全膝关节置换术中髌骨置换对骨性关节炎患者早期疗效及膝前痛的影响

目的：探讨全膝关节置换术中是否进行髌骨置换对骨性关节炎患者的临床疗效及术后疼痛的影响。方法笔者采用随机数字表法将骨科2011年5月～2013年7月收治的93例行人工全膝关节置换术患者分为髌骨置换组43例和未置换组50例,比较两组患者治疗前与治疗后不同时间的相关指标变化差异。结果术前髌骨置换组与非置换组的膝关节KSS（美国膝关节协会）评分、Feller评分差异不显著（ P＞0．05）;术后第3、6、12个月髌骨置换组膝关节KSS评分、Feller评分显著高于非置换组（P＜0．05）;术前髌骨置换组与非置换组的膝关节视觉模拟评分（VAS）差异不显著（P＞0．05）;术后第3、6、12个月髌骨置换组膝关节VAS评分显著低于非置换组（P＜0．05）;两组患者术前、术后的胫股角,髌韧带比值,关节活动度ROM屈、伸值在两组间比较差异均不显著（ P＞0．05）;术后第12个月两组患者的胫股角、髌韧带比值,关节活动度ROM屈、伸值较治疗前均显著好转（ P＜0．05）。结论全膝关节置换术中进行髌骨置换对改善膝关节功能评分、髌骨评分、术后疼痛评分均有显著的效果。     

Septic knee arthritis following ACL reconstruction: a systematic review

Although postoperative septic arthritis is rare after ACL reconstruction, it carries a high morbidity that results in poor clinical outcome. Despite low incidence, it is important to recognize that infection and treat it without delay because of devastating consequences, such as loss of hyaline cartilage and arthrofibrosis, in order to avoid osteoarthritis development and near full range of motion achieved. Herein we discuss the pathogenesis, risk factors, clinical presentation, diagnostic evaluation, treatment protocols and complications of septic knee arthritis after ACL reconstruction.     

Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials

Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain. A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL and Pre-CINAHL, PEDro, PubMed, SportDiscus, Web of Science, BIOSIS Previews, and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models. Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Meta-analysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI 0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD -0.21, 95% CI -0.64, 0.21; 8-12 weeks: SMD -0.22, 95% CI -0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control). Findings suggest that, in implementing evidence-based practice for the nonsurgical management of anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required.     

Participation in sporting activities following knee replacement: total versus unicompartmental

Few studies have been published assessing patients sporting activity after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). Common concerns of patients undergoing TKA or UKA are whether they can continue with sporting activities after surgery. This study compares the sporting activity of TKA and UKA patients preoperatively and postoperatively. A total of 110 patients were surveyed by questionnaire. Seventy-six patients had undergone TKA and 34 patients had undergone UKA. They were assessed for their participation in low-impact sport preoperatively and postoperatively at a mean follow up of 21.6 +/- 5.3 and 22.3 +/- 7.8 months, respectively. Low-impact sports are those which a surgeon would expect patients to be able to participate in postoperatively. Data were separately analysed for older and younger patients and women and men, respectively. The results were as follows: before surgery, 55 of 76 patients in the TKA group participated in an average of 1.3 different sports and postoperatively, 35 of 76 patients participated in an average of 0.7 different sports. In the UKA group, 30 of 34 patients participated in an average of 1.5 different sports preoperatively and postoperatively, 29 of 34 patients participated in an average of 1.4 different sports. The return to sport rate was 96.7% in the UKA group and 63.6% in the TKA group. In the TKA group, the average frequency of sport preoperatively was 3.0 sessions per week (62.7 min) and postoperatively it decreased to 2.0 sessions per week (37.5 minutes). In the UKA group, the average frequency of sport preoperatively was 3.2 sessions per week (85.0 min) and postoperatively it increased to 3.4 sessions per week (92.1 min). The average time before resuming sport after surgery was 4.1 months in the TKA group and 3.6 months in the UKA group; 42.9% of patients in the TKA group and 24.1% of patients in the UKA group reported pain during sports after surgery; 80.3% of the patients in the TKA group and 88.2% of the patients in the UKA group felt that surgery had increased or maintained their sporting ability. Oxford knee scores decreased significantly one year after surgery in both the TKA group and the UKA group. In conclusion, the patients in our study had a significantly greater return to sport rate after UKA than patients who had undergone TKA. A large proportion of patients in the TKA group did not return to sport which their surgeon would have expected them to including golf and bowls. Patients in the UKA group also took part in more sporting sessions and for a longer period of time than patients in the TKA group. Moreover, patients undergoing UKA also returned to sport more quickly than patients undergoing TKA.     

The effects of the menstrual cycle on anterior knee laxity: a systematic review

Female athletes are at a 4- to 6-fold increased risk of anterior cruciate ligament (ACL) injury compared with male athletes. There are several medical, emotional and financial burdens associated with these injuries. Sex hormones may be involved in the ACL injury disparity, with potential associations reported between phases of the menstrual cycle and ACL injury rates. The reported relationships between ACL injury and menstrual status may be related to associated changes in ligament mechanical properties from cyclic fluctuations of female sex hormones. A PubMed electronic database literature search, including MEDLINE (1966-2005) and CINAHL (1982-2005), with the search terms 'menstrual cycle' and 'knee laxity' was used for this systematic review. Studies were included in this systematic review if they were prospective cohort studies and investigated the association between the menstrual cycle and anterior knee laxity in females. Nine prospective cohort studies, published as 11 articles, were included in the systematic review. Six of nine studies reported no significant effect of the menstrual cycle on anterior knee laxity in women. Three studies observed significant associations between the menstrual cycle and anterior knee laxity. These studies all reported the finding that laxity increased during the ovulatory or post-ovulatory phases of the cycle. A meta-analysis, which included data from all nine reviewed studies, corroborated this significant effect of cycle phase on knee laxity (F-value = 56.59, p = 0.0001). In the analyses, the knee laxity data measured at 10-14 days was >15-28 days which was >1-9 days. Future studies testing the relationship between the menstrual cycle and potentially associated parameters should consider the limitations outlined in this article and control for potential biases and confounders. Power analyses should be utilised. Subjects should be randomly entered into the studies at alternate points in the cycle, and standard and consistent data acquisition and reporting methods should be utilised. Future studies should clearly define what constitutes a 'normal' cycle and appropriate control subjects should be utilised. Furthermore, there is a need to define cycle phase (and timing within cycle phase) with actual hormone levels rather than a day of the cycle. Although hormone confirmations were provided in many of the studies that selected specific days to depict a particular cycle for all women, it is unknown from these data if they truly captured times of peak hormone values in all women. A combined systematic review and meta-analysis of the literature indicate that the menstrual cycle may have an effect on anterior-posterior laxity of the knee; however, further investigation is needed to confirm or reject this hypothesis.     

Factors affecting anterior knee pain following anatomic double-bundle anterior cruciate ligament reconstruction

Purpose

The purpose of this study was to evaluate the prevalence of anterior knee pain in anatomic double-bundle anterior cruciate ligament (ACL) reconstruction and to identify critical factors affecting postoperative anterior knee pain development.

Methods

Subjects comprised 171 patients (171 knees) who underwent anatomic double-bundle ACL reconstruction with a follow-up period of ≥2?years. The procedure used bone-patellar tendon-bone plus gracilis tendon (BTB-G) in 56 knees, semitendinosus tendon (ST) in 71 knees, and ST-G in 44 knees. Clinical results and prevalence and severity of anterior knee pain were assessed at 3?months and 2?years postoperatively. Clinical variables influencing anterior knee pain development at each postoperative period were subjected to univariate analysis, followed by logistic regression analysis to identify risk factors for anterior knee pain.

Results

Overall prevalences of anterior knee pain at 3?months and 2?years postoperatively were 42.0 and 11.1%, respectively. Use of BTB-G graft represented the highest prevalence of anterior knee pain between the 3 different grafts (P?=?0.001); however, this statistical significance disappeared at 2?years postoperatively. Prevalence of postoperative extension deficit was significantly higher in anterior knee pain-positive cohort than in anterior knee pain-negative cohort at 3?months postoperatively. Level of quadriceps strength was significantly lower, and Lysholm score was significantly worse in anterior knee pain-positive cohort than in anterior knee pain-negative cohort at 2?years postoperatively. According to logistic regression analysis, knee extension deficit was a predisposing factor for the development of anterior knee pain at 3?months postoperatively (odds ratio, 2.76; P?=?0.004); however, there was no significant predisposing factor for anterior knee pain at 2?years postoperatively.

Conclusions

Knee extension deficit was an important predisposing factor for postoperative anterior knee pain in the early postoperative period, and anterior knee pain was associated with impaired quadriceps function and inferior subjective results over 2?years postoperatively. Early recovery of full extension may prevent postoperative development of anterior knee pain and achieve successful outcomes for ACL reconstruction.

Level of evidence

Retrospective comparative study, Level III.     

One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review

Purpose

Infection complicating total knee arthroplasty (TKA) has serious implications. Traditionally the debate on whether one- or two-stage exchange arthroplasty is the optimum management of infected TKA has favoured two-stage procedures; however, a paradigm shift in opinion is emerging. This study aimed to establish whether current evidence supports one-stage revision for managing infected TKA based on reinfection rates and functional outcomes post-surgery.

Methods

MEDLINE/PubMed and CENTRAL databases were reviewed for studies that compared one- and two-stage exchange arthroplasty TKA in more than ten patients with a minimum 2-year follow-up.

Results

From an initial sample of 796, five cohort studies with a total of 231 patients (46 single-stage/185 two-stage; median patient age 66 years, range 61–71 years) met inclusion criteria. Overall, there were no significant differences in risk of reinfection following one- or two-stage exchange arthroplasty (OR ?0.06, 95 % confidence interval ?0.13, 0.01). Subgroup analysis revealed that in studies published since 2000, one-stage procedures have a significantly lower reinfection rate. One study investigated functional outcomes and reported that one-stage surgery was associated with superior functional outcomes. Scarcity of data, inconsistent study designs, surgical technique and antibiotic regime disparities limit recommendations that can be made.

Conclusion

Recent studies suggest one-stage exchange arthroplasty may provide superior outcomes, including lower reinfection rates and superior function, in select patients. Clinically, for some patients, one-stage exchange arthroplasty may represent optimum treatment; however, patient selection criteria and key components of surgical and post-operative anti-microbial management remain to be defined.

Level of evidence

III.

     

Instrumented platforms for balance and proprioceptive assessment in patients with total knee replacement: A systematic review and meta-analysis

BackgroundThe functional outcome of total knee replacement (TKR) is usually satisfying. However, patients may show functional limitations for years after surgery, which have been ascribed to impairments in balance and proprioception, mainly during standing tasks. A number of instrumentations and parameters have been used, rising confusion for clinical decisions on the assessment of patients.Research questionWhich are the most widespread and consistent procedures to assess balance and proprioception following TKR?MethodsA literature review was conducted in Pubmed, PEDro, and Cochrane database. From a total sample of 112 articles, 23 original studies published between 2008 and 2019 met inclusion criteria. The primary outcomes selected were variables related to balance and proprioception assessment in static and dynamic tasks performed with instrumented platforms. Data from papers using the same instrumentation, on patients with unilateral TKA and at least 12 months postoperatively were synthesized quantitatively in a random effect meta-analysis.ResultsFourteen articles were appropriate for the review. A large variability was found both in the instrumentation and the parameters used. The Neurocom Balance Master System™ was the most used instrument (four articles). On a total population of 186 patients with unilateral TKR 12 months postoperatively, a low degree of heterogeneity was found adopting the random effect in the four tasks explored (Firm and Foam Surface both with Eyes Open and Eyes Closed).SignificanceThis review found a large variability in the instrumentation used to assess balance and proprioception in patients operated on TKR. The meta-analysis demonstrated that the Neurocom Balance Master System™ for static assessment of balance showed an acceptable consistency and can be considered as a reference for further studies. However, balance and proprioception impairments following TKR have not been widely quantified by means of instrumented platforms. Further research is needed to address this issue, and improve clinical practice.     

MRI of anterior knee pain

Anterior knee pain is the most common knee complaint. It may be due to a variety of soft tissue or osseous abnormalities. Knowledge of the radiologic appearance of the abnormalities allows more accurate diagnosis of the cause of the pain including chondral abnormalities, patellar instability and dislocation, femoral trochlear dysplasia, abnormal patellar location, bipartite patella, various tendinopathies, bursal inflammation, traction apophysitis in pediatric and adolescent patients, and miscellaneous diseases including mediopatellar plica syndrome and Hoffa’s disease. Radiographs are often obtained to exclude acute osseous abnormalities, such as fractures. Magnetic resonance (MR) imaging offers superior soft tissue contrast resolution and allows for more accurate evaluation of the underlying etiology and therefore may improve treatment and possible surgical planning.     

Effects of total knee arthroplasty for primary knee osteoarthritis on postural balance: A systematic review

BackgroundKnee osteoarthritis is often related to physical function impairment. Although total knee arthroplasty is considered effective for advanced cases of knee osteoarthritis, its effects on postural balance is a topic of debate.Research questionWhat are the effects of total knee arthroplasty for primary knee osteoarthritis on postural balance compared to preoperative status and/or to healthy controls?.MethodsLongitudinal studies (with more than 1-month follow-up) assessing postural balance measures (either clinical-based such as balance scales or laboratory-based such as postural sway) were considered eligible and selected in a 2-phase process. Six main electronic databases were searched, complemented by 3 grey literature sources. The risk of bias was evaluated using the Joanna Briggs Institute Critical Appraisal Tools.ResultsA total of 19 studies were included for qualitative synthesis, of which 14 had low and 5 had a moderate risk of bias. The follow-up period ranged from 1–24 months. Most studies (n = 11) presented comparisons to preoperative status only. From these, 7 studies reported relevant improvements in postural balance, 2 reported partial improvements, and 2 no improvements. The remaining studies (n = 8) presented comparisons to healthy controls and, although improvements following total knee arthroplasty were consistently observed, only one study reported postural balance measures comparable to that of controls.ConclusionsThe majority of studies reported relevant improvements (especially in clinical-based measures) compared to preoperative evaluations, although inconsistencies were found possibly due to variability in studies' populations, assessment tools, and follow-up times. Despite this, persistent deficits in postural balance were commonly observed when compared to healthy controls.SignificanceThis evidence synthesis could better inform clinicians and researchers about the therapeutic effects and limitations of total knee arthroplasty concerning postural balance. Standardization of assessment tools is recommended to strengthen the certainty of cumulative evidence.     

Diagnosis of anterior knee pain

A methodical approach to the evaluation of patients with anterior knee pain is extremely helpful. By exploring salient points from the patient's symptoms and history and adding important data from a comprehensive physical examination, the pieces of the puzzle can be fitted together and an accurate diagnosis can be made. This will allow the formulation of a specific plan of rehabilitation that is designed with a knowledge of patellofemoral biomechanics and that will expedite the recovery process and facilitate a return to full function.     

Sources of anterior knee pain

The anterior part of the knee consists mainly of structures belonging to the patellofemoral joint, which includes a variety of tissues, such as cartilage, subchondral bone, synovial plicae, infrapatellar fat pad, retinacula, capsule, and tendons. Each of these structures, alone or in combination, can be a source of anterior knee pain. Unphysiologic load or changed metabolic activities can lead to structural failure with loss of homeostatic conditions.     

MR imaging of anterior knee pain: a pictorial essay

Anterior knee pathology is a frequent cause of joint pain and limitation of function and mobility among patients presenting to an orthopaedic department. Proper recognition and treatment of pathologic conditions depend on the knowledge of normal anatomy and of the various abnormalities, which affect this area of the knee and may present with anterior knee pain. A broad array of benign and malignant processes may be manifested as anterior knee discomfort, and this common clinical entity is among the most frequent indications for MR imaging of the lower extremities. Clinical history and physical examination are also of paramount importance. The disorders can be categorized and differentiated primarily according to their location. Traumatic or non-traumatic disorders of the patella, patellar retinacula, quadriceps and patellar tendons and supra or infrapatellar fat pad can be the source of symptoms. This article includes a comprehensive pictorial essay of the characteristic MR features of common and uncommon disorders causing anterior knee pain. For accurate assessment of the aforementioned clinical problem, a radiologist should be able to identify typical MR imaging patterns that contribute in establishing the correct diagnosis and thus tailoring the appropriate therapy. Level of evidence IV.     

Less anterior knee pain with a routine lateral release in total knee arthroplasty without patellar resurfacing: a prospective,randomized study

Purpose

Anterior knee pain is a major cause of complaint in total knee arthroplasty (TKA) without patellar resurfacing. The concept of improved patellar tracking and decreased retropatellar contact pressure for lateral retinacular release theoretically suggests that patients with lateral retinacular release in TKA would achieve a lower incidence of anterior knee pain when compared without lateral retinacular release. We sought to determine (1) whether those patients who received a routine lateral retinacular release in TKA would attain lower incidence of anterior knee pain as compared to patients who received TKA without lateral retinacular release and (2) whether lateral retinacular release would increase the lateral retinacular release-related complications.

Methods

A total of 148 patients who underwent TKA with the use of the Gemini MK II mobile bearing were randomized to receive either routine lateral retinacular release (intervention group) or not (control group). Patients were assessed by the visual analogue scale for anterior knee pain, the Knee Society clinical scoring system of knee score and function score, and patellar score for clinical function. Patients’ satisfaction and lateral retinacular release-related complications were also evaluated.

Results

The overall incidence of anterior knee pain in the intervention group at 18 months follow-up was 5.6 %, while that of the control group was 20.6 % (p = 0.009). No statistical difference was detected between the two groups in terms of lateral retinacular release-related complications (n.s.), patients’ satisfaction (n.s.), knee score (n.s.), function score (n.s.), and patellar score (n.s.) at 18 months follow-up.

Conclusion

The present study suggests that routine lateral retinacular release can reduce anterior knee pain and does not increase lateral retinacular release-related complications, in TKA with the use of the Gemini MK II mobile bearing without patellar resurfacing.

Level of evidence

Therapeutic, Level I.