Associations between static foot posture, dynamic in-shoe plantar foot forces and knee pain in people with medial knee osteoarthritis: A cross-sectional exploratory study.

OBJECTIVE: To investigate relationships between static foot posture, dynamic plantar foot forces and knee pain in people with medial knee osteoarthritis (OA). DESIGN: Data from 164 participants with symptomatic, moderate to severe radiographic medial knee OA were analysed. Knee pain was self-reported using a numerical rating scale (NRS; scores 0-10; higher scores worse) and the Knee Injury and Osteoarthritis Outcome Score pain subscale (KOOS; scores 0-100; lower scores worse). Static foot posture was assessed using clinical tests (foot posture index, foot mobility magnitude, navicular drop). Dynamic plantar foot forces (lateral, medial, whole foot, medial-lateral ratio, arch index) were measured using an in-shoe plantar pressure system while walking. Relationships between foot posture and plantar forces (independent variables) and pain (dependent variables) were evaluated using linear regression models, unadjusted and adjusted for sex, walking speed, Kellgren & Lawrence grade, shoe category, and body mass (for dynamic plantar foot forces). RESULTS: No measure of static foot posture was associated with any knee pain measure. Higher medial-lateral foot force ratio at midstance, and a higher arch index during overall stance, were weakly associated with higher knee pain on the NRS (regression coefficient = 0.69, 95% confidence interval (CI) 0.09 to 1.28) and KOOS (coefficient=3.03, 95% CI 0.71 to 5.35) pain scales, respectively. CONCLUSION: Dynamic plantar foot forces, but not static foot posture, were associated with knee pain in people with medial knee OA. However, the amount of pain explained by increases in plantar foot force was small; thus, these associations are unlikely to be clinically meaningful.

'The unexpected journey': a qualitative interview study exploring patient and health professionals experiences of participating in the knee arthroplasty versus joint distraction study (KARDS).

OBJECTIVE: The aim of the knee arthroplasty versus joint distraction (KARDS) randomised trial was to investigate whether knee joint distraction (KJD) is non-inferior to knee arthroplasty, also known as knee replacement (KR). Here we report the findings from qualitative interviews that were part of the planned KARDS process evaluation. DESIGN AND METHODS: Semi-structured qualitative interviews with staff and participants in secondary care. Data were analysed using thematic content analysis. FINDINGS: We were unable to complete the full-planned KARDS process evaluation as recruitment to the trial was closed early but key common themes emerged.Eleven members of staff were interviewed from two KARDS sites (eight initial interviews just after site opening and three follow-up interviews at 12 months). Eleven KARDS participants (six KR and five KJD) were interviewed. One overarching theme emerged: 'An unexpected journey'. This incorporated subthemes including 'an important research question', 'a roller coaster ride', 'lessons learnt', 'managing expectations' and 'a slow recovery'. These encapsulate experiences of both staff and participants. CONCLUSION: The information that we were able to collect highlights that providing adequate and comprehensive information about all aspects of treatment including estimated timelines of recovery are essential in clinical trials of novel interventions. Incorporating a comprehensive rehabilitation package following KJD was a key learning. Process evaluations in these complex trials are essential to determine issues as early as possible so appropriate changes can be made to ensure participants have a smooth journey through the trial experience. TRIAL REGISTRATION NUMBER: ISRCTN14879004.

[Effect of different degrees of primary varus knee on short-term effectiveness of anterior cruciate ligament reconstruction].

Objective: To investigate whether different degrees of primary varus knee affect joint function and stability in patients undergoing anterior cruciate ligament (ACL) reconstruction. Methods: A clinical data of 160 patients with primary varus knee, who were admitted between January 2020 and December 2021 and met the selection criteria, was retrospectively analyzed. All patients underwent primary ACL reconstruction using autologous single-bundle hamstring tendon. Patients were divided into three groups based on the hip-knee-ankle angle (HKA): group A (64 patients with HKA 0°-3°), group B (55 patients with HKA 3°-6°), and group C (41 patients with HKA 6°-9°). Except for the significant difference in HKA among the three groups ( P<0.05), baseline data such as age, gender, affected side, body mass index, interval between injury and operation, Kellgren-Lawrence grading, posterior tibial slope, proportion of combined meniscal injuries, Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) objective score, anterior drawer test, Lachman test, pivot shift test, and the results of KT1000 (side-to-side difference, SSD) showed no significant difference ( P>0.05). At last follow-up, joint stability was assessed through the anterior drawer test, Lachman test, pivot shift test, and SSD; joint function was evaluated using the Tegner score, Lysholm score, and IKDC objective score. Results: All incisions in the three groups healed by first intention after operation. All patients were followed up 24-31 months, with an average of 26 months; there was no significant difference in the follow-up time among the three groups ( Z=0.675, P=0.714). At last follow-up, the knee stability and functional assessment indicators in each group significantly improved when compared to preoperative ones ( P<0.05); there was no significant difference among the three groups ( P>0.05) in terms of the anterior drawer test, Lachman test, pivot shift test, IKDC objective scores, and the changes of the Lysholm scores and Tegner scores. The Kellgren-Lawrence grading and HKA at last follow-up were consistent with preoperative results in the three groups. Conclusion: Varying degrees of primary varus knee do not affect early knee joint stability and functional recovery after ACL reconstruction, and there is no significant difference in effectiveness between different degrees of varus knee.

Comparison of the cost-effectiveness and safety between staged bilateral total knee arthroplasty and simultaneous bilateral total knee arthroplasty: a retrospective cohort study between 2001 and 2022.

INTRODUCTION: A substantial proportion of Hong Kong's aging population suffers from osteoarthritis in both knees. Bilateral total knee arthroplasty (BTKA) is a surgical option for addressing this condition and can be performed via two approaches: simultaneous (SimBTKA) and staged (StaBTKA) bilateral TKAs. We compared the cost-effectiveness and safety of these two methods in our institution. METHODS: We retrospectively reviewed 2,372 patients (SimBTKA, 772; StaBTKA, 1,600; female, 1,780; male, 592; mean age at SimBTKA, 70.4 ± 7.99 years; mean age at StaBTKA, 66.4 ± 7.50 years; p < 0.001) who underwent bilateral TKA in our institution from 2001 to 2022. Patients were categorized according to surgical approach. Patients undergoing BTKA in our institution were included. Particularly for SimBTKA, patients were assessed by anesthetists to be medically fit before undergoing SimBTKA according to their age, American Society of Anesthesiologists status, and osteoarthritis severity. Primary outcome was the length-of-stay (LOS) after surgery. Secondary outcomes were the 30-day unintended readmission, intensive care unit (ICU) admission, and death. RESULTS: SimBTKA had a short mean total LOS (acute hospital + rehabilitation center; SimBTKA, 13.09 days; StaBTKA, 18.12 days; p < 0.001) and mean LOS in acute hospital (SimBTKA, 7.70 days; StaBTKA, 10.42 days; p < 0.001). However, no significant difference was found in mean LOS in rehabilitation centers (SimBTKA, 5.47 days; StaBTKA, 6.32 days; p > 0.05) between the two approaches. The 30-day unintended readmission rate was low in SimBTKA (SimBTKA, 2.07%; StaBTKA, 3.30%; OR = 1.60; p > 0.05) but statistically insignificant. SimBTKA was less costly than StaBTKA by US$8,422.22. per patient. No significant differences in ICU admission and death rates were found (p > 0.05) between the two groups. CONCLUSION: SimBTKA had a shorter LOS and lower cost than StaBTKA and comparable complication rates. Therefore, SimBTKA should be indicated in medically stable patients.

Effects of 16 weeks of plyometric training on knee biomechanics during the landing phase in athletes.

This study investigated the effects of plyometric training on lower-limb muscle strength and knee biomechanical characteristics during the landing phase. Twenty-four male subjects were recruited for this study with a randomised controlled design. They were randomly divided into a plyometric training group and a traditional training group and underwent training for 16 weeks. Each subject was evaluated every 8 weeks for knee and hip isokinetic muscle strength as well as knee kinematics and kinetics during landing. The results indicated significant group and time interaction effects for knee extension strength (F = 74.942 and p = 0.001), hip extension strength (F = 99.763 and p = 0.000) and hip flexion strength (F = 182.922 and p = 0.000). For landing kinematics, there were significant group main effects for knee flexion angle range (F = 4.429 and p = 0.047), significant time main effects for valgus angle (F = 6.502 and p = 0.011) and significant group and time interaction effects for internal rotation angle range (F = 5.475 and p = 0.008). The group main effect for maximum knee flexion angle was significant (F = 7.534 and p = 0.012), and the group and time interaction effect for maximum internal rotation angle was significant (F = 15.737 and p = 0.001). For landing kinetics, the group main effect of the loading rate was significant (F = 4.576 and p = 0.044). Significant group and time interaction effects were observed for knee extension moment at the moment of maximum vertical ground reaction force (F = 5.095 and p = 0.010) and for abduction moment (F = 8.250 and p = 0.001). These findings suggest that plyometric training leads to greater improvements in hip and knee muscle strength and beneficial changes in knee biomechanics during landing compared to traditional training.

Changes in the anteroposterior position of the femur relative to the tibia impact patient satisfaction in total knee arthroplasty.

BACKGROUND: In this study, we aimed to investigate the preoperative and postoperative anteroposterior position (AP) of the femur relative to the tibia in total knee arthroplasty (TKA) and assess the influence of change in the AP position on clinical outcomes. METHODS: We evaluated 49 knees that underwent bi-cruciate-substituted TKA using a navigation system. The preoperative and postoperative AP position of the femur relative to the tibia at maximum extension, 15°, 30°, 45°, 60°, 90°, 105°, and 120° and maximum flexion angles were calculated. The 2011 Knee Society Score was evaluated preoperatively and 1 year postoperatively. The Wilcoxon signed rank and Spearman's rank correlation tests were performed, with statistical significance set at P < 0.05. RESULTS: The postoperative AP position was significantly correlated with the preoperative AP position at each measured angle. The postoperative AP positions were statistically more anterior than those preoperatively. Furthermore, the changes in the AP position after TKA negatively correlated with the symptom (P = 0.027 at 30°, P = 0.0018 at 45°, P = 0.0003 at 60°, P = 0.01 at 90°, and P = 0.028 at 105°) and patient satisfaction (P = 0.018 at 60° and P = 0.009 at 90°) scores at 1 year postoperatively. CONCLUSION: The postoperative AP position of the femur relative to the tibia was strongly influenced by the preoperative those in TKA. Postoperative anterior deviation of the femur relative to the tibia from mid-flexion to deep flexion could worsen clinical outcomes.

Open Repair of Posterior Cruciate Ligament Tibial Bony Avulsion With Metal Anchor: A Case Report.

Introduction: The posterior cruciate ligament (PCL) is the largest and strongest intra-articular ligament of the knee joint and the primary posterior stabilizer. PCL injuries are less frequent than other knee ligament injuries and are typically combined with meniscal and chondral injuries or in the context of multiligamentous injuries. It is critical to properly diagnose and treat these lesions in order to avoid the risk of PCL insufficiency, subsequent knee instability, and early osteoarthritis. Surgical management can vary, and the ideal fixation device is still debated. Suture anchors are an unusual mean of fixation of PCL tibial bony avulsion. We report on two patients treated with open anchor fixation for PCL tibial bony avulsion with a follow-up of 3 years. Case Presentation: A 15-year-old male and a 65-year-old male were treated with open anchor fixation for bony tibial avulsion of the PCL. Surgical treatment was performed at 5 weeks and 3 weeks after the trauma, respectively. Diagnosis was made with an X-ray followed by CT and MR scans. Repair was achieved by reinserting the PCL bony fragment to its posterior tibial eminence with suture anchors through an open posterior approach. Both patients recovered full knee stability and a pain-free full range of motion (ROM) within 4 months and returned to their previous activities with a high satisfaction. The patient has been followed up for 3 years, and no complications were observed. Conclusion: PCL bony avulsions are rare, and their optimal treatment remains a significant subject of debate, particularly in the skeletally immature patient. We believe that open repair with metal anchors could be a good choice to repair PCL bony tibial avulsion in patients without concomitant intra-articular lesions and immature growth plates or severe fragmentation.

The treatment of bacterial biofilms cultivated on knee arthroplasty implants using the bioelectric effect.

Introduction: The formation of bacterial biofilms on knee arthroplasty implants can have catastrophic consequences. The aim of this study was to analyze the effectiveness of the bioelectric effect in the elimination of bacterial biofilms on cultivated knee arthroplasty implants. Methods: A novel device was designed to deliver a bioelectric effect on the surface of knee arthroplasty implants. 4-femoral prosthetic implants were cultivated with a staphylococcus aureus inoculum for 15 days. The components were divided into four different groups: A (not treated), B (normal saline 20-minutes), C (bioelectric effect 10-minutes), D (bioelectric effect 20-minutes). The implants were sonicated, and the detached colonies were quantified as the number of colony-forming unit (CFUs). The implants were sterilised and the process was repeated in a standardized manner four more times, to obtain a total of five samples per group. Results: The number of the CFUs after a 10-minute exposure to the bioelectric effect was of 208.2 ± 240.4, compared with 6,041.6 ± 2010.7 CFUs in group A, representing a decrease of 96.5% ± 4.3 (p = 0.004). And a diminution of 91.8% ± 7.9 compared with 2,051.0 ± 1,364.0 CFUs in group B (p = 0.109). The number of bacterial colonies after a 20-minute exposure to the bioelectric effect was 70 ± 126.7 CFUs, representing a decrease of 98.9% ± 1.9 (p = 0.000) compared with group A. And a decrease of 97.8% ± 3.0 (p = 0.019) compared with group B. Conclusions: The bioelectric effect was effective in the elimination of bacterial biofilm from knee arthroplasty implants. This method could be used in the future as part of conventional surgical procedures.

Superior accuracy in knee double level osteotomy using a novel hybrid fixation technique compared to conventional double plating.

Purpose: This study aimed to compare two different double-level knee osteotomy (DLO) fixation techniques. The primary outcome reported the radiological coronal plane correction and its accuracy. The secondary outcomes reported the correction outliers, the clinical outcomes, the 5-year postoperative satisfaction and the complications. Methods: A retrospective review of a single surgeon osteotomy database identified 52 cases of DLO between 2011 and 2019, of which 24 cases met the inclusion criteria. Patients were categorised into two groups: the nail-plate (NP) group fixed with a magnetic extendable intramedullary tibial nail and femoral conventional plate, and the double-plate (DP) group fixed with conventional plates (tibia and femur). Radiographic parameters were recorded, including the mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA) and weight-bearing line ratio (Mikulicz %). Surgical accuracy was calculated as the difference between the achieved and the planned correction. Outliers were defined as those with a greater than 10% difference from the planned correction. Simple knee value scores and visual analogue scale for pain were recorded preoperatively and postoperatively at 2 and 5 years. Five-year patient satisfaction was recorded. Results: A total of 24 patients were included: the NP group (n = 12) and the DP group (n = 12). Significant coronal plane corrections were achieved in the NP group for the mean mFTA (preoperative 167.9° ± 3.4° to postoperative 182.1° ± 1.4°), the mean MPTA (preoperative 83.5° ± 2.9° to postoperative 91.3° ± 2.8°) and the mean mLDFA (preoperative 89.8° ± 3.4° to postoperative 85.9° ± 4.4°). Similarly, significant coronal plane corrections were achieved in the DP group for the mean mFTA (preoperative 168.6° ± 4.4° to postoperative 182.2° ± 2°), the mean MPTA (preoperative 84.2° ± 2° to postoperative 88.3° ± 4.1°) and the mean mLDFA (preoperative 90.7° ± 2.9° to postoperative 83.9° ± 1.7°) (all p < 0.05). The mean correction accuracy was higher for the NP versus DP group at 3.4 ± 3.4% versus 7.1 ± 3.9% (intergroup p < 0.05). There were no outliers in the NP group versus two outliers (overcorrected) (16.7%) in the DP group. Significant clinical improvement was reported in both groups at 2 and 5 years postoperatively (all p < 0.05). Conclusion: Superior correction accuracy and no outliers were achieved in hybrid fixation double-level knee osteotomy compared to the conventional double-plating technique. The magnetic extendable nail offers the advantage of fine-tuning the correction postoperatively and could be a potential research template for future designs of postoperative correction implants. Level of Evidence: Level III, retrospective cohort study.

Understanding the biopsychosocial knee osteoarthritis pain experience: an ecological momentary assessment.

Introduction: Psychological, social, and lifestyle factors contribute to the knee osteoarthritis (OA) pain experience. These factors could be measured more accurately using smartphone ecological momentary assessment (EMA). Objectives: The objective of this study was to characterise the pain experiences of those with knee OA by a smartphone EMA survey and explain how momentary psychological and social states influence knee OA pain experiences. Methods: A smartphone EMA survey was designed and piloted. Eligible participants completed smartphone EMA assessing the knee OA pain experience 3 times daily for 2 weeks. Descriptive statistics were used to characterise factors involved in knee OA pain followed by the development of mixed-effects location scale models to explore heterogeneity and relationships between symptoms involved in the knee OA pain experience. Results: Eighty-six community-dwelling volunteers with knee OA were recruited. Pain, psychosocial, and lifestyle factors involved in knee OA pain experience were heterogeneous and variable. Those with greater variability in pain, fatigue, negative affect, and stress had worse levels of these symptoms overall. In addition, fatigue, negative affect, stress, anxiety, loneliness, and joint stiffness demonstrated within-person relationships with knee OA pain outcomes. Conclusions: Knee OA pain is a heterogeneous biopsychosocial condition. Momentary experiences of psychological, social, fatigue, and joint stiffness explain individual and between-individual differences in momentary knee OA pain experiences. Addressing these momentary factors could improve pain and functional outcomes in those with knee OA. Validation studies, including individuals with more severe knee OA presentations, are required to support findings and guide clinical interventions to improve outcomes for those with knee OA.

Long-term outcomes of below-the-knee bypass surgery using heparin-bonded expanded polytetrafluoroethylene grafts.

PURPOSE: To report the outcomes of below-the-knee (BK) bypass surgery using heparin-bonded expanded polytetrafluoroethylene (ePTFE) grafts, performed in two centers since its launch in Japan. METHODS: We conducted a retrospective analysis of databases from two medical centers, evaluating 51 limbs in 42 consecutive patients with peripheral arterial disease (PAD), who underwent BK bypass surgery using heparin-bonded ePTFE grafts between October, 2013 and April, 2023. RESULTS: Thirty-three limbs (64.7%) were classified as Rutherford category 4-6 and 33 limbs (64.7%) had a history of ipsilateral revascularization. Technical success was achieved in 98% of the patients. The 30 day mortality rate was 2.4% (n = 1) and the overall 30 day complication rate was 9.5% (n = 4). The median follow-up period was 38 (interquartile range 13-67) months. Three patients required major amputation and 14 died during follow-up. Primary patency rates at 1, 3, and 5 years were 67.8%, 57.5%, and 46.5%, respectively, while secondary patency rates for these periods were 84.6%, 70.0%, and 66.0%, respectively. Overall survival rates at 1, 3, and 5 years were 90.1%, 74.5%, and 70.9%, respectively. CONCLUSIONS: BK bypass surgery using heparin-bonded ePTFE graft is a viable and durable option for patients with PAD, who are deemed unsuitable for autologous vein bypass surgery.

Association between Dietary total antioxidant capacity and knee osteoarthritis: a case-control study in the Iranian Population.

AIM: Knee osteoarthritis (KOA) is a prevalent chronic condition associated with significant pain, disability, and healthcare costs, particularly among the elderly population. Despite the considerable burden of KOA, effective treatment options for managing the condition's underlying causes remain limited. This case-control study aims to investigate the relationship between dietary total antioxidant capacity (DTAC) and knee osteoarthritis. METHODS: This case-control study was conducted on 105 patients with confirmed KOA and 210 controls. KOA was diagnosed based on the American College of Rheumatology criteria. Dietary total antioxidant capacity (DTAC) was calculated based on the ferric-reducing antioxidant power method. RESULTS: The mean age and BMI of the participants were 53.6 ± 8.8 years old and 27.3 ± 2.7 kg/m2, respectively. The study participant's DTAC score ranged from 3.56 to 25.32 with a mean and SD of 12.46 ± 5.12. In the crude model, individuals in the highest quartile of DTAC score had 71% lower odds of having knee osteoarthritis compared to those in the first quartile (OR: 0.29, 95%CI: 0.15 to 0.58, P-trend < 0.001). These associations remained significant after adjustment for potential confounders including age, sex, energy intake, family history of osteoarthritis, vitamin D and calcium use, physical activity level, cigarette smoking and BMI. Although the odds of having knee osteoarthritis decreased with increasing quartiles of DTAC in both sexes, this relationship was stronger among males than females. CONCLUSION: The results of this study showed that there was an inverse correlation between DTAC and KOA among the Iranian patients with KOA.

Postoperative management following osteotomies around the knee: a narrative review.

The present narrative review provides a summary of postoperative therapy modalities and their effectiveness following osteotomies around the knee. The topics that are discussed in the scientific discourse include support of cartilage cell regeneration, pain management, drainage insertion, tourniquet use, pharmacological and mechanical thromboembolism prophylaxis, weight-bearing protocols and bone consolidation. There is evidence for the use of pharmacological thromboembolism prophylaxis and weight-bearing protocols. A standardized postoperative treatment concept following osteotomies around the knee cannot be derived due to lack of evidence for the other topics in current literature.

Malnutrition in total joint arthroplasty: what should the orthopaedic surgeon consider?

Total joint arthroplasty (TJA) is rising globally, with an associated increase in associated complications, necessitating increased efforts in prevention of these complications with pre-operative optimisation. Malnutrition has been highlighted as one of the most important pre-operative modifiable risk factors to be addressed in TJA, with the term malnutrition in orthopaedic surgery having a broad definition that encompasses a wide range of nutritional abnormalities from undernutrition to overnutrition contributing to the outcomes of TJA. Complications associated with malnutrition include periprosthetic joint infection (PJI), periprosthetic fracture, dislocations, aseptic loosening, anaemia, prolonged length of stay (LOS), increased mortality, and raised health care costs. Standardised nutritional scoring tools, anthropometric measurements, and serological markers are all options available in pre-operative nutritional assessment in TJA, but there is no consensus yet regarding the standardisation of what parameters to assess and how to assess them. Abnormal parameters identified using any of the assessment methods results in the diagnosis of malnutrition, and correction of these parameters of overnutrition or undernutrition have shown to improve outcomes in TJA. With the multiple nutritional parameters contributing to the success of total joint arthroplasty, it is imperative that orthopaedic surgeon has a thorough knowledge regarding nutritional peri-operative optimisation in TJA.

Personalized total knee arthroplasty in patients with extra-articular deformities.

Over the years, with a better understanding of knee anatomy and biomechanics, superior implant designs, advanced surgical techniques, and the availability of precision tools such as robotics and navigation, a more personalized approach to total knee arthroplasty (TKA) has emerged. In the presence of extra-articular deformities, performing personalized TKA can be more challenging and specific considerations are required, since one has to deal with an acquired pathological anatomy. Performing personalized TKA surgery in patients with extra-articular deformities, the surgeon can: (1) resurface the joint, omitting the extra-articular deformity; (2) partially compensate the extra-articular deformity with intra-articular correction (hybrid technique), or (3) correct the extra-articular deformity combined with a joint resurfacing TKA (single stage or two-stage procedure). Omitting the acquired lower limb malalignment by resurfacing the knee has the advantages of respecting the joint surface anatomy and preserving soft tissue laxities. On the other hand, it maintains pathological joint load and lower limb kinematics with potentially detrimental outcomes. The hybrid technique can be performed in most cases. It circumvents complications associated with osteotomies and brings lower limb axes closer to native alignment. On the other hand, it creates some intra-articular imbalances, which may require soft tissue releases and/or constrained implants. Correcting the extra-articular deformity (through an osteotomy) in conjunction with joint resurfacing TKA represents the only true kinematic alignment technique, as it aims to reproduce native knee laxity and overall lower limb axis.

Effects of the combination of various pharmacological treatments and exercise on knee osteoarthritis: a systematic review and network meta-analysis.

Purpose: The combination of pharmacological and non-pharmacological interventions is strongly recommended by current guidelines for knee osteoarthritis. However, few systematic reviews have validated their combined efficacy. In this study, we investigated the effects of the combination of pharmacological agents and exercise on knee osteoarthritis. Methods: Randomized controlled trials that investigated the efficacy of pharmacological agents combined with exercise for knee osteoarthritis were searched in PubMed, Embase, and Cochrane Library up to February 2024. The network meta-analysis was performed within the frequentist framework. Standardized mean difference (SMD) with 95% CI was estimated for pain and function. Grading of recommendations, assessment, development, and evaluations were used to evaluate the certainty of evidence. Results: In total, 71 studies were included. The combination therapy outperformed pharmacological or exercise therapy alone. Among the various pharmacological agents combined with exercise, mesenchymal stem cell injection was ranked the best for short-term pain reduction (SMD: -1.53, 95% CI: -1.92 to -1.13, high certainty), followed by botulinum toxin A, dextrose, and platelet-rich plasma. For long-term pain relief, dextrose prolotherapy was the optimal (SMD: -1.76, 95% CI: -2.65 to -0.88, moderate certainty), followed by mesenchymal stem cells, platelet rich in growth factor, and platelet-rich plasma. Conclusion: Exercise programs should be incorporated into clinical practice and trial design. For patients undergoing exercise therapies, mesenchymal stem cell, dextrose, platelet-rich plasma, platelet rich in growth factor, and botulinum toxin A may be the optimal agents.

Charcot arthropathy of the knee accompanied by tethered cord syndrome and lumbosacral fur sinus.

Charcot arthropathy is a rare disease in clinic, which is easy to be misdiagnosed and delayed diagnosis. Imaging examination plays a key role in the diagnosis of Charcot arthropathy. It is important to improve the early diagnosis rate and strive for early treatment to improve the quality of life of these patients. Here we reported a rare case of charcot knee (CK) accompanied by tethered cord syndrome and lumbosacral fur sinus, who presented with joint destruction, joint deformity and multiple free bodies and received joint free bodies removal and joint replacement surgery with acceptable short and midterm follow-up results.

Postoperative early weight-bearing using double plating for periprosthetic, interprosthetic, and interimplant distal femur fractures following total knee arthroplasty: A report of three cases.

Background: Distal femur fractures (DFFs) following total knee arthroplasty (TKA) in older patients often require prolonged non-weight-bearing, thereby decreasing their activities of daily living (ADL) and increasing mortality. This report clarifies early weight-bearing safety and utility by using double-plate fixation on medial and lateral sides (LM180 double-plate fixation) for DFFs following TKA. Case presentation: Three cases of Su Type III periprosthetic, interprosthetic, and interimplant DFFs following TKA, where bone stock was limited, were treated with LM180 double-plate fixation using locking plates through medial and lateral incisions on the distal femur. In interprosthetic and interimplant DFF cases, the proximal section was secured by overlapping the lateral plate +/- medial plate with the proximal femur stem of the intramedullary nail by using monocortical screws and cerclage wires. Early postoperative partial weight-bearing was recommended, and full weight-bearing was allowed 4-5 weeks postoperation. All cases regained independent walking without hardware failure. Average ADL scores, namely, Barthel index (BI) and functional independence measure (FIM), were recovered to 85/100 and 114.7/126, respectively, approaching near-normal values. Conclusion: LM180 double-plate fixation for DFFs such as Su Type III periprosthetic, Vancouver type C interprosthetic, and interimplant DFFs following TKA with limited bone stock can be used to achieve early weight-bearing without fixation failure and help maintain ADL.

Are social determinants of health associated with an increased length of hospitalization after revision total hip and knee arthroplasty? A comparison study of social deprivation indices.

INTRODUCTION: Length of stay (LOS) has been extensively assessed as a marker for healthcare utilization, functional outcomes, and cost of care for patients undergoing arthroplasty. The notable patient-to-patient variation in LOS following revision hip and knee total joint arthroplasty (TJA) suggests a potential opportunity to reduce preventable discharge delays. Previous studies investigated the impact of social determinants of health (SDoH) on orthopaedic conditions and outcomes using deprivation indices with inconsistent findings. The aim of the study is to compare the association of three publicly available national indices of social deprivation with prolonged LOS in revision TJA patients. MATERIALS AND METHODS: 1,047 consecutive patients who underwent a revision TJA were included in this retrospective study. Patient demographics, comorbidities, and behavioral characteristics were extracted. Area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index (SVI) were recorded for each patient, following which univariate and multivariate logistic regression analyses were performed to determine the relationship between deprivation measures and prolonged LOS (greater than five days postoperatively). RESULTS: 193 patients had a prolonged LOS following surgery. Categorical ADI was significantly associated with prolonged LOS following surgery (OR = 2.14; 95% CI = 1.30-3.54; p = 0.003). No association with LOS was found using SDI and SVI. When accounting for other covariates, only ASA scores (ORrange=3.43-3.45; p < 0.001) and age (ORrange=1.00-1.03; prange=0.025-0.049) were independently associated with prolonged LOS. CONCLUSION: The varying relationship observed between the length of stay and socioeconomic markers in this study indicates that the selection of a deprivation index could significantly impact the outcomes when investigating the association between socioeconomic deprivation and clinical outcomes. These results suggest that ADI is a potential metric of social determinants of health that is applicable both clinically and in future policies related to hospital stays including bundled payment plan following revision TJA.

The impact of shoes versus ankle-restricted orthoses on sit-to-stand kinematics and centre of mass trajectories in adults with myelomeningocele.

BACKGROUND: Individuals with myelomeningocele (MMC) present with neurological and orthopaedic deficiencies, requiring orthoses during walking. Orthoses for counteracting dorsiflexion may restrict activities such as rising from a chair. RESEARCH QUESTION: How are sit-to-stand (STS) movements performed with ankle joint-restricted ankle-foot orthoses (AFO) and knee-ankle-foot orthoses with a free-articulated knee joint (KAFO-F)? METHODS: Twenty-eight adults with MMC, mean age 25.5 years (standard deviation: 3.5 years), were divided into an AnkleFree group (no orthosis or a foot orthosis) and an AnkleRestrict group (AFOs or KAFO-Fs). Study participants performed the five times STS test (5STS) while their movements were simultaneously captured with a three-dimensional motion system. Centre of mass (CoM) trajectories and joint kinematics were analysed using statistical parametric mapping. RESULTS: The AnkleRestrict group performed the STS slower than the AnkleFree group, median 8.8 s (min, max: 6.9, 14.61 s) vs 15.0 s (min, max: 7.5, 32.2 s) (p = 0.002), displayed reduced ankle dorsiflexion (mean difference: 6°, p = 0.044) (74-81 % of the STS cycle), reduced knee extension (mean difference: 14°, p = 0.002) (17-41 % of the STS cycle), larger anterior pelvic tilt angle (average difference: 11°, p = 0.024) (12-24 % of the STS cycle), and larger trunk flexion angle (on average 4°, p = 0.029) (6-15 % of the STS cycle). SIGNIFICANCE: The differences between the AnkleFree and AnkleRestrict groups in performing the STS seem consistent with the participants functional ambulation: community ambulation in the AnkleFree group, and household and nonfunctional ambulation with less hip muscle strength in the majority of the AnkleRestrict group. No differences in the 5STS CoM trajectories or the kinematics were found with respect to the AFO and KAFO-Fs groups. Because orthoses are constructed to enable walking, the environment needs to be adjusted for activities in daily living such as the STS movement.