Anterior Knee Pain: State of the Art

Concomitant Ipsilateral Knee Pain Is Associated With Worse Preoperative Functional Status and Short-Term Outcomes After Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome

PURPOSE

(1) To determine the effect of concomitant ipsilateral knee pain (IKP) on short-term outcomes after hip arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) and (2) to determine whether IKP would improve with surgery.

METHODS

Data between September 2021 and May 2022 were reviewed. Patients with a diagnosis of FAIS who underwent hip arthroscopy with a minimum of 1-year follow-up were included. The exclusion criteria were prior ipsilateral hip or knee surgery, hip Tönnis grade greater than 1, knee Kellgren-Lawrence grade greater than 2, hip conditions (avascular necrosis, Legg-Calvé-Perthes disease, pigmented villonodular synovitis, osteoid osteoma, synovial chondromatosis, and developmental dysplasia of the hip), and spine diseases. All patients underwent knee magnetic resonance imaging preoperatively. Preoperative and short-term (1-year) patient-reported outcomes were collected, consisting of the Hip Sports Activity Scale score, weekly sports participation, modified Harris Hip Score (mHHS), 12-component International Hip Outcome Tool (iHOT-12) score, and visual analog pain scale (VAS) scores for the hip and the ipsilateral knee. The percentages of patients achieving the minimal clinically important difference and patient acceptable symptom state (PASS) for the mHHS and iHOT-12 score were calculated. Multivariate regression analysis was performed to determine the effect of IKP severity on postoperative outcomes. Subgroup analysis was performed between patients with IKP alleviation and those without IKP alleviation.

RESULTS

Among the 107 patients included, 47 presented with preoperative IKP. Compared with patients without IKP, the IKP cohort had comparable knee structural abnormalities (all with P > .05). Still, the IKP cohort showed inferior preoperative values for the mHHS (P = .003), iHOT-12 score (P = .016), hip VAS score (P = .001), and weekly sports participation (P = .039). Postoperatively, the IKP cohort had a lower mHHS (P = .046), lower iHOT-12 score (P = .037), and lower hip VAS score (P = .003) and were less likely to achieve the PASS for the mHHS (P = .021) and iHOT-12 score (P = .049). Patients with higher knee VAS scores were less likely to achieve the PASS for the mHHS (odds ratio, 0.61; P = .023). Within the IKP group, the knee VAS score improved from 2.3 to 1.0 (P < .001). Patients with alleviated IKP showed superior postoperative iHOT-12 scores (P = .038) compared with patients with persistent IKP.

CONCLUSIONS

Concomitant IKP at baseline negatively affected preoperative status and short-term clinical outcomes after arthroscopic treatment of FAIS. Patients with IKP were less likely to meet clinical thresholds. Most patients achieved IKP alleviation postoperatively, which was associated with superior clinical outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

ACL Reconstruction using Achilles Allograft in a Case of Genu Recurvatum with Supracondylar Osteotomy

Introduction

People with post-polio syndrome usually have some residual deformities. Genu recurvatum is very commonly seen in such cases which are a risk factor for anterior cruciate ligament (ACL) injury due to the altered biomechanics. To the best of our knowledge, this is the first report in literature presenting ACL reconstruction in a limb with genu recurvatum deformity treated with supracondylar osteotomy.

Case Report

A 49-year-old female with genu recurvatum and history of polio presented with pain and instability. Staged procedure of supracondylar osteotomy and ACL reconstruction Achilles allograft was done.

Conclusion

ACL tears in a poliotic limb with genu recurvatum deformity can be a challenging case. Precise pre-operative preparation can aid in managing the case successfully.

Abnormal femoral trochlea morphology is a risk factor for secondary injury of anterior cruciate ligament after reconstruction

Secondary injury of the anterior cruciate ligament (ACL) is a common concern after anterior cruciate ligament (ACL) reconstruction, and identification of morphological risk factors is essential to prevent these injuries. We hypothesized that abnormal femoral trochlea morphology is associated with secondary ACL injuries after reconstruction. This study aimed to investigate the relationship between femoral trochlear morphology and secondary ACL injuries after reconstruction. A retrospective analysis was conducted on 20 patients who experienced secondary ACL injuries after reconstruction in our hospital between 2017 and 2022 (experimental group), and 40 patients were included in the control group. The following femoral trochlear characteristics were compared between the 2 groups: medial condylar height (MCH), trochlear sulcus height (TSH), lateral condylar height (LCH), trochlear sulcus depth (TSD), trochlear sulcus angle (TSA), medial trochlear inclination (MTI), and lateral trochlear inclination (LTI). The study found that patients in the secondary ACL injury after reconstruction group exhibited the following differences when compared to the control group: decreased MCH (56.33 ± 3.52 vs 59.93 ± 3.24, P value = .015), decreased TSD (4.89 ± 1.56 vs 6.98 ± 1.23, P value ˂ .001), decreased MTI (12.54 ± 6.57 vs 19.45 ± 6.35, P value ˂ .001), and increased TSA (145.23 ± 9.76 vs 139.25 ± 8.42, P value ˂ .001). This study demonstrated a significant correlation between abnormal femoral trochlear morphological characteristics and secondary ACL injuries after reconstruction. Decreased MCH, TSD, and MTI along with increased TSA are associated with a higher risk of secondary ACL injury. These data could thus help identify individuals susceptible to secondary ACL injuries after reconstruction.

Lateral trochlear inclination measured by the transepicondylar axis holds potential for evaluating trochlear dysplasia in patients with lateral patellar dislocation

PURPOSE

To verify that lateral trochlear inclination (LTI) measured by the transepicondylar axis can reliably be used to evaluate trochlear dysplasia (TD) on MRI and can serve as an objective indication of trochleoplasty for patients with lateral patellar dislocation (LPD).

METHODS

Eighty patients with recurrent LPD and eighty healthy subjects were included. TD, posterior condylar angle (PCA), and LTI measured by the posterior condylar reference line (LTIp), surgical transepicondylar axis (LTIs), and anatomical transepicondylar axis (LTIa) were assessed on MRI. The intraclass correlation coefficient (ICC) and Bland-Altman analysis were performed, the correlations and differences amongst the parameters were identified, and a binary logistic regression model was established.

RESULTS

Each measurement had excellent inter- and intra-observer agreement. The LTIp, LTIs and LTIa were smaller in the study group than in the control group, with mean differences of 9.0°, 7.2° and 7.0°, respectively (P < 0.001). The PCA was larger in patients with LPD than in the control group (P < 0.001). LTIp was associated with PCA in the study group (r = - 0.41, P < 0.001). The pathological values of LTIp, LTIs and LTIa were 11.7°, 15.3° and 17.4°, respectively. LTIs and LTIa were independent risk factors for LPD, with ORs of 7.33 (95% CI [1.06-52.90], P = 0.048) and 10.29 (95% CI [1.38-76.96], P = 0.023), respectively.

CONCLUSION

The LTI can be reliably measured by MRI, but LTIp could potentially decrease the recorded value from the actual inclination angle. LTIs and LTIa are more appropriate to serve as trochleoplasty indications for patients with LPD, which could help orthopedists with surgical decision-making.

LEVEL OF EVIDENCE

Level III.

Low-load exercises with concurrent blood flow restriction as rehabilitation for unspecific knee pain to a former American football player: A case report

Former athlete, 30 years of age, suffered several months of moderate anterior knee pain during daily life activities where daily life activities such as negotiating stairs and lifting heavy objects were moderately painful. Magnetic resonance imaging showed normal meniscus and cruciate ligaments and no extra joint fluid. The patient was referred to a physiotherapist who introduced a strengthening program. Low-load resistance training with concurrent blood flow restriction can induce significant gains in maximal muscle strength and mass with minimal exacerbation of knee-joint pain. We describe the outcome of 12 weeks low-load resistance training with concurrent blood flow restriction as a rehabilitation method for anterior knee pain. The patient performed low-load resistance training with concurrent blood flow restriction for the lower limbs (goblet squat, single-leg knee extensions and flexions). After the low-load resistance training with concurrent blood flow restriction, the patient increased isometric knee extensor muscle strength (31%), single-leg hop test performance (23%), obtained clinically relevant improvements in patient-reported outcomes and was able to return to his usual high-loading training regime. Low-load resistance training with concurrent blood flow restriction seems promising to transition patients back to a healthy lifestyle of training and being physically active.

Association of patellofemoral pain syndrome (PFPS) with quadratus lumborum and lower limb muscle tightness a cross-sectional study

Background

Patellofemoral pain syndrome (PFPS) is characterized by peripatellar or retro patellar pain, as a result of changes in the physical and biochemical components of the patellofemoral joint. The main contributory factor is being the excessive load on the patellofemoral joint. The change in the flexibility of lower limb muscles is one of the factors for developing PFPS.

Objective

To find the association of quadratus lumborum (QL) and lower limb muscles tightness in patients with unilateral PFPS.

Materials and methods

50 PFPS participants (21 male and 29 female) were included and assessed for muscle tightness on both affected and unaffected side. The QL, rectus femoris, hamstring, iliotibial band (ITB) and gastrocnemius tightness were measured using inch tape and mobile inclinometer. A Chi Square test and phi crammer's v criteria were used to check the association and the strength of it.

Results

A significant association was found between tightness of rectus femoris (PFPS-right Chi 19.99 p < 0.001; Phi-0.632, PFPS-left Chi-5.52 p = 0.019 and Phi- 0.332), gastrocnemius (PFPS-right Chi 8.78 p = 0.003; Phi-0.419, PFPS-left Chi- 11.41 p = 0.001; Phi- 0.478), iliotibial band (PFPS-right Chi 7.83 p = 0.005; Phi-0.396, PFPS left Chi-3.68 p = 0.055; Phi- 0.27). There was no significant association of hamstring tightness (PFPS-right Chi - 3.68 p = 0.055; Phi-0.055, PFPS left Chi-1.11 p = 0.291; Phi- 0.019) and QL (PFPS right Chi - 1.10 p = 0.293; Phi-0.293, PFPS left Chi-0.79 p = 0.372; Phi- 0.372).

Conclusion

PFPS was associated with tightness of rectus femoris, gastrocnemius, ITB and no association found between hamstring and QL muscle tightness and PFPS.

Morphometrics of Facies Patellaris Femoris in Dry Bones

INTRODUCTION

The aim of this study was to investigate the morphological features of the distal femur, with a specific focus on the facies patellaris femoris.

METHODS

A total of 45 dry femurs from adult individuals (24 right, 21 left) were used for the study. Measurements were taken using a calibrated digital vernier caliper and a contour gauge.

RESULTS

Anteroposterior (AP) measurements were taken for the medial and lateral condyles of the femur, as well as the articular surfaces of the facies patellaris, sulcus height (51.186±3.81mm), trochlear depth (7.436±1.19mm), and trochlear index (2.295±0.06mm). The results showed that the width of the facies patellaris had a significant positive correlation with the trochlear depth and trochlear index. The length of the facies patellaris was positively correlated with the AP length of the medial condyle and sulcus height, although it was not statistically significant. Additionally, there was a statistically significant positive correlation between the length, width, and medial and lateral articular surfaces of the facies patellaris (p<0.005).

CONCLUSION

Understanding the relationship between the morphometry of the medial and lateral condyles of the distal femur and the morphometry of the facies patellaris, sulcus height, trochlear depth, and trochlear index and examining the anatomy of the distal femur and patella in individuals are crucial factors for determining appropriate medical treatment and implant selection and compatibility. The findings of this study are expected to contribute to clinicians' interventions in this region (total knee arthroplasty/replacement operation etc.). These data can also be used by implant designers and forensic experts during investigations.

No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft.

METHODS

A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score.

RESULTS

Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052).

CONCLUSION

The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction.

LEVEL OF EVIDENCE

Level IV.

Femoral Anteversion Measured by the Surgical Transepicondylar Axis Is Correlated with the Tibial Tubercle-Roman Arch Distance in Patients with Lateral Patellar Dislocation

Background and Objectives: Various predisposing factors for lateral patellar dislocation (LPD) have been identified, but the relation between femoral rotational deformity and the tibial tubercle-Roman arch (TT-RA) distance remains elusive. Materials and Methods: We conducted this study including 72 consecutive patients with unilateral LPD. Femoral anteversion was measured by the surgical transepicondylar axis (S-tAV), and the posterior condylar reference line (P-tAV), TT-RA distance, trochlear dysplasia, knee joint rotation, patellar height, and hip-knee-ankle angle were measured by CT images or by radiographs. The correlations among these parameters were analyzed, and the parameters were compared between patients with and without a pathological TT-RA distance. Binary regression analysis was performed, and receiver operating characteristic curves were obtained. Results: The TT-RA distance was correlated with S-tAV (r = 0.360, p = 0.002), but the correlation between P-tAV and the TT-RA distance was not significant. S-tAV had an AUC of 0.711 for predicting a pathological TT-RA, with a value of >18.6° indicating 54.8% sensitivity and 82.9% specificity. S-tAV revealed an OR of 1.13 (95% CI [1.04, 1.22], p = 0.003) with regard to the pathological TT-RA distance by an adjusted regression model. Conclusions: S-tAV was significantly correlated with the TT-RA distance, with a correlation coefficient of 0.360, and was identified as an independent risk factor for a pathological TT-RA distance. However, the TT-RA distance was found to be independent of P-tAV.

Management of the first episode of traumatic patellar dislocation: an international survey

PURPOSE

This international survey aimed to evaluate the potential controversies regarding the management of first patellar dislocation amongst experienced knee surgeries in the treatment of the first episode of patellar dislocation without osteochondral fragments.

METHODS

An online survey was conducted from February 2021 to December 2021 to assess the global trend in the diagnosis and management of first-time patellar dislocation without osteochondral fragments. The online survey was accessible on the homepage of the website of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The questionnaire consisted of multiple-choice questions and was divided into three sections. The first section consisted of eight questions regarding demographic information, professional activity, and responder experience. The second section consisted of 13 questions regarding the approach to a first patellar dislocation (clinical examination, imaging, and rehabilitation). The third section contained 2 questions concerning the relevance of patient characteristics to the therapeutic algorithm (age, sports, and pathoanatomical predisposing risk factors).

RESULTS

A total of 438 orthopaedic surgeons worldwide completed the questionnaire. At the first approach to diagnose a first-time patellar dislocation, 251 (57%) of the surgeons requested plain radiographs, and 158 (36%) requested magnetic resonance imaging (MRI). In conservatively treated patients, 368 (84%) of the respondents recommended the use of a knee brace. Amongst them, 14 (3%) advocated its use for one week, 75 (17%) for two weeks, 123 (28%) for three weeks, 105 (24%) for four weeks, and 97 (22%) for six weeks. In conservatively treated patients, 215 (49%) of the surgeons recommended load to tolerance, 148 (34%) recommended 30% to 60% of the bodyweight, and 75 (17%) advised against weight-bearing. More than half of the surgeons considered a patient aged less than 35 years practising contact sports to be a candidate for the medial patello-femoral ligament (MPFL) procedure. In addition, a tibial tuberosity to trochlear groove distance (TT-TG) distance of 15 to > 20 mm (for > 75% of the surgeons) and a trochlea types C and D (for > 70% of the surgeons) were considered possible indications for direct surgical management.

CONCLUSION

At the first approach to diagnose a first-time patellar dislocation, plain radiographs and MRI should be performed. In conservatively treated patients, most of the surgeons recommend weight-bearing to tolerance and a knee brace during the first four weeks, with range of motion of full extension to 30° during the first 15 days and up to 60° for an additional 15 days. Surgical management should be performed in patients in the second and third decades of life practising contact sports and in those patients who present types C and D trochlea dysplasia and patella alta.

LEVEL OF EVIDENCE

IV.

Articular cartilage delamination at eight years following cellular-based repair procedures: a case reports

This report describes two cases of late cartilage delamination in two young adults after two different autologous cell-based techniques for cartilage restoration: 1. Matrix-assisted autologous chondrocyte implantation (MACI) and 2. Hyaluronic acid-bone marrow aspirate concentrate (HA-BMAC). Both cases demonstrate that even in patients who do not present with any ongoing symptoms after primary surgery, a cellular-based graft's subsequent delamination can occur later. It is possible that regardless of the technique used or the time passed since the surgery, a graft failure may occur at some level, causing delamination of a previously asymptomatic cartilage restoration graft and a traumatic event with long-term follow-up. Surgeons must be alert to this injury and describe histologic findings to determine where failure occurs.

Tibial Tubercle to Trochlear Groove Distance Measured by Posterior Condylar Reference Line on MRI Can Over-Evaluate Lateralization Deformity of Tibial Tubercle in Patients with Recurrent Patellar Dislocation

Background: The tibial tubercle to trochlear groove (TT-TG) distance is currently considered as an indication for tibial tubercle osteotomy. While the influence of femoral condylar morphology on such measurement remains unclear. Methods: A total of 86 patients with patellar dislocation (PD) and 86 healthy individuals were enrolled. Femoral condylar morphology and the TT-TG distance measured by anatomical transepicondylar axis (TT-TGa), by surgical transepicondylar axis (TT-TGs), and by posterior condylar reference line (TT-TGp) were assessed by MRI. Unpaired t-test, Spearman, and Pearson correlation analysis were conducted. We determined the pathological value of the parameters and established a binary regression model. Results: The interclass correlation coefficients of all the TT-TG distances were greater than 0.75 in all types of trochlear dysplasia. The lateral/posterior femoral condyle was shorter and the medial/posterior condyle was longer in the study group (28.5 ± 3.3 and 35.2 ± 2.8, respectively) than in the control group (30.9 ± 2.7 and 33.5 ± 2.3, respectively). In the study group, the TT-TGp distance was greater than TT-TGs and TT-TGa distance (p < 0.001). The pathological value of the TT-TG distance was 13.0 mm. Each TT-TG distance revealed a significant OR with regard to PD. Conclusion: The TT-TGa, TT-TGs, and TT-TGp distance can be reliably measured by MRI even in patients with trochlear dysplasia. While the TT-TGp distance may overestimate the lateralization deformity of the tibial tubercle. Posterior femoral condylar dysplasia may be a reason for such overestimating. These findings have not been correlated to clinical outcomes and further studies are required.