Restoring the Preoperative Phenotype According to the Coronal Plane Alignment of the Knee (CPAK) Classification After Total Knee Arthroplasty Leads to Better Functional Results.

PURPOSE: Mechanical alignment after total knee arthroplasty (TKA) is still widely used in the surgical community, but the alignment finally obtained by conventional techniques remains uncertain. The recent Coronal Plane Alignment of the Knee (CPAK) classification distinguishes nine knee phenotypes according to constitutional alignment and joint line obliquity (JLO). The aim of this study was to assess the phenotypes of osteoarthritic patients before and after TKA using mechanical alignment and to analyze the influence of CPAK restoration on functional outcomes. METHODS: This retrospective multicenter study included 178 TKA with a minimum follow-up of two years. Patients were operated on using a conventional technique with the goal of neutral mechanical alignment. The CPAK grade (1 to 9), considering the arithmetic Hip Knee Ankle angle (HKA) and the joint line obliquity, was determined before and after TKA. Functional results were assessed using the following patient-reported outcome measures (PROMS): Knee Injury and Osteoarthritis Outcome Score (KOOS), the Simple Knee Value (SKV), and the Forgotten Joint Score (FJS). RESULTS: A true neutral mechanical alignment was obtained in only 37.1%. Isolated restoration of Joint Line Obliquity (JLO) was found in 31.4%, and isolated restoration of the arithmetic HKA in 44.9%. Exact restoration of the CPAK phenotype was found in 14.6%. Restoration of the CPAK grade was associated with an improvement in the ''daily living'': 79.2 ± 5.3 versus 62.5 ± 2.3 (R2 = 0,05, P < 0.05) and ''Quality of life'' KOOS subscales: 73.8 ± 5.0 versus 62.9 ± 2.2 (R2 = 0.02, P < 0.05). CONCLUSION: This study shows that few neutral mechanical alignments are finally obtained after total knee arthroplasty by conventional technique. A major number of patients present a postoperative modification of their constitutional phenotype. Functional results at two years' follow-up appear to be improved by the restoration of the CPAK phenotype, JLO, and aHKA.

A practical guide to the implementation of artificial intelligence in orthopaedic research-Part 2: A technical introduction.

Recent advances in artificial intelligence (AI) present a broad range of possibilities in medical research. However, orthopaedic researchers aiming to participate in research projects implementing AI-based techniques require a sound understanding of the technical fundamentals of this rapidly developing field. Initial sections of this technical primer provide an overview of the general and the more detailed taxonomy of AI methods. Researchers are presented with the technical basics of the most frequently performed machine learning (ML) tasks, such as classification, regression, clustering and dimensionality reduction. Additionally, the spectrum of supervision in ML including the domains of supervised, unsupervised, semisupervised and self-supervised learning will be explored. Recent advances in neural networks (NNs) and deep learning (DL) architectures have rendered them essential tools for the analysis of complex medical data, which warrants a rudimentary technical introduction to orthopaedic researchers. Furthermore, the capability of natural language processing (NLP) to interpret patterns in human language is discussed and may offer several potential applications in medical text classification, patient sentiment analysis and clinical decision support. The technical discussion concludes with the transformative potential of generative AI and large language models (LLMs) on AI research. Consequently, this second article of the series aims to equip orthopaedic researchers with the fundamental technical knowledge required to engage in interdisciplinary collaboration in AI-driven orthopaedic research. Level of Evidence: Level IV.

Joint line and knee osteotomy.

This review explores the intricate relationship between knee osteotomy and frontal plane joint line orientation, emphasizing the dynamic nature of the joint line's influence on knee forces and kinematics. Consideration of coronal alignments, knee phenotypes, and associated angles (medial proximal tibial angle (MTPA), lateral distal femoral angle (LDFA), joint line convergence angle (JLCA)) becomes crucial in surgical planning to avoid joint line deformities. The double-level osteotomy is to be considered a valid option, especially for severe deformities; however, the target patient cannot be selected solely based on high predicted postoperative joint line obliquity (JLO) and MPTA.

Information videos posted on Instagram by orthopaedics and sports traumatology surgeons mostly explain surgical technique, and the least mentioned topics are injury prevention and complications.

PURPOSE: Social media has become the new information acquisition platform for all content producers. In the current literature, there are no studies examining the content quality and the strengths and weaknesses of videos on Instagram that explain anterior cruciate ligament (ACL) injuries, which is the most discussed topic of sports surgery. The aim of this study was to evaluate the quality, strengths and weaknesses of information pertaining to ACL surgery that is disseminated on Instagram. METHOD: An Instagram search was conducted from 30 May 2023 to 30 January 2024. The search encompassed six languages (English, Spanish, German, French, Italian and Turkish) and was performed by six different observers. The investigation focused on eight subheadings derived from current literature on the ACL. These subheadings were addressed in Instagram videos, covering ACL biology or biomechanics, injury mechanism, injury prevention, injury evaluation, surgical technique, injury or surgery complications, injury rehabilitation process and return to sport or work. RESULT: The content was assessed of 127 videos from 127 Instagram accounts, spanning six different languages. Across the review of eight subheadings, the average number covered for the entire group was 3 (range, 0-8). Further analysis revealed that surgical technique was the most frequently mentioned subheading for the whole group (68.5%), followed by injury evaluation (54.3%). Prevention (10.2%) and complications (19.6%) were the least mentioned subheadings. The number of followers showed a correlation with video content quality. CONCLUSION: Although the video quality scores were found to be moderate, the content often focused on surgery and evaluation subheadings. The prevalence of incomplete information underscores the importance of developing strategies to ensure more comprehensive and accurate dissemination of medical knowledge. LEVEL OF EVIDENCE: Level V.

Females show worse functional outcome and quality of life compared to males 2 years after meniscus surgery: Data analysis from the German Arthroscopy Registry.

PURPOSE: The purpose of this study was to investigate the impact of sex on knee function, activity and quality of life following meniscus surgery using data from the German Arthroscopy Registry. METHODS: This is a retrospective cohort study with data collected between 2017 and 2022. Patient-reported outcome measures (PROMs), namely Knee Injury and Osteoarthritis Outcome Score (KOOS), EuroQol Visual Analogue Scale (EQ Scale), and Marx Activity Rating Scale (MARS), were collected preoperatively and at 6, 12 and 24 months postoperatively. Data were analysed to examine differences between male and female patients regarding PROMs, pre-existing conditions, meniscus lesion types and surgical treatments. RESULTS: A total of 1106 female (36.6%) and 1945 male patients (63.7%) were included. Males were significantly younger than females and had a higher body mass index. Overall, there were four times more medial meniscus lesions (MMLs) (77.5%) than lateral meniscus lesions (LMLs) (27.9%). Degenerative LMLs were more frequent in females, while traumatic LMLs were more common in males. Frequencies of traumatic and degenerative MMLs were similar among males and females. Males had higher absolute KOOS irrespective of treatment or meniscus lesion type. Meniscus repair resulted in similar improvements in ΔKOOS for both sexes, while meniscus resection exhibited higher absolute KOOS for males at each time point. Males generally had higher EQ Scale and MARS than females. CONCLUSION: Greater improvements in knee function, activity and quality of life were observed in males. While MMLs appear to be comparable among sexes, the nature of LML differed significantly. These results may help surgeons to refine patient selection for specific treatments to improve overall clinical outcomes. LEVEL OF EVIDENCE: Level III.

Anterior cruciate ligament injuries in elite ski jumping reliably allow return to competition but severely affect future top performance.

PURPOSE: In recent years, anterior cruciate ligament (ACL) injuries have been frequently observed in ski jumping. However, available data in this discipline are very scarce. Therefore, the purpose of this study was to investigate whether an ACL injury in elite-level ski jumping limits the performance level after ACL reconstruction (ACLR). METHODS: Both male and female elite-level ski jumpers from five national A-teams who suffered an ACL injury were identified retrospectively by searching available media reports and Fédération Internationale de Ski (FIS) database. World Cup (WC) results and time-out-of-competition before ACL injury and after ACLR were compared. Only athletes who suffered the injury during or after the 2009-2010 season and who participated in at least one WC competition before the injury were included in this study. The level of athletes' performance from two full seasons before until three seasons after the injury was compared. RESULTS: Eighteen elite-level ski jumpers (11 males/seven females) were eligible for the study. All male and four female athletes returned to professional competition after ACLR. One female athlete ended her career due to prolonged recovery and two have not yet recovered due to a recent injury. The mean return-to-competition (RTC) time was 14.6 months in males and 13.5 months in females. The mean WC placement decreased after the ACL injury: two seasons before injury the mean position was 17.9 ± 11.0 (n = 12), one season before it was 22.4 ± 12.8 (n = 15). After recovery, the mean placement in seasons 1-3 was: 26.4 ± 8.9 (n = 7), 25.7 ± 10.3 (n = 13), 33.6 ± 12.2 (n = 10) (p = 0.008). Among the athletes returning to competition, only six males and three females reached their preinjury level and only one male and one female (compared to seven males and three females preinjury) reached an individual top-3 placement after ACLR, accounting for less than 10% of podiums compared to preinjury. CONCLUSION: Only 60% of the professional ski jumpers reached the preinjury level and less than 15% reached a top-3 placement after the ACL injury. These results support the fact that ACL tear during a ski jumping career may be a significant factor limiting high-level performance. In terms of clinical relevance, the findings implicate the need to analyse the reasons of these very low rates of return to elite-level performance, to analyse ACL injury and RTC rates at lower levels of performance and to develop specific prevention strategies in order to reduce the number of ACL injuries in this sport. LEVEL OF EVIDENCE: Level IV.

Presentation of an intraosseous suspensory fixation technique for pediatric and adult ACL reconstruction.

The aim is to present a technique for pediatric and adult ACL reconstruction using an intraosseous suspensory fixation. This technique uses a 4-strands hamstring graft fixed in the femoral tunnel, with a loop locked in a polyetheretherketone (PEEK) cage. The ACLip® device offers an inside-out drilling system and a closer fixation to the joint than an extracortical button fixation. The technique can be easily used both in adults and in skeletally immature patients. The first practical experience shows promising results regarding the safety and the effectiveness of the technique. Level of evidence: IV.

Surgical technique: posterior cruciate ligament (PCL) reconstruction using double posteromedial arthroscopic portals.

The posterior cruciate ligament (PCL) reconstruction is a technically demanding surgical procedure that requires optimal identification of both the femoral and the tibial anatomical footprints. To aid the tibial tunnel placement and many authors recommend creating a posteromedial (PM) portal. The further addition of a second PM portal, which could be used as a "working portal", may further allow a more straightforward reconstruction by improving the identification of the anatomical footprint, the clearing of the stump, and the graft passage.

Case report: unusual posteromedial capsular lesion with posterior lateral meniscus root tear in two patients with constitutional genu recurvatum presenting after an acute ACL injury.

Ramp lesions of the medial meniscus and posterior lateral meniscus root tears (LMPRT) can be present simultaneously in up to 8% of patients undergoing anterior cruciate ligament (ACL) reconstruction. The prevalence of these complex and highly unstable meniscal tears increases exponentially with the severity of the injury. The posteromedial capsule (PMC) has often been disregarded in the past when discussing ligamentous and meniscal injuries, but the recent interest in ramp lesions has drawn surgeons' attention to the posteromedial structures of the ACL injured knee. While the meniscocapsular junction is commonly repaired in unstable ramp lesions, in the current literature there is no report regarding proximal PMC lesions, be they in isolation or associated with complex meniscal injuries.We report here two cases of proximal posteromedial capsular lesions associated with medial meniscus instability and posterior lateral root tears after ACL injury. The first case involves a meniscus ramp lesion associated with a proximal PMC tear and a posteromedial fluid collection in the muscle plane on magnetic resonance in a 22-year-old male soccer player. The second case involves a 21-year-old female soccer player who presented with a PMC lesion after hyperextension/valgus knee injury. The capsular lesions were repaired to restore capsular tension and improve medial meniscus posterior horn stability.

A systematic approach to managing complications after proximal tibial osteotomies of the knee.

Proximal tibial osteotomy (PTO) is an effective procedure for active and young adult patients with symptomatic unicompartmental osteoarthritis and malalignment. They were considered technically demanding and prone to various complications related to the surgical technique, biomechanical or biological origin. Among the most important are hinge fractures and delayed or non-healing, neurovascular complications, loss of correction, implant-related problems, patellofemoral complaints, biological complications and changes in limb length. Being aware of these problems can help minimizing their prevalence and improve the results of the procedure.The aim of this narrative review is to discuss the potential complications that may occur during and after proximal tibial osteotomies, their origin and ways to prevent them.

A practical guide to the implementation of AI in orthopaedic research - part 1: opportunities in clinical application and overcoming existing challenges.

Artificial intelligence (AI) has the potential to transform medical research by improving disease diagnosis, clinical decision-making, and outcome prediction. Despite the rapid adoption of AI and machine learning (ML) in other domains and industry, deployment in medical research and clinical practice poses several challenges due to the inherent characteristics and barriers of the healthcare sector. Therefore, researchers aiming to perform AI-intensive studies require a fundamental understanding of the key concepts, biases, and clinical safety concerns associated with the use of AI. Through the analysis of large, multimodal datasets, AI has the potential to revolutionize orthopaedic research, with new insights regarding the optimal diagnosis and management of patients affected musculoskeletal injury and disease. The article is the first in a series introducing fundamental concepts and best practices to guide healthcare professionals and researcher interested in performing AI-intensive orthopaedic research studies. The vast potential of AI in orthopaedics is illustrated through examples involving disease- or injury-specific outcome prediction, medical image analysis, clinical decision support systems and digital twin technology. Furthermore, it is essential to address the role of human involvement in training unbiased, generalizable AI models, their explainability in high-risk clinical settings and the implementation of expert oversight and clinical safety measures for failure. In conclusion, the opportunities and challenges of AI in medicine are presented to ensure the safe and ethical deployment of AI models for orthopaedic research and clinical application. Level of evidence IV.

Meniscal Ramp Repair: Double-Row Anatomic Repair in Acute Anterior Cruciate Ligament Tears.

The surgical management of medial meniscus ramp lesions can be challenging. Currently, repairs are performed via a trans-notch view, combined with a single posteromedial working portal. This technique, however, does not allow for a direct and complete visualization of the structures being injured, making a precise appreciation of the injured structures, as well as an anatomical repair, difficult. To overcome this limitation, a 2-portal posteromedial approach has recently been described. It allows better visualization of the mediolateral extent of the tear and a precise identification of the injured structures. In this Technical Note, an anatomic repair technique using this approach is presented. It consists of a double-row of sutures to repair individually both the meniscotibial and meniscocapsular ligament, thus restoring the 2 main components of the posterior horn of the medial meniscus to their natural insertion site.

ESSKA consensus initiative: why, when and how?

The goal of a Consensus in clinical practice is to provide daily practitioners with evidence- based recommendations on data from the literature, clinical expertise and expectations of professionals and patients. In this context, a consensus aligns with the principles of evidence-based medicine in clinical practice and is consequently regarded as a scientific work of a certain level of evidence (LOE). It is expected that such a project may contribute to filling the gap observed between scientific evidence and reality of the daily practice.A Clinical Consensus is particularly needed for those topics that are of interest to daily practice but controversial due to lack of evidence, and for which expert agreement can provide valuable support in reaching conclusions.A Consensus requires a strict methodology, based on two principles: an iterative process with independence of the involved groups and pluralism (geographical and professional representation). These processes guarantee the scientific quality of the recommendations.Among the various consensus modalities, ESSKA has adopted the Formal Consensus derived from the Delphi method, and the RAND/UCLA appropriateness method. These two methods are complementary. The first one, based on questions-answers sets, is particularly suitable for questions of terminology, diagnosis, planning, strategy. The second one is based on the concept of scenarios, particularly adapted to treatment indications. These two methods can also be used within the same consensus.The aim of this article is to define what is a consensus initiative, to detail the methodology ESSKA has chosen, and to point out the key role of the dissemination.

The posterior cruciate ligament-posterior femoral cortex angle (PCL-PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury.

PURPOSE: The posterior cruciate ligament-posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL-PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL-PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees. METHODS: Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6 months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL-PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB. RESULTS: Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL-PCA was 16.2° (Q1-Q3: 10.6-24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL-PCA was significantly lower (- 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL-PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres). CONCLUSION: The PCL-PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL-PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary. LEVEL OF EVIDENCE: III.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision. METHODS: Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document. RESULTS: The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article. CONCLUSION: ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults. LEVEL OF EVIDENCE: Level II.

Impact of COVID-19 Vaccination on Short-Term Perceived Change in Physical Performance among Elite Athletes: An International Survey.

COVID-19 vaccination raised concerns about its potential effects on physical performance. To assess the impact of COVID-19 vaccination on the perceived change in physical performance, we conducted an online survey among elite athletes from Belgium, Canada, France and Luxembourg, with questions about socio-demographics, COVID-19 vaccination, perceived impact on physical performance and perceived pressure to get vaccinated. Full vaccination was defined as two doses of mRNA or vector vaccine or a heterologous vaccine scheme. Among 1106 eligible athletes contacted, 306 athletes answered the survey and were included in this study. Of these, 72% perceived no change in their physical performance, 4% an improvement and 24% a negative impact following full COVID-19 vaccination. For 82% of the included athletes, the duration of the negative vaccine reactions was ≤3 days. After adjustment for potential confounding variables, practicing an individual sport, a duration of vaccine reactions longer than 3 days, a high level of vaccine reaction and the perceived pressure to get vaccinated were independently associated with a perceived negative impact on physical performance of more than 3 days after the vaccination. The perceived pressure to get vaccinated appears to be a parameter associated with the negative perceived change in the physical performance and deserves further consideration.

Ramp Lesions of the Medial Meniscus.

PURPOSE OF REVIEW: To provide an overview of the recent scientific literature about ramp lesions of the medial meniscus and to summarise the current evidence on their prevalence, classification, biomechanics, surgical techniques and clinical outcomes. RECENT FINDINGS: Ramp lesions may be present in more than 1 patient undergoing ACL reconstruction out of 5 and almost half of the medial meniscal tears observed in this population. Due to the risk of persistent anterior and rotational laxity after ACL reconstruction, their repair has been advocated. There is no general agreement to date on whether and when ramp lesions should be treated surgically. Comparative studies have failed to show that the repair of stable lesions was superior in comparison to nonoperative approaches. A lower failure rate and secondary meniscectomy has been reported with a suture hook repair through the posteromedial portal in comparison with an all-inside technique. Furthermore, reconstructions of the anterolateral complex in association with ACL reconstruction may have a protective effect on ramp repair. Ramp lesions of the medial meniscus in ACL-injured knees cannot be neglected anymore. Given their novelty, their clinical impact has not been fully assessed yet, but the evidence is growing that they need to be systematically identified and eventually repaired, for which they require advanced surgical knowledge. There is, to date, no consensus on whether and when ramp lesions should be treated surgically. Their subtypes, size and stability may influence the decision-making process.