CASE PRESENTATION: A 57-year-old man presented to our orthopedic outpatient department with 3-months history of an unusual painful swelling at the operated area following DFO. The leakage of joint fluid from the penetrated suprapatellar pouch was assumed to be the reason for this complication.
CONCLUSIONS: The overall aim of this case report is to provide a lesson to budding surgeons who might experience a similar situation that cannot be easily explained, like the unexpected complication in the present case.
METHODS: This is a dual-center randomized controlled trial (RCT). Sixty-nine patients aged 18 to 55 years with International Cartilage Repair Society grade 3 and 4 chondral lesions (size ≥3 cm2) of the knee joint were randomized equally into (1) a control group receiving intra-articular injections of HA plus physiotherapy and (2) an intervention group receiving arthroscopic subchondral drilling into chondral defects and postoperative intra-articular injections of PBSCs plus HA. The coprimary efficacy endpoints were subjective International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain subdomain measured at month 24. The secondary efficacy endpoints included all other KOOS subdomains, Numeric Rating Scale (NRS), and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores.
RESULTS: At 24 months, the mean IKDC scores for the control and intervention groups were 48.1 and 65.6, respectively (P < .0001). The mean for KOOS-pain subdomain scores were 59.0 (control) and 86.0 (intervention) with P < .0001. All other KOOS subdomain, NRS, and MOCART scores were statistically significant (P < .0001) at month 24. Moreover, for the intervention group, 70.8% of patients had IKDC and KOOS-pain subdomain scores exceeding the minimal clinically important difference values, indicating clinical significance. There were no notable adverse events that were unexpected and related to the study drug or procedures.
CONCLUSIONS: Arthroscopic marrow stimulation with subchondral drilling into massive chondral defects of the knee joint followed by postoperative intra-articular injections of autologous PBSCs plus HA is safe and showed a significant improvement of clinical and radiologic scores compared with HA plus physiotherapy.
LEVEL OF EVIDENCE: Level I, RCT.
METHODS: Three different cams (triangle, ellipse, and circle) and three different posts (straight, convex, concave) geometries were considered in this study and were analysed using kinematic analyses. Femoral rollback did not occur until reaching 50° of knee flexion. Beyond this angle, two of the nine combinations demonstrate poor knee flexion and were eliminated from the study.
RESULTS: The combination of circle cam with concave post, straight post and convex post showed 15.6, 15.9 and 16.1 mm posterior translation of the femur, respectively. The use of ellipse cam with convex post and straight post demonstrated a 15.3 and 14.9 mm femoral rollback, whilst the combination of triangle cam with convex post and straight post showed 16.1 and 15.8 mm femoral rollback, respectively.
CONCLUSION: The present study demonstrates that the use of circle cam and convex post created the best femoral rollback effect which in turn produces the highest amount of knee flexion. The findings of the study suggest that if the design is applied for knee implants, superior knee flexion may be possible for future patients.
LEVEL OF EVIDENCE: IV.
METHODS: Search was performed using a MEDLINE, EMBASE, and Cochrane database, and each of the selected studies was evaluated for methodological quality using a risk of bias (ROB) covering 7 criteria. Clinical and radiological outcomes with more than 5 years of follow-up were evaluated after surgical treatment of DLM. They were analyzed according to the age, follow-up period, kind of surgery, DLM type, and alignment.
RESULTS: Eleven articles (422 DLM cases) were included in the final analysis. Among 7 criteria, 3 criteria showed little ROB in all studies. However, 4 criteria showed some ROB ("Yes" in 63.6% to 81.8%). The minimal follow-up period was 5.5 years (weighted mean follow-up: 9.1 years). Surgical procedures were performed with open or arthroscopic partial central meniscectomy, subtotal meniscectomy, total meniscectomy, or partial meniscectomy with repair. The majority of the studies showed good clinical results. Mild joint space narrowing was reported in the lateral compartment, but none of the knees demonstrated moderate or advanced degenerative changes. Increased age at surgery, longer follow-up period, and subtotal or total meniscectomy could be related to degenerative change. The majority of the complications was osteochondritis dissecans at the lateral femoral condyle (13 cases) and reoperation was performed by osteochondritis dissecans (4 cases), recurrent swelling (2 cases), residual symptom (1 case), stiffness (1 case), and popliteal stenosis (1 case).
CONCLUSIONS: Good clinical results were obtained with surgical treatment of symptomatic DLM. The progression of degenerative change was minimal and none of the knees demonstrated moderate or advanced degenerative changes. Increased age at surgery, longer follow-up period, and subtotal or total meniscectomy were possible risk factors for degenerative changes.
LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.
METHODS: A total of 137 patients with 212 consecutive knees who underwent TKAs with or without functional stepwise MNP of superficial medial collateral ligament was recruited in this prospective cohort. Eighty-one patients with 129 knees who performed serial stress radiographs were enrolled in the final assessment. Superficial medial collateral ligament was punctured selectively (anteriorly or posteriorly or both) and sequentially depending on the site and degree of tightness. Mediolateral stability was assessed using serial stress radiographs and comparison was performed between the MNP and the non-MNP groups at postoperative 6 months and 1 year. Clinical outcomes were also evaluated between 2 groups.
RESULTS: Fifty-five TKAs required additional stepwise MNP (anterior needling 19, posterior needling 3, both anterior and posterior needling 33). Preoperative hip-knee-ankle angle and the difference in varus-valgus stress angle showed significant difference between the MNP and the non-MNP groups, respectively (P = .009, P = .037). However, there was no significant difference when comparing the varus-valgus stress angle between the MNP and the non-MNP groups during serial assessment. Clinical outcomes including range of motion also showed no significant differences between the 2 groups.
CONCLUSION: Functional medial ligament balancing with stepwise MNP can provide sufficient medial release with safety in TKA with varus aligned knee without clinical deterioration or complication such as instability.
LEVEL OF EVIDENCE: Level II, Prospective cohort study.
METHODS: This single-blind, prospective, randomized, controlled trial involved intraoperative measurements for 271 femoral component implantations from 3 contemporary TKA systems, with 2 systems offering narrow sizing options. The difference between femoral component dimensions and the resected surface of distal femur was measured in millimeters at 5 distinct zones.
RESULTS: Overhang of standard femoral component was common in the anterior-medial condyle and anterior-lateral condyle ranging from 50.8% to 99.0% and 21.5% to 88.0%, respectively. With narrow femoral components, the rate of overhang reduced to 21.5%-30.2% and 9.2%-32.1%. Conversely, underhang rates were higher over the anterior flange width, middle medial-lateral and posterior medial-lateral zones. Standard components displayed higher underhang rates at these zones compared to narrow components. The good fit rate for femoral component was low among the 3 systems ranging from 1.0% to 56.0%. System with narrow option sizing increases the underhang rates in males, while improving the component fit among females at similar zones with rate ranging from 5.2% to 52.9%.
CONCLUSION: Currently available TKA implant designs may not provide a perfect match for the distal femoral shape of the Korean population. The availability of implants with standard and narrow options can substantially improve the optimal fitting of femoral components in the Korean population.
METHODS: From April 2014 to December 2015, a total of 72 knees in 64 patients that underwent OWHTO, second-look arthroscopy, and magnetic resonance imaging (MRI) assessment, were enrolled. Preoperative and postoperative coronal and sagittal translation, joint line orientation angle, the distance between medial femoral notch marginal line and medial tibial spine, and PTS were evaluated. ACL status was arthroscopically graded from grade 1 (best) to 4 (worst). The MRI signal of the graft in three portions (proximal, middle, and distal) was graded from grade 1 (best) to 4 (worst).
RESULTS: High grade (3: partial, and 4: complete rupture) was noted in 28 cases (38.9%) at the second-look arthroscopy compared with 10 cases (13.9%) at index arthroscopy. The MRI signal grade significantly increased at follow up MRI compared with preoperative MRI (P<0.01). An increased signal was commonly noted in the middle and distal portions of the graft.
CONCLUSIONS: Geometric changes after OWHTO were related to ACL deterioration. The ACL was commonly affected at the middle and distal portions and rarely at the proximal portion. There is a possibility of impingement because of the geometric changes.
LEVEL OF EVIDENCE: Level IV.