Abstract Background Failure rates are higher in medial unicompartmental knee arthroplasty (UKA) than total knee arthroplasty. To improve these failure rates, it is important to understand why medial ...UKA fail. Because individual studies lack power to show failure modes, a systematic review was performed to assess medial UKA failure modes. Furthermore, we compared cohort studies with registry-based studies, early with midterm and late failures and fixed-bearing with mobile-bearing implants. Methods Databases of PubMed, EMBASE, and Cochrane and annual registries were searched for medial UKA failures. Studies were included when they reported >25 failures or when they reported early (<5 years), midterm (5-10 years), or late failures (>10 years). Results Thirty-seven cohort studies (4 level II studies and 33 level III studies) and 2 registry-based studies were included. A total of 3967 overall failures, 388 time-dependent failures, and 1305 implant design failures were identified. Aseptic loosening (36%) and osteoarthritis (OA) progression (20%) were the most common failure modes. Aseptic loosening (26%) was most common early failure mode, whereas OA progression was more commonly seen in midterm and late failures (38% and 40%, respectively). Polyethylene wear (12%) and instability (12%) were more common in fixed-bearing implants, whereas pain (14%) and bearing dislocation (11%) were more common in mobile-bearing implants. Conclusion This level III systematic review identified aseptic loosening and OA progression as the major failure modes. Aseptic loosening was the main failure mode in early years and mobile-bearing implants, whereas OA progression caused most failures in late years and fixed-bearing implants.
Purpose
Recent outcomes of arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears have been promising in small cohort studies. The purpose of this study was to assess outcomes ...of arthroscopic ACL repair in a larger cohort and to assess the role of additional augmentation.
Methods
The first 56 consecutive patients that underwent arthroscopic ACL repair were examined at minimum 2-year follow-up. The latter 27 patients 48.2% (27/56) received additional internal bracing with ACL repair. All 56 patients were included (100% follow-up). Mean age at surgery was 33.5 ± 11.3 years (59% male) and mean follow-up 3.2 ± 1.7 years. Clinical examination was performed using the objective International Knee Documentation Committee (IKDC) form. Subjective outcomes were obtained using the Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation (SANE), and subjective IKDC scores.
Results
Six repairs (10.7%) failed and four additional patients underwent reoperation (7.1%): two for meniscus tears and two for suture anchor irritation. Objective IKDC scores were A in 38 (73%), B in 8 (15%) and C/D in 6 (12%) patients. Mean Lysholm score was 94 ± 7.6, modified Cincinnati 94 ± 8.9, SANE 90 ± 12.5, pre-injury Tegner 6.7 ± 1.5, current Tegner 6.2 ± 1.5, and subjective IKDC 90 ± 10.9. Failures rates were 7.4% with and 13.8% without internal bracing (
P
= 0.672). There were no statistically significant or clinically relevant differences in subjective outcomes.
Conclusion
Arthroscopic primary repair has resulted in good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population. The role of additional internal bracing is possibly beneficial, but larger groups are needed to assess this.
Level of evidence
III.
Purpose
Due to the lack of comparative studies, a systematic review was conducted to determine revision rates of unicompartmental and total knee arthroplasty (UKA and TKA), and compare functional ...outcomes, range of motion and activity scores in patients less than 65 years of age.
Methods
A literature search was performed using PubMed, Embase, and Cochrane systems since 2000. 27 UKA and 33 TKA studies were identified and included. Annual revision rate (ARR), functional outcomes, and return to activity were assessed for both types of arthroplasty using independent
t
tests.
Results
Four level I studies, 12 level II, 16 level III, and 29 level IV were included, which reported on outcomes in 2224 UKAs and 4737 TKAs. UKA studies reported 183 revisions, yielding an ARR of 1.00 and extrapolated 10-year survivorship of 90.0%. TKA studies reported 324 TKA revisions, resulting in an ARR of 0.53 and extrapolated 10-year survivorship of 94.7%. Functional outcomes scores following UKA and TKA were equivalent, however, following UKA larger ROM (125° versus 114°,
p
= 0.004) and higher UCLA scores were observed compared to TKA (6.9 versus 6.0, n.s.).
Conclusion
These results show that good-to-excellent outcomes can be achieved following UKA and TKA in patients less than 65 years of age. A higher ARR was noted following UKA compared to TKA. However, improved functional outcomes, ROM and return to activity were found after UKA than TKA in this young population. Comparative studies are needed to confirm these findings and assess factors contributing to failure at the younger patient population. Outcomes of UKA and TKA in patients younger than 65 years are both satisfying, and therefore, both procedures are not contraindicated at younger age. UKA has several important advantages over TKA in this young and frequently more active population.
Level of evidence
IV.
Purpose
During recent years
, there has been an intensive growth of interest in the patient’s perception of functional outcome. The Forgotten Joint Score (FJS) is a recently introduced score that ...measures joint awareness of patients who have undergone knee arthroplasty and is less limited by ceiling effects. The aim of this study was to compare the FJS between patients who undergo medial unicompartmental knee arthroplasty (UKA) and patients who undergo total knee arthroplasty (TKA) 1 and 2 years post-operatively.
Methods
This prospective study compares the FJS at a minimum of one (average 1.5 years, range 1.0–1.9) and a minimum of 2 years (average 2.5 years, range 2.0–3.6) post-operatively between patients who underwent medial UKA and TKA.
Results
One-hundred and thirty patients were included. Sixty-five patients underwent medial UKA and 65 patients underwent TKA. At both follow-up points, the FJS was significantly higher in the UKA group (FJS 1 year 73.9 ± 22.8, FJS 2 year 74.3 ± 24.8) in contrast to the TKA group (FJS 1 year 59.3 ± 29.5 (
p
= 0.002), FJS 2 year 59.8 ± 31.5, (
p
= 0.004)). No significant improvement in the FJS was observed between 1- and 2-year follow-up of the two cohorts.
Conclusion
Patients who undergo UKA are more likely to forget their artificial joint in daily life and consequently may be more satisfied.
Level of evidence
II.
Recently, there is a growing interest in surgical variables that are intraoperatively controlled by orthopaedic surgeons, including lower leg alignment, component positioning and soft tissues ...balancing. Since more tight control over these factors is associated with improved outcomes of unicompartmental knee arthroplasty and total knee arthroplasty (TKA), several computer navigation and robotic-assisted systems have been developed. Although mechanical axis accuracy and component positioning have been shown to improve with computer navigation, no superiority in functional outcomes has yet been shown. This could be explained by the fact that many differences exist between the number and type of surgical variables these systems control. Most systems control lower leg alignment and component positioning, while some in addition control soft tissue balancing. Finally, robotic-assisted systems have the additional advantage of improving surgical precision. A systematic search in PubMed, Embase and Cochrane Library resulted in 40 comparative studies and three registries on computer navigation reporting outcomes of 474,197 patients, and 21 basic science and clinical studies on robotic-assisted knee arthroplasty. Twenty-eight of these comparative computer navigation studies reported Knee Society Total scores in 3504 patients. Stratifying by type of surgical variables, no significant differences were noted in outcomes between surgery with computer-navigated TKA controlling for alignment and component positioning versus conventional TKA (
p
= 0.63). However, significantly better outcomes were noted following computer-navigated TKA that also controlled for soft tissue balancing versus conventional TKA (mean difference 4.84, 95 % Confidence Interval 1.61, 8.07,
p
= 0.003). A literature review of robotic systems showed that these systems can, similarly to computer navigation, reliably improve lower leg alignment, component positioning and soft tissues balancing. Furthermore, two studies comparing robotic-assisted with computer-navigated surgery reported superiority of robotic-assisted surgery in controlling these factors. Manually controlling all these surgical variables can be difficult for the orthopaedic surgeon. Findings in this study suggest that computer navigation or robotic assistance may help managing these multiple variables and could improve outcomes. Future studies assessing the role of soft tissue balancing in knee arthroplasty and long-term follow-up studies assessing the role of computer-navigated and robotic-assisted knee arthroplasty are needed.
To assess the mid-term clinical outcomes in patients with proximal avulsion anterior cruciate ligament (ACL) tears undergoing arthroscopic primary repair with suture anchors.
The first 11 consecutive ...patients with proximal avulsion tears treated with arthroscopic primary repair were evaluated at mid-term (minimum 5-year) follow-up. Physical examination was performed; laxity examination consisting of the Lachman, pivot-shift, and anterior drawer tests was performed; and patients were asked to complete the Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, and International Knee Documentation Committee (IKDC) questionnaires.
Of the 11 patients, 10 were seen at a mean follow-up of 6.0 ± 1.5 years (range, 4.8-9.2 years). One patient was lost to follow-up, in whom failure had already occurred at short-term follow-up. One additional patient underwent reoperation for a medial meniscus tear and also had a partial ACL tear; this patient was clinically stable at last follow-up. All patients had full range of motion. Nine patients had negative Lachman and negative pivot-shift examination findings (IKDC score of A), and 1 patient had a 1A Lachman result and 1+ pivot-shift result (IKDC score of B). The mean Lysholm score was 96.0 ± 4.5 (range, 88-100); modified Cincinnati score, 95.6 ± 7.4 (range, 80-100); Single Assessment Numeric Evaluation score, 95.4 ± 5.4 (range, 85-100); preinjury Tegner score, 7.2 ± 1.2 (range, 5-9); postoperative Tegner score, 6.6 ± 1.8 (range, 3-9); and IKDC subjective score, 92.3 ± 11.3 (range, 64-100).
The clinical outcomes of arthroscopic primary repair of proximal ACL tears with suture anchors are excellent and are maintained at mid-term follow-up in a carefully selected subset of patients with proximal tears and excellent tissue quality.
Level IV, therapeutic case series.
Many surgeons performing anterior cruciate ligament (ACL) reconstruction have encountered the problem of harvesting small hamstring grafts. For this situation, several options are available such as ...harvesting contralateral hamstring tendons, reinforce the ACL graft with allografts, take a bone-patellar tendon-bone or quadriceps graft or add an anterolateral ligament reconstruction or lateral extra-articular tenodesis. Recent studies have shown that the presence of a lateral extra-articular procedure might be more important than the thickness of an isolated ACL graft, which is reassuring news. Current evidence suggests that both anterolateral ligament reconstruction and modified Lemaire tenodesis are similar biomechanically and clinically and could solve the problem of small-diameter hamstring ACL autografts.
Background:
Recent epidemiologic reports have demonstrated rising injury rates in Major League Baseball (MLB) and Minor League Baseball (MiLB). Although several studies have recently been published ...on specific injuries, the majority of injuries have not yet been formally studied.
Purpose:
The purpose of this study is to (1) generate a summative analysis of all injuries that occur in MLB and MiLB, (2) identify the 50 most common injuries, and (3) generate focused reports and fact sheets on the characteristics of each of those diagnoses.
Study Design:
Case series; Level of evidence, 4.
Methods:
The MLB Health and Injury Tracking System was used to identify injuries occurring in MLB and MiLB players from 2011 to 2016. Injuries were defined as those that occurred during normal baseball activity and resulted in at least 1 day out of play. A multitude of player and injury characteristics were analyzed, and detailed reports of the 50 most commonly occurring injuries were generated.
Results:
A total of 49,955 injuries occurred during the study period; 45,123 were non–season ending, and they resulted in 722,176 days out of play. The mean (median) days missed per injury was 16 (6) days. Overall, 39.1% of all injuries occurred in pitchers. The upper extremity was involved in 39% of injuries, while 35% occurred in the hip/groin/lower extremity. Surgery was required in 6.5% of cases, and 9.7% of injuries were season ending. Hamstring strains were the most common injury (n = 3337), followed by rotator cuff strain/tear (n = 1874), paralumbar muscle strain (n = 1313), biceps tendinitis (n = 1264), oblique strain (n = 1249), and elbow ulnar collateral ligament injury (n = 1191). The diagnoses that were most likely to end a player’s season were elbow ulnar collateral ligament injury (60% season ending) and superior labrum anterior and posterior tear (50.9% season ending).
Conclusion:
Contrary to prior reports relying on disabled list data, the annual number of injuries in professional baseball remained steady from 2011 to 2016. Similar trends were noted for the annual number of days missed and mean days missed per injury. Although the mean days missed per injury was high (16), the median was much lower at 6 days.
Background:
Outcomes of rotator cuff repair (RCR) are influenced by several well-described factors, but the role of delay from injury to surgery on the outcomes is not clear.
Purpose:
To assess the ...role of delay to surgery on the outcomes of RCR in the literature.
Study Design:
Systematic review with meta-analysis; Level of evidence, 4.
Methods:
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. All studies assessing outcomes after RCR—either retear rates or patient-reported outcome measures (PROMs)—and reporting delay to surgery were identified through June 2021 in PubMed, Embase, and Cochrane. Inclusion criteria consisted of traumatic injuries, mean age <65 years, minimum 6-month follow-up, and assessment of retear rates with radiologic examination or reporting of PROMs. Random-effect models were used to assess outcomes, reported in odds ratio (OR) or mean difference (MD) with 95% CIs.
Results:
A total of 8118 patients were included from 33 studies, with a mean age of 59 years (range, 53-64) and mean follow-up of 3.0 years (range, 0.5-8.2), among whom 53% were male and 74% had dominant-side injury. Patients undergoing surgery >3 months after injury did not have significantly higher retear rates (OR, 1.1 95% CI, 0.5 to 3.1; P = .700), lower Constant-Murley score (MD, −6.2 95% CI, −16.4 to 4.1; P = .240), or lower ASES score (American Shoulder and Elbow Surgeons; MD, –12.9 95% CI, −26.0 to −0.2; P = .050) compared with those having surgery within 3 months. Similarly, delaying surgery for 6 months did not result in higher retear rates (OR, 1.7 95% CI, 0.8 to 3.7; P = .190) or lower PROMs. Delaying surgery for 1 year, however, led to an increased likelihood of retear when compared with <1 year (OR, 2.9 95% CI, 2.1 to 4.0; P < .001), and this was similar for the 2-year cutoff (OR, 5.9 95% CI, 1.1 to 32.1; P = .040). It was also noted that patients with an intact cuff at follow-up had a mean 3.9 months’ shorter time from injury to surgery than patients with retear (95% CI, 1.0-6.8 months; P = .009).
Conclusion:
This systematic review with meta-analysis found that delaying rotator cuff surgery for 3 to 6 months did not lead to higher retear rates or inferior PROMs as compared with undergoing earlier surgery. However, delaying surgery for ≥1 year clearly resulted in higher retear rates after RCR. This study is limited by relying on retrospective studies, and larger prospective studies are needed to confirm these findings.
Registration:
CRD42021240720 (PROSPERO).
Abstract Introduction Recently, there has been a resurgence of interest in anterior cruciate ligament (ACL) preservation using arthroscopic primary repair for proximal tears. The procedure is less ...invasive than ACL reconstruction, yet studies assessing the early postoperative course are lacking. The goal of this study was to assess postoperative range of motion (ROM), complications and operative times following primary repair and compare this to the gold standard of ACL reconstruction. Methods A retrospective search was performed for patients undergoing primary repair and reconstruction for isolated ACL injuries. Fifty-two repair patients and 90 reconstruction patients were included. Patients were examined at one week and one, three and six months. Rehabilitation protocol consisted of early ROM and was equal for both groups. Outcomes were compared using independent t-tests and chi-square tests. Results Patients undergoing repair had more ROM than patients undergoing reconstruction at one week (89° ± 18 vs. 61° ± 21, p < 0.01) and one month (125° ± 14 vs. 116° ± 18, p < 0.01) postoperatively. All patients had full ROM at six months. Fewer repair patients had < 90° ROM at one week (23% vs. 84%, p < 0.01), and more repair patients had full ROM at one month (57% vs. 30%, p < 0.01) than reconstruction patients. Treatment of meniscal lesions, but not chondral lesions, influenced ROM. Trends towards fewer complications (2% vs. 9%, p = 0.19) and infections (0% vs. 6%, p = 0.20) were noted following primary repair, and the procedure was significantly shorter. Conclusions Following primary repair, patients had better ROM, and trends towards fewer complications than reconstruction. Primary repair is a safe, brief procedure with early ROM and low complication rates.
