-making was 0.822. Conclusion: Tibial subchondral bone area is an independent imaging marker for radiographic severity, and is superior to JSW for surgical decision-making between UKA and TKA in advanced OA patients.

Lipoma arborescens of the knee: A case report.

Lipoma arborescens is a rare and benign intra-articular lesion characterized by a lipomatous proliferation of the synovial membrane, usually affects the knee joint. It presents as an unusual cause of intermittent knee pain and joint effusion. We report a case of lipoma arborescens of the knee in a 23-year-old man that initially resembled inflammatory arthropathy. The diagnosis of Lipoma arborescens was made by magnetic resonance imaging of the knee and confirmed histologically by synovectomy. The purpose of our case is to show the imaging features enabling early diagnosis and appropriate treatment.

The potential impact of polymorphisms in METTL3 gene on knee osteoarthritis susceptibility.

Objective: This study was aimed to explore the correlation between METTL3 polymorphisms and susceptibility to knee osteoarthritis (KOA). Methods: The relationship of five single nucleotide polymorphisms (SNPs) in the METTL3 gene with the susceptibility of KOA was analyzed through multinomial logistic regression analysis in this a case-control study. Genotyping was performed on 228 KOA patients and 252 unaffected individuals from South China based on the TaqMan method. The MDR software (version 3.0.2) was utilized for the analysis of SNP interactions. Results: Out of the five SNPs examined, the T > G change in the METTL3 gene at the rs1061026 locus increased the risk of KOA, while rs1139130 A > G and rs1263802 C > T variants were found to be linked with a reduced risk of developing KOA with statistical significance. The rs1061027 A > C and rs1263801 C > G variants did not show significant association (p＞0.05). The rs1061026 TG/GG genotype showed a significant correlation with an increased risk of KOA in the following subgroups: the males, individuals with a BMI ranging from 24 to 28, smokers, those who were not engaged in physical exercise (PE), patients who had experienced KOA symptoms for eight years or longer, and those without a family history of the disease or reported swelling. On the other hand, the rs1139130 AG/GG genotype demonstrated a protective effect against KOA among the females, individuals with a BMI greater than or equal to 24, a unilateral KOA, or a KOA duration of 8 years or less, non-smokers, non-alcohol drinkers, those who were not engaged in PE, and those who had no injury or family history, or no experience of knee swelling. Additionally, it was observed that the rs1263802 CT/TT genotypes showed a protective effect among patients without a history of injury. Furthermore, individuals with the haplotypes GAT, GGC, TAT, and TGC were found to have a significantly lower susceptibility to KOA compared to the reference haplotype TAC. Conclusions: The METTL3 gene variant rs1061026 could increase the risk of KOA, whereas the variants of rs1139130 as well as rs1263802 might exert a protective effect against KOA. These variants could potentially function as susceptibility markers for KOA among the population from South China.

Adolescents with hemophilic knee arthropathy can improve their gait characteristics, functional ability, and physical activity level through kinect-based virtual reality: A randomized clinical trial.

Background: Hemophilic arthropathy is caused by recurrent intra-articular bleeding, most commonly in the knee joints. In terms of physical impact, this arthropathy causes significant disability and hampers the physical activity and functionality of he affected individuals. Objective: This study intended to examine the effect of a physical rehabilitation program incorporating Kinect-based virtual reality (KBVR) on gait characteristics, functional ability, and physical activity level in adolescents diagnosed with hemophilic knee arthropathy (HKA). Materials and methods: In a randomized clinical trial, 56 boys, aged 10-14 years, with moderate HKA, were randomly allocated into two groups. The control group (n = 28) received conventional physical therapy (CPT), while the KBVR group (n = 52) received a 30-min KBVR exercise program in addition to the CPT. Training was conducted three times/week for 12 successive weeks. Gait characteristics (step length, cadence, velocity, peak knee extension moment during stance, and knee flexion amplitude during swing) were assessed using a gait analysis system, the functional ability was assessed through the 6-min walk test, and physical activity level assessed by the Adolescents' Physical Activity Questionnaire on the pre- and post-treatment occasions. Results: The KBVR group achieved more favorable changes in the gait characteristics [step length (P = 0.015), cadence (P = 0.004), velocity (P = 0.024), peak knee extension moment during stance (P = 0.018), and Knee flexion amplitude during swing (P = 0.032)], functional capacity (P = 0.002), and physical activity levels (P = 0.007) compared to the control group. Conclusion: The use of KBVR exercises within a rehabilitation program is a potentially effective therapeutic option for the total care of adolescents with HKA.

Computer Navigation-assisted Bilateral Total Knee Arthroplasty with Osteosynthesis in Single Sitting in Patients Presenting with Distal Femur Fracture with Pre-existing Knee Arthritis: A Case Series.

Background: Intra-articular and periarticular distal femur fractures with pre-existing osteoporosis (OP) and osteoarthritis (OA) pose a significant challenge to ambulatory patients because of the higher chances of implant failure and severe disability of OA. To reduce OA-related morbidity, we advocate simultaneous total knee arthroplasty (TKA) with fracture fixation instead of fracture fixation alone using computer-assisted navigation to achieve proper ligament balance, restoration of the mechanical axis, and component alignment. Case Report: A case series of four patients (male - 2 and females - 2) with periarticular fractures of the distal femur with severe OA and OP were primarily fixed with different modalities such as distal femur locking plates, cannulated-cancellous screw, and Herbert screw followed by computer navigation-assisted cruciate retaining TKA. All patients had Kellgren Lawrence grade ≥3 OA and underwent bilateral TKA. All patients were aggressively treated for OP using pulsed PTH therapy. Patients were found to have a faster recovery with the initiation of early partial weight bearing with crutches postoperatively in all patients, followed by unassisted weight bearing once radiological union was seen. Conclusion: Based on satisfactory quality evidence and navigation-assisted cruciate-retaining TKA appears to be a useful treatment option for distal femoral fractures with pre-existing OA and OP. This is cost-effective and is associated with the least morbidity and excellent patient satisfaction.

Post-surgical Pyoderma Gangrenosum after Total Knee Arthroplasty: A Rare Case Report and Literature Review.

Introduction: Pyoderma gangrenosum (PG) following a primary total knee arthroplasty (TKA) surgery is extremely rare, with very few cases reported in the literature. Case Report: We report our clinical experience of a 65-year-old female who developed PG following a primary TKA surgery. Corticosteroids and local wound care with vacuum-assisted closure dressing helped achieve rapid improvement in the wound condition. Conclusion: Post-surgical PG in TKA can be challenging with limited evidence for its definitive treatment. A high degree of suspicion and a multidisciplinary management approach will help in the timely diagnosis and optimization of treatment for this condition.

A Rare Case of Synovial Chondromatosis of Knee with both Intra-articular and Extra-articular Involvement: A Case Report.

Introduction: Synovial chondromatosis (SC) is a relatively rare benign disorder characterized by developing many nodules composed of cartilage within the synovial cavities of joints. It impacts several joints, with the knee joint being the most often affected. Extra-articular involvement, such as bursae or tendon sheaths, is rare. Furthermore, the coexistence of intra- and extra-articular SC is an infrequent condition. Hence, we present a rare case of SC with intra- and extra-articular involvement. Case Presentation: The patient, a 38-year-old woman, reported experiencing progressive right knee discomfort for 2 months. In addition, a growing mass was observed on the medial aspect of the right knee that was noticeable for the past 2 months. MRI examination revealed the presence of both intra-articular and extra-articular lesions. A two-step surgical procedure, including arthroscopy synovectomy involving the debridement of the lesions and removal of the extra-articular mass through an open incision, was performed. Histopathological analysis confirmed SC. At the 1-year follow-up, the patient reported complete relief of discomfort in the right knee. Conclusion: The coexistence of extra-articular and intra-articular SC is an exceedingly rare condition. Surgical removal of the loose bodies and a synovectomy performed as thoroughly as possible constitute the mainstay of treatment in managing SC.

Knee Arthrodesis Using Dual-Plate Construct is Following Failed Distal Femur Megaprosthesis-A Case Report.

Introduction: Knee arthrodesis following failed total knee arthroplasty is a viable limb salvage option, and this procedure is reserved for failed two-stage revision surgery in severe comorbid patients with irreparable extensor mechanism disruption, severe instability, and extensive soft tissue loss. Knee arthrodesis using a dual-plate construct has been scarcely reported. We report a case of knee arthrodesis using a dual-plate construct in a male in his 20s who presented to us with a broken distal femur megaprosthesis. Case Report: An anterior midline incision was given. The cement mantle and broken prosthetic components were removed. The bone surfaces were freshened up and fixed using two orthogonal locking plates. After 4 months, there was a solid fusion in the knee, and the patient started walking independently with a short limb gait. The patient was advised limb lengthening for a shortening of 3 cm, but he denied it and managed with a shoe raise. After 4 years, he was pain free, and radiographs revealed a solid knee fusion. The patient was fully satisfied with the procedure, and he resumed manual work. Conclusion: This case report revealed that knee arthrodesis using a dual-plate construct is an economically viable salvage option for failed distal femur megaprosthesis.

Pediatric Synovial Osteochondromatosis of the Knee with Leg Length Discrepancy: A Case Report.

Introduction: Synovial chondromatosis (SC) is very rare among children. We are aware of no reports of patients with SC accompanied by leg length discrepancy (LLD). Case Report: We describe a case of synovial osteochondromatosis of a 7-year-old boy complicated by LLD. We performed epiphysiodesis of the distal femur and arthroscopic resection of loose bodies and total synovectomy. Three years after surgery, LLD had been corrected and there was no sign of recurrence. Conclusion: Physicians should be aware of synovial osteochondromatosis complicated by LLD in childhood and take radiographs of the whole length of lower legs when this condition is suspected.

Discoid Double-layered Lateral Meniscus: A Case Report.

Introduction: Abnormalities of the double-layered meniscus are rare and can be difficult to diagnose. The main pathology in this abnormality, which is predominantly seen in the lateral compartment, is an accessory meniscus lying over the normal meniscus. Anatomically, this structure can appear in different forms. Although other meniscal abnormalities associated with a double-layered meniscus have been reported, this case presents a previously undescribed type in the literature. Case Report: A 12-year-old girl presented to our clinic with complaints of knee locking and pain. When the patient underwent arthroscopy, an accessory incomplete discoid meniscus was found overlying the normal lateral meniscus. We performed an excision of the upper accessory meniscus and the patient had no problems during 3 years of follow-up after surgery. Conclusion: Abnormalities of the lateral meniscus are rare and can be difficult to diagnose. In cases where we suspect a meniscal abnormality, a proper arthroscopic examination should be performed and if a discoid meniscus is seen, it should be considered that this may be a double-layered meniscus.

Effect of Intraoperative infusion Magnesium Sulfate Infusion on Postoperative Quality of Recovery in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial.

Background: Magnesium sulfate, an intravenous adjuvant, has recently attracted immense attention in multimodal analgesia. Previous studies confirmed the crucial role of magnesium sulfate in postoperative pain and nociceptive hypersensitivity. However, the effect of magnesium sulfate in multimodal analgesia on the quality of recovery (QoR) for elderly patients has not been thoroughly studied. Therefore, the present experiment aimed to investigate the effect of continuous intravenous magnesium sulfate on the quality of postoperative recovery in elderly patients undergoing total knee arthroplasty (TKA). Patients and Methods: In this study, a total of 148 patients scheduled to undergo unilateral total knee arthroplasty were randomized into a magnesium sulfate group (Group M, n=68) and a control group (Group C, n=66) using a double-blind, randomized controlled trial. Before induction of anesthesia, Group M received intravenous magnesium sulfate (40 mg/kg) for 15 min, followed by a continuous infusion (15 mg/kg) until the end of the procedure. In the same manner, Group C received an infusion of the same amount of isotonic saline using the same method as the Group M. Results: Compared with Group C, Group M had significantly better QoR-15 scores on postoperative day 1(POD1) than Group C (P <0.05). Analysis of the dimensions of QoR-15 scores indicated that Group M exhibited notably reduced levels of pain, and higher levels of emotional state and physical comfort than Group C (P <0.05). Furthermore, Group C had significantly higher numerical rating scale (NRS) scores at POD1 than Group M (P <0.05). Conclusion: For elderly patients undergoing knee arthroplasty, magnesium sulfate can be used as an adjuvant in a multimodal analgesic regimen to reduce early postoperative pain and improve the quality of early postoperative recovery.

Application of digital technology in rehabilitation of total knee arthroplasty: A systematic review.

Purpose: Total Knee Arthroplasty (TKA) aids in reducing pain and improving knee mobility, function, and quality of life in osteoarthritis knee (OA Knee). Techology-based rehabiliation has proved to be promising post-TKA. The objective of this systematic review was to summarize the digital technology after TKA. Methods: The PRISMA Checklist was used for the present systematic review. Randomized and non-randomized studies were included. Joanna Briggs Critical Appraisal Checklist was used to assess risk of bias by two independent reviewers. The data was summarized narratively for the digital technologies utilized. Results: 177 studies were screened from the databases, and 14 studies were included. The risk of bias assessment showed low to moderate-quality evidence. The technologies were divided into 2 broad categories-mobile-based and web-based- although the individual studies had unique technologies utilizing sensors, motion trackers, and game-based and video-based. Conclusion: Various digital technologies focus on providing exercise intervention post-TKA. Clinicians can use face-to-face and technology-based approaches for TKA rehabilitation for a comprehensive subjective and objective assessment post-TKA based on low to moderate quality studies.

Does backward gait require more proprioception and balance in older adults after total knee arthroplasty?

Objectives: Some basic and instrumental daily living activities include backward gait. There is a need to clarify which parameters should be focused more on to improve backward gait in older individuals. This research investigated the proprioception, and balance in forward-backward gait of older individuals with total knee arthroplasty (TKA). Methods: A prospective cross-sectional research was conducted with 105 older adults with TKA. Individuals' forward and backward gait performance was assessed with the Timed Up & Go Test (TUG) and 3 Meter Walk Back Test (3MBWT), respectively. Proprioception was measured with a mobile application-based inclinometer. Berg Balance Scale (BBS) and Activity Specific Balance Confidence Scale (ABC) were used to assess balance and balance confidence levels, respectively. A single clinician evaluated the individuals. Results: TUG was weakly and positively correlated with the Right and Left Leg Proprioception Test (RLPT and LLPT) (r1 = 0.386, r2 = 0.391, p < 0.01). Also, the 3MBWT was weakly and positively correlated with RLPT and LLPT, respectively (r1 = 0.293, r2 = 0.251, p < 0.01). In addition, TUG was strongly and negatively correlated with BBS and ABC, respectively (r1 = -0,693, r2 = -0.722, p < 0.01). Besides, 3MBWT was strongly and negatively correlated with BBS and ABC (r1 = -0.642, r2 = -0.645, p < 0.01). Conclusion: The study revealed that forward and backward walking were similarly associated with balance and proprioception in older adults with TKA. Clinicians should focus more on balance ability than proprioception to improve backward walking performance in older individuals with THA.

Budget impact of the Walk With Ease program for knee osteoarthritis.

Objective: Walk With Ease (WWE) is an effective low-cost walking program. We estimated the budget impact of implementing WWE in persons with knee osteoarthritis (OA) as a measure of affordability that can inform payers' funding decisions. Methods: We estimated changes in two-year healthcare costs with and without WWE. We used the Osteoarthritis Policy (OAPol) Model to estimate per-person medical expenditures. We estimated total and per-member-per-month (PMPM) costs of funding WWE for a hypothetical insurance plan with 75,000 members under two conditions: 1) all individuals aged 45+ with knee OA eligible for WWE, and 2) inactive and insufficiently active individuals aged 45+ with knee OA eligible. In sensitivity analyses, we varied WWE cost and efficacy and considered productivity costs. Results: With eligibility unrestricted by activity level, implementing WWE results in an additional $1,002,408 to the insurance plan over two years ($0.56 PMPM). With eligibility restricted to inactive and insufficiently active individuals, funding WWE results in an additional $571,931 over two years ($0.32 PMPM). In sensitivity analyses, when per-person costs of $10 to $1000 were added with 10-50% decreases in failure rate (enhanced sustainability of WWE benefits), two-year budget impact varied from $242,684 to $6,985,674 with unrestricted eligibility and from -$43,194 (cost-saving) to $4,484,122 with restricted eligibility. Conclusion: Along with the cost-effectiveness of WWE at widely accepted willingness-to-pay thresholds, these results can inform payers in deciding to fund WWE. In the absence of accepted thresholds to define affordability, these results can assist in comparing the affordability of WWE with other behavioral interventions.

Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials.

Objective: This study aims to evaluate the efficacy and safety of various acupuncture treatments in conjunction with multimodal analgesia (MA) for managing postoperative pain and improving knee function in patients undergoing total knee arthroplasty (TKA), based on the findings from clinical research indicating the potential benefits of acupuncture-related therapies in this context. Methods: We searched Web of Science, PubMed, SCI-hub, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials of acupuncture-related therapies for post-TKA pain. After independent screening and data extraction, the quality of the included literature was evaluated. The potential for bias in the studies incorporated in the analysis was assessed according to the guidelines outlined in the Cochrane Handbook 5.1. Network meta-analysis (NMA) was conducted using RevMan 5.4 and Stata 16.0 software, with primary outcome measures including visual analog scale (VAS), pain pressure threshold (PPT), hospital for special surgery knee score (HSS), and knee joint range of motion (ROM). Furthermore, the interventions were ranked based on the SUCRA value. Results: We conducted an analysis of 41 qualifying studies encompassing 3,003 patients, examining the efficacy of four acupuncture therapies (acupuncture ACU, electroacupuncture EA, transcutaneous electrical acupoint stimulation TEAS, and auricular acupoint therapy AAT) in conjunction with multimodal analgesia (MA) and MA alone. The VAS results showed no significant difference in efficacy among the five interventions for VAS-3 score. However, TEAS+MA (SMD: 0.67; 95%CI: 0.01, 1.32) was more effective than MA alone for VAS-7 score. There was no significant difference in PPT score among the three interventions. ACU + MA (SMD: 6.45; 95%CI: 3.30, 9.60), EA + MA (SMD: 4.89; 95%CI: 1.46, 8.32), and TEAS+MA (SMD: 5.31; 95%CI: 0.85, 9.78) were found to be more effective than MA alone for HSS score. For ROM score, ACU + MA was more efficacious than EA + MA, TEAS+MA, and AAT + MA, MA. Regarding the incidence of postoperative adverse reactions, nausea and vomiting were more prevalent after using only MA. Additionally, the incidence of postoperative dizziness and drowsiness following ACU + MA (OR = 4.98; 95%CI: 1.01, 24.42) was observed to be higher compared to that after AAT + MA intervention. Similarly, the occurrence of dizziness and drowsiness after MA was found to be significantly higher compared to the following interventions: TEAS+MA (OR = 0.36; 95%CI: 0.18, 0.70) and AAT + MA (OR = 0.20; 95%CI: 0.08, 0.50). The SUCRA ranking indicated that ACU + MA, EA + MA, TEAS+MA, and AAT + MA displayed superior SUCRA scores for each outcome index, respectively. Conclusion: For the clinical treatment of post-TKA pain, acupuncture-related therapies can be selected as a complementary and alternative therapy. EA + MA and TEAS+MA demonstrate superior efficacy in alleviating postoperative pain among TKA patients. ACU + MA is the optimal choice for promoting postoperative knee joint function recovery in TKA patients. AAT + MA is recommended for preventing postoperative adverse reactions. Systematic review registration: https://www.crd.york.ac.uk/, identifier (CRD42023492859).

Functional electrostimulation therapy for vastus medialis decreases the varus thrust during gait.

[Purpose] This study aimed to investigate whether modification of vastus medialis activity can delay the varus thrust. [Participants and Methods] Ten participants (Kellgren-Laurence grades I: n=2, II: n=6, and III: n=2) diagnosed with knee osteoarthritis were enrolled. The intervention involved free walking on a 10-m walkway at any speed after donning a functional electrical stimulation set to contract the vastus medialis before heel contact. Using a Vicon Nexus ground reaction force meter and a wireless electromyograph DELSYS, varus thrust, maximal knee extension angle, maximal knee adduction moment, and vastus medialis onset time were assessed both before and after intervention. [Results] A significant difference in varus thrust was detected from before to after the intervention (2.7 ± 1.1° vs. 2.2 ± 1.3°). Both the vastus medialis activation time (-0.06 ± 0.09 vs. -0.21 ± 0.1) and the knee-joint extension angle (8.7 ± 5.1° vs. 5.5 ± 5.9°) decreased following intervention, whereas the knee adduction moment significantly increased (0.50 ± 0.20° vs 0.56 ± 0.18°). [Conclusion] Wearing the functional electrical stimulation set caused the vastus medialis to act earlier in response to heel strike, thereby improving the knee-joint extension angle and suppressing varus thrust.