Intraoperative changes in medial joint gap after posterior femoral condylar resection,posterior osteophyte removal,and femoral component placement during primary total knee arthroplasty

Background“Mid-flexion stability” is important for superior patient satisfaction following total knee arthroplasty (TKA). Thus, it is important to control medial joint gap intraoperatively as a countermeasure. However, reports on the precise intraoperative changes in medial joint gap during TKA are scarce. This study evaluated the intraoperative changes in medial joint gap during TKA.MethodsWe studied 167 knees with varus osteoarthritis that underwent 80 cruciate-retaining (CR) and 87 posterior-stabilized (PS) TKAs between January 2018 and December 2020. We measured the intraoperative changes in medial joint gap with a tensor device at 137.5 N.ResultsThe medial joint gap after posterior femoral condylar resection was significantly increased not only at 90° of flexion but also at 0° of extension in CR and PS TKAs (p < 0.01). The medial joint gap after posterior osteophyte removal was significantly increased not only at 0° of extension but also at 90° of flexion in CR and PS TKAs (p < 0.01). The medial joint gap at 0° of extension was reduced by 0.60 mm after femoral component placement in PS TKA.ConclusionSurgeons need to pay close attention to these intraoperative changes in medial joint gap by measuring the medial joint gap before and after each procedure or assuming the changes in those values before bone cutting to achieve superior patient satisfaction following TKA.     

CR-lipped bearing is an adequate functional solution to patients with perioperative excessive laxity in cruciate retaining total knee arthroplasty

BackgroundThe cruciate retaining lipped (CR-lipped) bearing is designed to provide more anterior-posterior (AP) stability and could be employed to resolve excessive intraoperative laxity during the cruciate retaining TKA (CR-TKA). The aim of the study was to determine whether the CR-lipped bearing in CR-TKAs with a perioperative excessive laxity allows equivalent functional results as compared to the standard CR articulation.MethodsA cohort of 111 TKAs with CR-lipped bearings was matched to a cohort of conventional CR bearings regarding age and sex. The CR-lipped bearing was used in patients with excessive knee AP laxity and the regular CR bearing was used in patients without excessive AP laxity during TKA. Various PROMs (WOMAC, KSS, SF-36) were assessed preoperatively and at 5-years postoperative in combination with revision rate and Range of Motion (ROM).ResultsPROMs did not differ significantly between both groups 5-years postoperatively. Mean ROM (flexion) 5-years postoperatively was not significantly different. The implant survivorship was 100% for both cohorts with revision for any reason as end point.ConclusionBased on these results, the CR-lipped bearing is a safe and effective solution for mild interoperatively assessed PCL laxity during CR-TKA without loss of function or decreased survivorship at 5 years. Peroperative conversion to a PS-TKA in order to obtain satisfactory functional scores might therefore not be necessary when mild PCL laxity is observed during surgery. Further research should focus on verifying this approach and longer follow-up is needed to generate data on long term survivorship.Level of evidenceLevel IV therapeutic, retrospective, cohort study.     

Mid-term results of complex primary total knee arthroplasty using a rotating-hinge implant

BackgroundThe indications and outcomes of semi- or fully-constrained knee implants in primary total knee arthroplasty (TKA) are still controversially discussed. The present study aims to evaluate the mid-term results and complications of a modular/non-modular rotating-hinge implant in complex primary TKA.MethodsEighty-two patients (86 knees) following primary TKA were retrospectively evaluated with a mean follow-up of 63 months. The functional outcome was assessed using the American Knee Society Score (AKSS) and the Oxford Knee Score (OKS). A Visual Analog Scale (VAS) was used to determine pain levels. Implant survival and reoperation rates were estimated using competing risk analysis. Cox regression analysis was performed to evaluate the influence of modularity on implant survival.ResultsThe survival rate with the endpoint implant revision was 90% (95 %CI:83–98%) and the survival rate with the endpoint all reoperations was 84% (95 %CI:75–94%) at 7 years. The AKSS improved significantly from 24 (SD 14.9, range:0–69) preoperatively to 83 (SD 14.3, range:57–100) postoperatively (p < 0.001); functional AKSS improved significantly from 27 (SD 24.3, range:0–100) to 46 (SD: 32.9, range 0–100) (p = 0.003), and OKS from 19 (SD: 8.3, range:5–43) to 29 (SD: 10.7, range:6–48), respectively (p < 0.0001). VAS decreased significantly from 8 (SD: 2.6, range:0–10) preoperatively to 3 (SD: 2.9, range:0–9) postoperatively (p < 0.0001). There was no significant influence of modularity on revision rates comparing modular to non-modular implants (p = 0.072).ConclusionsThe present rotating-hinge implant provides substantial improvement in function and reduction of pain with good implant survival in the mid-term. Modularity was not associated with higher rates of revision.     

Comparison of the clinical and patient-reported outcomes between medial stabilized and posterior stabilized total knee arthroplasty: A systematic review and meta-analysis

BackgroundTotal knee arthroplasty (TKA) is effective in relieving pain and improving function in patients with end-stage knee osteoarthritis. Both medial stabilized total knee arthroplasty (MS-TKA) and posterior stabilized total knee arthroplasty (PS-TKA) can achieve satisfactory clinical results, but comparisons between MS-TKA and PS-TKA have yielded contradictory conclusions. This systematic review and meta-analysis were performed to investigate the differences in clinical and patient-reported outcomes (PROMs) between MS-TKA and PS-TKA.MethodsIn December 2020, systematic searches of the following databases were undertaken: Pubmed, Embase, Cochrane Library, Clinical Trials.gov. Studies with PROMs comparing MS-TKA to PS-TKA were included. Meta-analysis was conducted for range of motion (ROM), Knee Society Score (KSS), Knee Society Functional Score (KFS), Forgotten Joint Score (FJS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Oxford Knee Score (OKS).ResultsThere were 17 studies included in this review, 13 studies used for quantitative analysis, and 4 studies used for qualitative synthesis. Meta-analysis concluded that the WOMAC mean difference (MD) for MS-TKA was 1.55 higher than for PS-TKA (MD = −1.55; 95 %CI = −2.45 to −0.64, P = 0.0008); however, this difference was less than the minimum clinically important difference (MCID) value of 15. Assessment using the OKS determined that the MD for PS-TKA was 0.58 higher than for MS-TKA (MD = 0.58; 95 %CI = 0.25 to 0.91, P = 0.0006); again, this MD was less than the MCID value of 5. There were no significant differences between MS-TKA and PS-TKA when assessed by ROM (P = 0.23), KSS (P = 0.13), KFS (P = 0.61), or FJS (P = 0.22).ConclusionDerived from numerous sources, utilizing a multitude of validated functional and patient-reported outcome assessment tools, there was no clinically evident advantage of MS-TKA compared to PS-TKA.RegistrationThe registration number on PROSPERO is CRD42021228555.     

Assessment of popliteal neurovascular safety during all-inside suturing of the posterior horn of the lateral meniscus using Upright MRIs of the knee joint

BackgroundTo examine the risk of injury to the popliteal neurovascular bundle (pNVB) during all-inside repair of the posterior horn of the lateral meniscus (PHLM) using Upright-MRIs.MethodsUpright-MRIs of 61 knees in extension (ext) and 90°-flexion (flex) were included. Distance D from the PHLM to the pNVB was compared between extended and 90°-flexed position, subgroups with/without joint-effusion and evaluated according to demographics. Portal safety was assessed simulating suturing of the PHLM via four arthroscopy portals. Distance d (shortest space from the simulated suturing-device trajectory lines to the pNVB) was compared among portals in increasing distances from the posterior cruciate ligament (PCL).ResultsD is longer in flex (17.3 ± 6.0 mm) than in ext (11.3 ± 4.2 mm, p < 0.0001). MRIs with joint-effusion displayed longer values of D than scans without joint-effusion (flex: 20.4 ± 7.1 mm vs. 16.1 ± 5.2 mm, p = 0.012). Shorter distances are associated with female gender, lower body weight and lower BMI. At 0 mm from the PCL, the 1 cm-lateral portal was the safest (p < 0.0001) whereas at 3 mm/6mm/9mm/12 mm the 1 cm-medial portal showed the longest d values (p < 0.0001 each).ConclusionAll-inside suturing of the PHLM is safer in 90°-flexion, in presence of intraarticular fluid and in male patients with increasing weight/BMI. Sutures of the PHLM at 0 mm from the PCL are safer from a 1 cm-lateral portal whereas for tears located ≥ 3 mm from the PCL a 1 cm-medial portal involves a lower neurovascular risk. Upright-MRI proves excellent for preoperative planning to minimize neurovascular risks.     

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial

BackgroundUltrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.MethodsSeventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.ResultsThere was no difference in pain score during movement between the groups (mean difference −0.48 [−1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.ConclusionsThe SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.     

A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE

BackgroundHigh physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3–10 years) and long term (>10 years) follow up in patients with TKA.MethodsDatabases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.ResultsFive cohort studies and one case–control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4–12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24–1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34–5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2–4.7, level of certainty: low).ConclusionDuring the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.     

Fast-track revision knee arthroplasty.

BackgroundLimited data exist on fast-track protocols in relation to revision knee arthroplasty. Hence, the aim of this study was to report length of stay (LOS), risk of LOS > 5 days and readmission ≤ 90 days after revision knee arthroplasty in centers with a well-established fast-track protocol in both primary and revision surgery.MethodsAn observational cohort study from the Centre for Fast-track Hip and Knee Replacement and the Danish Knee Arthroplasty Register. We included elective aseptic major component revision knee arthroplasties consecutively from 6 dedicated fast-track centers from 2010 to 2018.Results1439 revision knee arthroplasties were analyzed, including 900 total revisions, 171 large partial revisions (revision of either femoral or tibia component) and 368 revisions of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA). Mean age was 65 years (SD 10.9) and 66% were females. Mean LOS was 3.7 days (SD 3.9) in the study period, but decreased to 2.4 days (SD 1.3) in 2018. Risk factors for LOS > 5 days was ≥ 1 previous revision, use of walking aid, BMI > 35, ages < 50, 70–79 and ≥ 80 years, whereas revision of UKA to TKA and large partial revision were negatively associated. The 90-day readmission and mortality risk was 9.1% and 0.5%. Cardiac disease and use of walking aid were associated with increased risk of readmission ≤ 90 days.ConclusionElective aseptic major component revision knee arthroplasty using similar fast-track protocols as in primary TKA is safe with short and decreasing LOS.     

Approximately 80% of Japanese osteoarthritic patients fall out of the safety range in restricted kinematically-aligned total knee arthroplasty in an analysis of preoperative long-leg radiograms

BackgroundRestricted kinematically-aligned total knee arthroplasty (KA-TKA) is a reasonable modification to avoid the alignment outlier that may cause implant failure. However, despite a noted high incidence of constitutional varus in Japanese individuals, there has been no investigation into how many knees require the restriction in restricted KA-TKA (RKA-TKA) among Japanese patients. Therefore, we conducted a study using preoperative long-leg radiograms.MethodsWe studied long-leg radiographs of 228 knees in 114 consecutive patients. The numbers of knees within the safety range and their corrective osteotomy angle in the restriction algorithms advocated by Almaawi et al. (2017) and MacDessi et al. (2020) were evaluated.ResultsAccording to the algorithms used by Almaawi et al. and MacDessi et al., out of 228 knees, 46 (20%) and 39 (17%) fell within the safety range, respectively. The mean correction angles of the hip-knee-ankle angle, lateral distal femoral angle and medial proximal tibial angle were 2.8 ± 3.4°, 0.4 ± 1.4° and 2.4 ± 2.8° in the algorithm used by Almaawi et al., while they were −4.9 ± 4.7°, 1.1 ± 2.5° and −6.0 ± 3.4° in the algorithm used by MacDessi et al. Most of the knees needed to be restricted in order to perform RKA-TKA, regardless of the algorithm used.ConclusionsBased on a preoperative analysis of long-leg radiograms in a Japanese population, most knees fall out of the safety range in RKA-TKA. Surgeons must consider whether to allow component outlier or to perform corrective osteotomy that likely requires soft tissue release.     

A posterior anchoring method decreases pullout suture translation of the medial meniscus posterior root repair during knee flexion

BackgroundThe medial meniscus (MM) translates posteriorly and extrudes severely from the medial tibial plateau (MTP) during knee flexion in the MM posterior root tear (PRT) knee. Transtibial pullout repair of the MMPRT has been performed to regulate MM extrusion. This study aimed to evaluate pullout suture translation during knee flexion before and after posterior anchoring during pullout repair. We hypothesized that suture translation after posterior anchoring would be significantly decreased relative to that before posterior anchoring.MethodsThirty-five patients who underwent MM posterior root repair were prospectively investigated. Pullout repair was performed using two cinch sutures (outer and inner sutures) and posterior anchoring through the MM posterior horn and an additional bone tunnel on the MTP. The translation of the outer suture from 0° to 90° of knee flexion was measured and compared before and after posterior anchoring intraoperatively. The MM morphologic features were measured using preoperative magnetic resonance imaging, and the correlation between these values and outer suture translation was evaluated.ResultsThe average outer suture translation after posterior anchoring (1.6 ± 1.5 mm) was significantly decreased relative to that before posterior anchoring (2.5 ± 1.7 mm, P < 0.01). No significant correlations were observed between the MM morphological features and outer suture translation.ConclusionsThe posterior anchoring method with an MM posterior root repair is useful in decreasing posterior translation of the pullout suture during knee flexion, which might have an advantage in preventing suture pullout from the repaired MM, leading to good clinical outcomes.     

Evaluation of different coatings of the tibial tray in uncemented total knee arthroplasty. A randomized controlled trial with 5 years follow-up with RSA and DEXA

BackgroundRegenerex® is a porous titanium construct with a 3D interconnecting pore structure and biomechanical characteristics close to that of normal trabecular bone. This study aimed to compare the Regenerex (VR) to the non-interconnecting pore structure Porous Plasma Spray (VP) on tibial implants for total knee arthroplasty (TKA) at 5 years.MethodsWe enrolled and randomized 61 patients (mean age = 63(49–71) years, Female/Male = 35/26) who were planned for an uncemented Vanguard TKA (Biomet, Warsaw, Indiana, USA) to receive either a VR or a VP coated tibial component (31/29). We performed radiostereometric analysis (RSA) and Dual Energy X-ray Absorptiometry (DEXA) postoperatively, and at three, six, 12, 24 and 60 months with measurements of migration. In total 55 patients attended the 5-year follow-up.ResultsOne patient died and four were reoperated during the 60-months period; none due to aseptic loosening. All reoperations were in the VR-group. The mean (range) 60-months MTPM was 1.4 mm (0.5–3.7) for the VP-group and 1.8 mm (0.4–4.9) for the VR-group (p = 0.8). The 24 to 60-months mean (range) MTPM was −0.3 mm (−5 to 1.24) in the VP-group and 0.2 mm (−0.4 to 3.5) in the VR-group (p = 0.8).ConclusionWe did not find any statistically significant differences between the VP- and VR-group and both groups show recognizable migration. We will continue to follow the groups for years to come.     

Usefulness of gait parameters obtained from inertial sensors attached to the lower trunk and foot for assessment of gait performance in the early postoperative period after total knee arthroplasty

BackgroundThis study was performed to (i) compare gait parameters obtained from inertial sensors attached to the lower trunk and foot between patients in the early postoperative period after total knee arthroplasty (TKA) and healthy age- and sex-matched controls and (ii) elucidate the association between the gait parameters and patient-reported outcome measures (PROMs).MethodThe gait performance of 19 patients who had undergone TKA was assessed using inertial sensors and PROMs obtained from the Knee Injury and Osteoarthritis Outcome Score (KOOS) 1 week before hospital discharge. The patients walked along a 15-m walkway and we calculated the following gait parameters: walking speed, coefficient of variation (CV) of stride time, unbiased autocorrelation coefficient (AC), harmonic ratio (HR), and symmetry index (SI). The same gait parameter data from 19 age- and sex-matched healthy adults (controls) were obtained from our past study.ResultsThe TKA group demonstrated slower walking speed, larger CV of stride time, lower HR in all three directions, lower AC in the vertical direction, and higher SI in the vertical direction than the healthy control group (all p < 0.05). Correlation analysis revealed that the SI in the anteroposterior direction was significantly correlated with the KOOS symptoms subscore and ADL subscore (p < 0.05).ConclusionsPatients in the early postoperative period after TKA exhibited worse gait performance as assessed by inertial sensors compared with healthy controls. Gait symmetry was correlated with PROMs. These results indicate the usefulness of assessing gait parameters after TKA.     

Preoperative morphologic changes of the medial meniscus correlate with suture translations during knee flexion in pullout repair of medial meniscus posterior root tear

BackgroundMedial meniscus (MM) translates and extrudes posteriorly during knee flexion in MM posterior root tear (MMPRT) knees, and transtibial pullout repair of MMPRT has been performed to regulate the MM extrusion. This study aimed to calculate each suture translation during knee flexion in transtibial pullout repair of MMPRT, and to investigate the morphologic features of the MM that lead to longer suture translations during knee flexion.MethodsThirty patients with MMPRT who met the operative indication of pullout repair were enrolled and investigated prospectively. Pullout repair was performed by using two simple stitches (outer and inner sutures) and an all-inside suture in the posteromedial part of the MM. Each suture’s translation from 0° to 90° of knee flexion was measured intraoperatively. The MM morphologic features, including MM medial extrusion (MMME) and MM posterior height (MMPH), were measured using preoperative magnetic resonance imaging, and the correlation between these values and each suture translation was evaluated.ResultsThe average outer, inner, and all-inside suture translations were 4.8 mm, 3.9 mm, and 1.3 mm, respectively. Significant correlations were observed between the outer suture translation and MMME, and MMPH (p < 0.001 and <0.01, respectively). The thresholds for preoperative MMME and MMPH for longer outer suture translations (≥6 mm) were 2.1 mm and 5.4 mm, respectively.ConclusionsPreoperative longer MMME and higher MMPH were associated with longer meniscus translations during knee flexion during MMPRT repair.     

Personalized volumetric assessment of lower body muscles in patients with knee injuries: A descriptive case series

BackgroundPatients with knee joint pathology present with variable muscular responses across the muscles of the lower limb and pelvis. Conventional approaches to characterizing muscle function are limited to gross strength assessments that may overlook subtle changes both in the thigh, hip and shank musculature.PurposeTo describe individualized patterns of lower extremity muscle volumes in patients with knee pathologies.MethodsThis was a retrospective case series performed in a University medical center. Nine patients diagnosed with meniscus tear recommended to undergo meniscectomy volunteered. Participants underwent 3.0 Tesla magnetic resonance imaging (MRI) of the lower extremities. Thirty-five MRI-derived muscle volumes were compared between limbs and expressed as percentage asymmetry. For additional context, z-scores were also calculated for mass- and height-normalized muscles and pre-determined muscle groupings relative to a normative database.ResultsThere were no consistent patterns observed when considering between-limb asymmetries among all patients. The ankle musculature (dorsiflexors, plantar flexors, and invertors) was the only muscle group to be consistently smaller than normal for all patients, with the psoas major and flexor hallucis longus being the only individual muscles. The severity or chronicity of injury and presence of surgical intervention did not appear to have a clear effect on muscle volumes.ConclusionPatients with a history of meniscal pathology demonstrate inconsistent patterns of lower extremity muscle volumes about the hip, knee, and ankle between limbs and in comparison to uninjured individuals. These data support the need for individualized assessment and intervention in this population.     

Does pin configuration matter in modified tension band wiring for transverse patellar fracture? A biomechanical study

BackgroundModified tension band wiring has been widely used for the treatment of transverse patellar fractures. The optimal position of a Kirschner wire (K-wire) in modified tension band wiring, however, has not yet been determined. The purpose of the present study was to evaluate biomechanically the effect of K-wire position in a modified tension band wiring technique.MethodsForty-two polyurethane foam patellae with a midway transverse fracture were assigned to six different fixation groups regarding different pin configurations in tension band wiring. The depth or sagittal position of the K-wire was divided into anterior and posterior. The coronal position of the K-wire was divided into central, medial and lateral. A specially designed set up simulated a knee with 60° flexion. All specimens were tested under axial traction. Loads at 2 mm and 4 mm fracture displacement and at the failure of the construct were recorded.ResultsAt 2 mm fracture displacement, anterolateral (AL) placement of K-wires revealed significantly less durability when compared with five other groups (P < 0.001). At 4 mm fracture displacement, the AL group also revealed inferior biomechanical strength when compared with other groups. Posteromedial (PM) K-wire placement group revealed more durability when compared with the posterolateral (PL) group (P < 0.05). At failure of the osteosynthesis, anteromedial (AM) and anterocentral (AC) groups revealed superior biomechanical strengths (P < 0.05).ConclusionsThe coronal and sagittal position of K-wire affects the biomechanical characteristics of modified tension band wiring. Anterolateral placement of K-wires revealed inferior strength to all other constructs in modified anterior tension band wiring.     

MRI signal intensity of anterior cruciate ligament graft after transtibial versus anteromedial portal technique (TRANSIG): A randomised controlled clinical trial

BackgroundTwo primary surgical femoral drilling techniques are used to reconstruct the anterior cruciate ligament (ACL): the transtibial (TT) technique and the anteromedial portal (AMP) technique. Currently there is no consensus on which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study was to assess MRI-derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare graft maturation of both AMP and TT ACL reconstruction techniques.MethodsThis randomised controlled trial included 33 patients admitted for primary unilateral ACL reconstruction. Primary outcome was MRI Signal intensity ratio (SIR) of the ACL graft one year after ACL reconstruction. Differences in MRI SIR were assessed on two MRI sequencies: sagittal Proton Density Turbo Spin Echo weighted images (PDTSE) and 3D T2 Gradient Echo (T2*) weighted images. Analysis of interobserver and intraobserver variability was conducted for the SIR measurements.ResultsNo difference in signal intensity of the graft was found between the TT and AMP techniques one year after ACL reconstruction (PDTSE p = 0.665, T2* p = 0.957). Both interobserver and intraobserver variability showed strong agreement (ICC 0.64–0.94).ConclusionNo differences in signal intensity of the graft on MRI were seen between the femoral drilling techniques one year after ACL reconstruction, suggesting similar graft maturation at that time. Follow-up studies are needed to determine whether graft intensity changes in the long term.Level of evidenceTherapeutic study with level of evidence I.     

Immune and gene expression profiling during tacrolimus to everolimus conversion early after liver transplantation

Early elimination of tacrolimus in favor of everolimus can improve renal function in liver transplant recipients. However, as this approach increases the risk of acute rejection, it may benefit from predictive biomarkers guiding weaning. We enrolled 20 recipients on stable tacrolimus + everolimus to undergo tacrolimus withdrawal early post-liver transplant. Blood samples were collected at month 3 (withdrawal initiation), 4 (withdrawal completion), 4.5 and 6 (both everolimus alone). 15 patients did not reject and 5 had mild rejection responding to tacrolimus resumption. Before tacrolimus withdrawal, eventual rejecters had higher percentages of CD56⁺ NK cells and CD19⁺CD27⁺CD24⁺ memory B cells, and lower levels of T cells expressing the exhaustion marker PD-1. Over time, memory B cells, Ki-67⁺CD3⁺ (proliferating) cells and CD4⁺CD127^-CD25^HIGH FOXP3⁺ Tregs increased in rejecters. Tregs also increased in non-rejecters over time. The number of differentially expressed genes progressively increased in rejecters, particularly in mTOR, Eukaryotic Initiation Factor 2, and Neuroinflammation signaling pathways. There was no difference in anti-HLA antibodies between the groups. In summary, blood mononuclear cell and gene expression may predict successful vs. failed early tacrolimus withdrawal in liver transplant recipients. While needing validation, these preliminary findings highlight the potential for cellular and molecular biomarkers to guide decision-making during tacrolimus weaning.     

Osteotomy around the knee: Assessment of quality,content and readability of online information

BackgroundAs knee osteotomy surgery becomes increasingly accessible, more patients may turn to the Internet for information. This study examined the source, quality, content and readability of online information regarding osteotomy around the knee.MethodsThe first 70 websites returned by the top four search engines were identified using the key words: “knee osteotomy” and “high tibial osteotomy.” The websites were categorised by type and assessed using the DISCERN score, Journal of the American Medical Association (JAMA) benchmark criteria and a novel Knee Osteotomy-Specific Score (KOSS). The presence of the Health On the Net (HON) code accreditation seal was noted. Readability of each website was assessed using eight readability formulae. The mean reading grade level (RGL) was compared to the 6th and 8th grade reading levels. The mean RGL of each category was also compared.ResultsOf the 45 unique websites analysed, the majority were Physician (33%) and Journal websites (31%). The mean DISCERN score was 36.7 (±8.9) which is classified as ‘poor.’ The mean JAMA benchmark criteria score was 2.04 (±1.5) and Physician websites were most likely to be scored zero. The mean KOSS was 15.4 (±5.7). The highest scoring website was a Commercial site but, overall, Journal category sites provided the best quality information. Websites that bore the HONcode seal obtained higher DISCERN, JAMA benchmark criteria and Knee Osteotomy - Specific Scores.The cumulative mean RGL was 13.2 (±2.2) which exceeded the 6th grade level by an average of 7.2 grade levels and the 8th grade level by an average of 5.2 grade levels. No website (0%) was written at or below either the 6th or the 8th grade reading levels. The mean Flesch Reading Ease Score of all websites was 41.13 (±14.7) which is classified as ‘difficult.’ Journal websites had the highest RGL.ConclusionThe information available online regarding osteotomy around the knee varies tremendously in quality and completeness. Physician sites predominate, but these were among the lowest scoring of all websites. Even where high quality information is available, it is set at too high a level to be easily understood.Level of evidenceSurvey of materials – Internet.     

Association between SARS-CoV-2 infection and de novo HLA donor specific antibody production in lung transplant recipients: Single-center study

The COVID-19 pandemic has led to significant morbidity and mortality in lung transplant recipients. Respiratory viral infections may be associated with de-novo HLA donor-specific antibody production and impact lung transplant outcome. Since one of the immunomodulation strategies post-SARS-CoV-2 infection in lung transplant recipients include decreasing or holding anti-metabolites, concerns have been raised for higher incidence of de-novo HLA donor specific antibody production in lung transplant recipients. We performed a retrospective chart review of 24 consecutive lung transplant recipients diagnosed with COVID-19 to investigate this concern. We observed no significant differences in the CPRA or MFI levels of HLA class I and II antibodies pre- COVID-19 compared to 1 and 6 months post-COVID-19 diagnosis in 11/24 (45.8 %) LTR (p = 0.98 and p = 0.63 respectively). HLA class I and II DSA were detected in 5/24 LTR pre-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.89). De-novo HLA class I and II DSA were detected in 1/24 (4.2 %) LTR at one month post-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.54). Our results suggest that there was no significant association between SARS-CoV-2 infection and immunomodulation on pre-existing or de novo HLA donor specific antibodies.     

Calprotectin as a novel diagnostic approach to screen male infertility risk: A pilot study

Research QuestionDiagnosis of male infertility is essentially based on the evaluation of semen quality (sperm concentration, motility, viability, and morphology). However, there is a lack of knowledge about possible molecules used as candidates for the early identification of male infertility risk. Calprotectin is a biological marker for inflammation, measured prevalently in stool specimens, widely used to discriminate between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), and for the subsequent monitoring of gastrointestinal diseases’ development. Would it be possible to use calprotectin determination to identify also male infertility risk?DesignCross-sectional pilot study investigated calprotectin concentration in the seminal fluid of 45 men (range: 23–51 yrs) that were under evaluation for semen quality at our Center for Reproductive Medicine. Calprotectin concentration was determined with a commercially available immuno-chromatographic test and successfully detected in 37 of the 45 analyzed men (age: 37.38 ± 6.59). A correlation with semen quality (concentration, motility, morphology) was assessed.ResultsHigher calprotectin concentration seemed to indicate a better quality of the seminal fluid. Normozoospermic subjects (Group A) had on average a calprotectin value of 0.215 ± 0.162 µg/ml (mean ± SD), while subjects with at least one of the semen parameters below reference values (Group B) showed lower calprotectin concentration (mean ± SD: 0.126 ± 0.068, p-value < 0.05). A significant difference was clearly evident between calprotectin concentration measured in seminal fluids with physiological sperm morphology (≥4%) as compared with teratozoospermic samples (<4%) (p-value < 0.05). Indeed, the developed ROC curves showed a good diagnostic accuracy (around 67 %) using calprotectin concentration (threshold value: 0.121 μg/ml) as a preliminary test to discriminate subjects with and without abnormal semen parameters, especially morphology.ConclusionsCalprotectin determination in the seminal fluid may be proposed as a biological marker for preliminary screening in male subjects at risk of infertility due to one or more alterations of semen quality.