Limitations of the knee society score in kinematically aligned total knee arthroplasty.

Purpose: The Knee Society Scoring System (KSS) is a frequently used outcome score which quantifies functional patients' outcomes before and after total knee arthroplasty (TKA). Several problems arise when trying to implement KSS for obtaining postoperative outcomes after more personalised aligned TKAs. Scoring for valgus femorotibial angle (FTA) intervals outside moderate ranges is often poorly explained, the specific version of KSS used for outcome collection is frequently unclear and the exact measuring methods are typically not described in the literature. The aims of this systematic review were to investigate the latest user practice, the application of KSS and its limitations after kinematically aligned (KA) TKA. Methods: A systematic literature search following PRISMA guidelines was conducted on PubMed, Embase, Medline and Scopus to identify potentially relevant articles for this review, published from the beginning of January 2013 until the end of January 2023. Broad Mesh terms such as 'kinematic alignment', 'total knee arthroplasty' and 'knee society score' were used for building search strategy in each database accordingly. Articles reporting postoperative values of the objective surgeon-assessed KSS after KA TKA or KA and mechanically aligned TKA were included. For assessing included randomised control trials (RCTs), an Agency for Healthcare Research and Quality's design-specific scale for assessing RCTs was used. The non-RCTs were assessed by using the Joanna Briggs Institute Critical Appraisal Tool. The Ottawa-Newcastle Score system was also used. Studies were additionally evaluated for their radiological methodology by using a five-question checklist (Radiological Assessment Qualit criteria). Results: The initial search identified 167 studies, of which 129 were considered for screening. Ten studies reporting outcomes after KA TKA did not use the objective surgeon-assessed part of KSS for clinical outcome measurement, and 30 studies reporting outcomes after KA TKA did not use KSS at all for clinical and/or functional outcomes. From the 10 included studies, only six have used the latest KSS score (2011), the rest using its 1989 variant; and out of these six studies, only two presented values of the FTA, which is needed for calculating the KSS's 'alignment' subcomponent, the rest presenting hip-knee-ankle angle (HKA) values. Additionally, when converting these HKA values to FTA intervals, the authors of this systematic review found that KA TKA FTA intervals display limits, which tend to be outside the 'well-scored' KSS anatomical alignment interval. Conclusion: The inconsistent and nonstandardised use of the surgeon-assessed KSS across studies reviewed compromises assessment reliability and patient outcome scores. To enhance precision and comparability, it is crucial to standardise the KSS application, incorporating personalised alignment strategies for more accurate patient evaluations. Level of Evidence: Level III.

Only 26% of Native Knees Show an Identical Coronal Functional Knee Phenotype in the Contralateral Knee.

BACKGROUND: A comprehensive exploration evaluating left-to-right knee symmetry across all anatomical planes utilizing three-dimensional (3D) scans stands absent from the existing body of research. Therefore, the primary objectives of this investigation involved examining potential differences and resemblances in alignment and structure between left and right non-osteoarthritic (native) knees in various planes (coronal, sagittal, and axial) using three-dimensional single-photon emission computed tomography/computed tomography (SPECT/CT) images. METHODS: A total of 282 native knees from 141 patients were retrospectively gathered from the hospital's records. Patients, aged between 16 and 45, who underwent Tc99m-methyl diphosphonate SPECT/CT scans for both knees, adhering to the Imperial Knee Protocol, were included. A statistical analysis was conducted, including 23 knee morphometric parameters, comparing left and right knees, and classifying them based on functional knee phenotypes across the coronal, sagittal, and axial planes. RESULTS: Regarding the functional coronal knee phenotype, 26% of patients (n = 37) exhibited identical phenotypes in both knees (p < 0.001). Significant correlated similarities between the left and right knees were observed in the coronal plane (Pearson's r = 0.76, 0.68, 0.76, 0.76, p < 0.001) and in several morphometric measures in the sagittal plane (Pearson's r = 0.92, 0.72, 0.64, p < 0.001). Moderately correlated similarities were noted in the axial plane (Pearson's r = 0.43, 0.44, 0.43, p < 0.001). CONCLUSIONS: Only 26% of native knees exhibit an identical coronal phenotype in their contralateral knee, whereas 67% have the adjacent coronal phenotype. Strongly correlated resemblances were established across various left and right knee morphometric parameters in the coronal, sagittal, and axial planes. These findings could enhance decisions in procedures like total knee arthroplasties or osteotomies, where alignment is key to outcomes, and reveal a potential for future artificial intelligence-driven models to improve our understanding and improve personalized treatment strategies for knee osteoarthritis.

The "Candy-Stripe" Graft for Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is a common surgical procedure; however, graft failure with recurrent instability occurs in a significant percentage of patients. One known predictor of suboptimal outcomes is the diameter of the ACL graft, with grafts less than 8 mm in diameter associated with poorer outcomes. Factors such as graft harvest technique, preparation, and biological remodeling can also affect success. In this regard, a technique for biological ACL reconstruction is presented with a graft preparation protocol called "candy-stripe." This technique involves preserving muscle remnants on the graft and the tibial ACL stump, resulting in a better graft volume, regenerative potential, and knee function. The article presents the step-by-step surgical technique, which differs from the standard technique in some steps. Hamstring tendons are harvested, and the graft is sized and prepared, with up to 1 mm of muscle tissue left attached to the tendon. This technique has the potential to improve the outcomes of ACL reconstruction surgeries.

Significant correlations between postoperative outcomes and various limb and component alignment strategies in medial unicompartmental knee arthroplasty: a systematic review.

PURPOSE: To investigate the correlation between postoperative limb/component alignments and clinical/functional outcomes following medial unicondylar knee arthroplasty (mUKA). METHODS: Inclusion criteria included peer-reviewed English- or German-language publications assessing postoperative limb or implant alignment and clinical outcomes of mUKA. Methodological Index for Non-Randomized Studies (MINORS) was used to assess article quality. RESULTS: A total of 2767 knees from 2604 patients were evaluated. Significant correlations were observed between postoperative limb/component alignments and clinical/functional outcomes after mUKA. Inferior outcomes were associated with lower placement and excessive valgus alignment of the tibia component (> 3°). A recommended external rotation of 4°-5° was identified for the tibia component, with specific cut-off values for the femoral and tibia components. CONCLUSIONS: Optimal outcomes in mUKA were associated with a varus coronal limb alignment. The tibia implant component performed well within a specific alignment range. An exact external rotation value was recommended for the tibia component, while internal rotation correlated negatively with the femoral component. LEVEL OF EVIDENCE: IV (level IV retrospective case series were included).

Patellofemoral arthroplasty with onlay prosthesis leads to higher rates of osteoarthritis progression than inlay design implants: a systematic review.

PURPOSE: The aim of this study was to report the clinical and functional outcomes, complication rates, implant survivorship and the progression of tibiofemoral osteoarthritis (OA), after new inlay or onlay patellofemoral arthroplasty (PFA), for isolated patellofemoral OA. Comparison of different implant types and models, where it was possible, also represented one of the objectives. METHODS: A systematic literature search following PRISMA guidelines was conducted on PubMed, Scopus, Embase and Cochrane databases, to identify possible relevant studies, published from the inception of these databases until 11.11.2022. Randomized control trials (RCTs), case series, case control studies and cohort studies, written in English or German, and published in peer-reviewed journals after 2010, were included. Not original studies, case reports, simulation studies, systematic reviews, or studies that included patients who underwent TKA or unicompartmental arthroplasty (UKA) of the medial or lateral compartment of the knee, were excluded. Additionally, only articles that assessed functional and/or clinical outcomes, patient-reported outcomes (PROMs), radiographic progression of OA, complication rates, implant survival rates, pain, as well as conversion to TKA rates in patients treated with PFA, using inlay or onlay trochlea designs, were included. For quality assessment, the Methodological Index for Non-Randomized Studies (MINORS) for non-comparative and comparative clinical intervention studies was used. RESULTS: The literature search identified 404 articles. 29 of them met all the inclusion criteria following the selection process. Median MINORS for non-comparative studies value was 12.5 (range 11-14), and for comparative studies 20.1 (range 17-24). In terms of clinical and functional outcomes, no difference between onlay and inlay PFA has been described. Both designs yielded satisfactory results at short, medium and long-term follow-ups. Both designs improved pain postoperatively and no difference between them in terms of postoperative VAS has been noted, although the onlay groups presented a higher preoperative VAS. When comparing the inlay to onlay trochlea designs, the inlay group displayed a lower progression of OA rate. CONCLUSION: There is no difference in functional or clinical outcomes after PFA between the new inlay and the onlay designs, with both presenting an improvement in most of the scores that were used. A higher rate of OA progression was observed in the onlay design group. LEVEL OF EVIDENCE: III.

Verasense sensor-assisted total knee arthroplasty showed no difference in range of motion, reoperation rate or functional outcomes when compared to manually balanced total knee arthroplasty: a systematic review.

PURPOSE: The aim of this systematic review was to investigate the clinical and functional knee outcomes after Verasense sensor-assisted total knee arthroplasty (VA TKA), and to compare these outcomes, where possible, with those from manually balanced total knee arthroplasty (MB TKA). METHODS: A systematic literature search following PRISMA guidelines was conducted on PubMed, Embase, Medline and Scopus from the beginning of January 2012 until the end of June 2022, to identify potentially relevant articles for this review. Selection was based on the following inclusion criteria: full text English- or German-language clinical studies, published in peer-reviewed journals, which assessed clinical and functional outcomes following VA TKA. Not original research, preprints, abstract-only papers, protocols, reviews, expert opinion papers, book chapters, surgical technique papers, and studies pertaining only to unicondylar knee arthroplasty (UKA) or patellofemoral arthroplasty (PFA) were excluded. Several scores (Knee Society Score [KSS], Oxford Knee Score [OKS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Knee injury and Osteoarthritis Outcome Score-4 subscales [KOOS4] and Physical Function-Computerised Adaptive Testing [PF-CAT]), alongside postoperative measurements of range of motion [ROM], reoperation rates and the rate of manipulation under anaesthesia [MUA]) were used to evaluate clinical and functional outcomes. The quality of included papers, except randomised control trials (RCTs), was evaluated using the Methodological Index for Non-Randomised Studies (MINORS). For the assessment of included RCTs, the Jadad Scale was used. RESULTS: The literature search identified 243 articles. After removing duplicates, 184 papers were included in the initial screening process. Fourteen of them met all the inclusion criteria following the selection process. Mean MINORS for non-comparative studies value was 11.5 (11-12), and for comparative studies 18.2 (13-21). Mean Jadad Scale score was 3.6 (2-5). Outcomes from a total number of 3633 patients were evaluated (mean age at surgery 68.5 years [32-88 years]). In terms of clinical outcomes, the overwhelming majority of studies observed an improvement after VA TKA, but no statistically significant difference in ROM and reoperation rate when compared to MB TKA. On the other hand, lower rates of MUA have been described in the VA TKA group. An increase in postoperative clinical and functional scores values, when compared to the preoperative ones, has been reported in both groups, although no statistically significant difference between them has been observed. CONCLUSION: The use of Verasense pressure sensors in TKA leads to no significant improvement in ROM, reoperation rate or functional outcomes, when compared to the standard manually balancing technique. However, lower rates of MUA have been described in the VA TKA group. These findings highlight the importance of tools being able to measure ligament stresses or joint pressure for achieving an optimally balanced knee. LEVEL OF EVIDENCE: III.

The menisci and articular cartilage: a life-long fascination.

The menisci and articular cartilage of the knee have a close embryological, anatomical and functional relationship, which explains why often a pathology of one also affects the other.Traumatic meniscus tears should be repaired, when possible, to protect the articular cartilage.Traumatic articular cartilage lesions can be treated with success using biological treatment options such as microfracture or microdrilling, autologous chondrocyte transplantation (ACT), or osteochondral transplantation (OCT) depending on the depth and area of the lesion.Degenerative cartilage and meniscus lesions often occur together, and osteoarthritis is already present or impending. Most degenerative meniscus lesions should be treated first conservatively and, after failed conservative treatment, should undergo arthroscopic partial meniscus resection. Degenerative cartilage lesions should also be treated conservatively initially and then surgically; thereby treating the cartilage defect itself and also maintaining the axis of the leg if necessary.Tears of the meniscus roots are devastating injuries to the knee and should be repaired e.g. by transtibial re-fixation.The clinical role of 'ramp' lesions of the meniscus is still under investigation. Cite this article: EFORT Open Rev 2020;5:652-662. DOI: 10.1302/2058-5241.5.200016.