Management of Iatrogenic Medial Collateral Ligament Injury in Primary Total Knee Arthroplasty: A Systematic Review.

Objectives: The medial collateral ligament (MCL) injury is one of the possible complications of primary total knee arthroplasty (TKA), which can lead to coronal-plane instability that requires surgical revision. Injured MCL can result in joint instability and polyethylene wear. Different strategies have been proposed for MCL reconstruction based on the location of the injury. However, there is a lack of clarity regarding the optimal method for handling an iatrogenic MCL injury throughout a TKA. Methods: A PRISMA flow diagram was used to guide the systematic literature review. An extensive search was conducted in PubMed, Embase, Scopus, Web of Science, and Google Scholar. Newcastle Ottawa scale checklist was used to assess the methodological quality of the articles. Results: A total of 19 qualitative studies, including non-cadaveric patients with MCL injury during TKA, were identified after analyzing the full text of the articles. All included studies were either retrospective, observational cohort or case series. A total of 486 patients were studied to gather information on the methods used to repair the MCL and their results. Most injuries arose in the tibial attachment, which surgeons mostly realized during the final stages of surgery. Used techniques can be categorized into three main groups: Primary repair, Repair with augmentation, and changing prosthesis characteristics. Conclusion: This systematic review demonstrated that the most popular management of iatrogenic MCL injury was using suture anchors, staples, screws and washers, and more constrained prostheses. The proper method should be decided considering the site of the MCL injury.

Is Posterior Cruciate Ligament Needle Pie-Crusting Safe and Effective in Balancing Cruciate-Retained Total Knee Arthroplasty? A Comparative Study.

Background: There is still debate over whether to sacrifice the posterior cruciate ligament (PCL) during total knee arthroplasty (TKA). Several studies reported the costs and benefits of each approach regarding technical difficulties in PCL balancing and postoperation complications. In this study, we aimed to evaluate PCL needling as a safe method for balancing the cruciate-retained TKA (CR-TKA). Methods: In this comparative study, 120 patients underwent CR-TKA and were divided into 2 groups. Fifty-four patients with an acceptable PCL tightness were included in group A, and 66 cases with a tight PCL were included in group B. In group B, needle pie-crusting of the PCL was performed instead of releasing the PCL from its insertions as the standard procedure. The participants' functional outcomes, pain severity, knee range of motion, and PCL laxity were evaluated during multiple follow-ups in 3 years postoperatively. Results: The participants' age, weight, and body mass index did not differ between the 2 groups. The mean age of the patients was 69 ± 5.9 years. The functional outcomes and range of motion of the patients in the 2 groups significantly improved after the operation compared to the preoperative status, but the postoperative score was not significantly different between groups (P > .05). Clinical examinations were normal in all patients in both groups in all follow-up stages. Conclusions: PCL balancing is a time-consuming yet essential step for the outcome of CR-TKA and patient satisfaction. PCL needling technique shows promising results and a few complications for PCL balancing in CR-TKA.

Cross­cultural adaptation and validation of the Persian version of the new Knee Society Knee Scoring System (KSS).

BACKGROUND: The new Knee Society Knee Scoring System (KSS) has been widely used to assess the symptoms, satisfaction, expectations, and physical activities of patients who undergo total knee arthroplasty (TKA). KSS has been translated and validated into many languages but not Persian. The aim of this study was to translate and evaluate the validity and reliability of the Persian version of the new KSS. METHODS: The Persian version of the new KSS was translated and culturally adapted according to international guidelines, including translation, back-translation, pre-testing, and expert committee review. A total of 142 patients scheduled to undergo TKA were included in this study and were asked to complete the Persian-KSS, Oxford Knee Score (OKS), and the Visual Analogue Scale (VAS) index both two weeks before the surgery and 6 months after the surgery. Face, content, and construct validity were evaluated to assess the validity of Persian-KSS. RESULTS: The Persian-KSS was comprehensive, indicating that the Persian version of KSS was clear and easy to understand for Persian-speaking patients undergoing TKA. The reliability of the Persian-KSS, assessed by Cronbach's alpha, was 0.894 and 0.800 for the pre- and post-operative stages, respectively. The intraclass correlation coefficient (ICC) assessed the test-retest reliability, which was 0.766 and 0.796 for the pre- and post-operative stages, respectively. The construct validity analysis of Persian-KSS demonstrated a statistically significant correlation between Persian-KSS and the OKS (r = - 0.935, p-value = 0.000 for the pre-operative stage, and r = - 0.809, p-value = 0.000 for the post-operative stage) and VAS index (r = - 0.401, p-value = 0.001 for the pre-operative stage and r = - 0.259, p-value = 0.029 for the post-operative stage). CONCLUSION: The Persian-KSS, developed after the translation and cross-cultural adaptation process, was proven to be a reliable and valid assessment measure for those who undergo TKA.

High Tibial Osteotomy Effects on Subtalar Joint in Patients with Genu Varum.

Background: osteotomy around the knee is one of the most common corrective surgeries for lower limb deformities. The exact relationship between the effects of these surgeries on the ankle joint is unclear.This study aimed to investigate the effect of HTO on the subtalar joint in patients with genu varum. Methods: In the case series study33 patients including 27.2% men and 72.7% womenwith an average age of 41.9, with genu varum who underwent corrective surgery of open wedge high tibial osteotomy were studied. the heel alignment angle was determined before and after surgery in 10-months follow-up based on Saltzman view in conventional radiography. The data were then compared. Results: Average genu varum correction angle was 11.9±1.3°. Heel alignment degree was 5.9±1.3° before HTO surgery, and after the surgery,in final follow-up,it was to 3.4±1.2° valgus, this value was statisticallysignificant(p=0.04). Moreover, there was a significant statistical relationship between average correction of Varus deformity and heel alignment anglechanges (P=0.02, r=0.3). Conclusion: Correcting Varus knee deformity can be effectiveon heel alignment angle in patients undergoing HTO surgery with genu varum. The angle of the subtalar valgus decreases as a result.

The 'low-volume acetabulum': dysplasia in disguise.

Although there are well described radiological criteria for diagnosing DDH, our experience has highlighted that a new sub-category of hips exists in which the classic radiographic characteristics for DDH may be normal but the coverage of the femoral head is compromised. The purpose of this study was to validate a simple radiographic measurement method for calculating the depth of the acetabulum in order to detect individuals with 'low-volume' acetabuli and under-covered femoral heads. We identified 24 patients who were suspected of having low-volume acetabuli and compared their radiographs with those of 150 patients with non-dysplastic hips. The radiographic indices measured included the lateral center-edge (CE) angle, the anterior CE angle, the femoral neck-shaft angle, the extrusion index, integrity of the Shenton's line, the crossover sign, and ischial spine sign. We have developed a novel, but a simple method, named the 'coverage index' (CI) to identify the presence of a low-volume acetabulum on plain radiographs. Comparisons were made between the low-volume hips and the non-dysplastic hips. The radiographic parameters indicative of developmental dysplasia of the hip (DDH) were within normal limits in all patients with low-volume acetabuli and therefore these hips could not be classified as 'dysplastic' based on the traditional radiological parameters. There was no difference between the mean radius of the femoral head in two groups. The mean CI was significantly greater in the non-dysplastic group compared with the low-volume acetabula cohort (1.62 ± 0.117 in non-dysplastic group versus 1.07 ± 0.11 in low-volume hips) (P = 0.0001). Orthopaedic surgeons should be aware of a hip abnormality in which the femoral head coverage is deficient, yet all the conventional parameters for measuring coverage, including the center edge angle, are within normal limits. We have introduced a simple radiographic measurement method that may help surgeons identify these patients using the anteroposterior radiographs of the hip.

Evaluation of Changes in the Tibiotalar joint after High Tibial Osteotomy.

BACKGROUND: There are limited studies regarding the effects of high tibial osteotomy (HTO) on other areas of lower extremity. In current study, we investigated the changes of tibiotalar joint following HTO. METHODS: A total of 39 patients with genu varum requiring HTO were enrolled in this before and after study. The genu varus, joint diversion (JDA), lateral distal tibial (LDTA) and lateral distal tibial-ground surface (LDT-GSA) angles were measured before the operation and compared with 6 months after the surgery. RESULTS: Twenty threeout of39 patients (59%) were females. The genu varus angle decreased significantly (13°±1.7° versus 0.6°±1°). No significant changes were seen in JDA (P=0.45) and LDTA (P=0.071). LDT-GSA changed significantly (P=0.011) from 8.1°±1° in varus to -0.3°±0.5° in valgus. CONCLUSION: Although HTO did not change the JDA and LDTA, however, significant change in LDT-GSAindicates that HTO can significantly decrease the shearing forces exerted on the ankle joint.

Modified retro-tubercle opening-wedge versus conventional high tibial osteotomy.

Despite the fact that common surgical techniques for the treatment of genu varum usually correct the malalignment in the affected knee, these methods have significant complications and cause problems in the long term. Retro-tubercle opening-wedge high tibial osteotomy is among the newer techniques for the treatment of genu varum. The goal of this study was to compare the results of retro-tubercle opening-wedge high tibial osteotomy with those of medial opening-wedge osteotomy. In a randomized, controlled trial, 72 patients with varus knees who were scheduled for surgery were assigned into either the retro-tubercle opening-wedge high tibial osteotomy (n=34) or medial opening-wedge osteotomy groups (n=38). Groups were matched for age and sex. The position of the patella was compared with respect to the tuberosity and the upper tibial slope pre- and postoperatively. Patients were followed for an average of 13 months (range, 10-21 months). In the retro-tubercle opening-wedge high tibial osteotomy group, the length of the patellar tendon did not significantly differ pre- and postoperatively (P≥.5); however, in the medial opening-wedge osteotomy group, a statistically significant shortening was noted in patellar tendon postoperatively (P≤.05). Similarly, the tibial plateau inclination showed a statistically significant difference postoperatively in the medial opening-wedge osteotomy group, while the difference in the retro-tubercle opening-wedge high tibial osteotomy group did not reach statistical significance.