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Arthroscopy : the Journal of... Jun 2024To compare the sagittal position of the tibial tubercle in relation the trochlea groove in patients with and without trochlear dysplasia (TD).
PURPOSE
To compare the sagittal position of the tibial tubercle in relation the trochlea groove in patients with and without trochlear dysplasia (TD).
METHODS
All patients between January 2017 and December 2020 with high-grade TD (Dejour type B, C and D) who underwent patellar stabilizing surgery for patellar instability at a single institution were included in the current study. Patients without preoperative magnetic resonance imaging (MRI), any prior osteotomy on the affected lower extremity or cruciate ligament insufficiency were excluded. Patients who underwent knee arthroscopy for meniscal repair/debridement without any signs of TD or any of the above-mentioned criteria served as control group. Preoperative magnetic-resonance imaging (MRI) was retrospectively assessed to compare common patellofemoral anatomic parameters including patellar angle, patellar tilt, patella morphology according to Wiberg, Caton-Deschamps index (CDI), PF index, trochlear sulcus angle, sulcus depth, lateral inclination angle of the trochlea, tibiofemoral rotation, TTTG and sTTTG distance, between both groups. The sTTTG is measured as the distance between the nadir point of the cartilaginous trochlear groove and the most anterior point of the tibial tubercle on an axial MRI. Independent predictors for the sTTTG were assessed for patients with TD.
RESULTS
Patients with high-grade TD (n=82) showed an increased patellar tilt, CDI, trochlear sulcus angle, lateral tibiofemoral rotation angle, TTTG and sTTTG (9.16 ± 4.47 mm vs. 2.66 ± 4.21 mm) compared to the control group (n=83) (p<0.001). Patellar angle, PF index, sulcus depth and lateral inclination angle of the trochlear were significantly decreased in the TD group (p<0.001). The sTTTG was similar in all TD groups (n.s.). Among patients with TD, both tibiofemoral rotation and patellar height were independent predictors of the sTTTG (p<0.05).
CONCLUSION
Patients with high-grade TD show not only abnormal values in common patellofemoral instability risk factors, but also a significantly increased sTTTG compared to patients without TD.
LEVEL OF EVIDENCE
Retrospective case comparative study, III.
PubMed: 38844015
DOI: 10.1016/j.arthro.2024.05.023 -
Arthroscopy Techniques May 2024Patellar tendinopathy is an overuse injury of the patella tendon common in jumping sports or activities. Degeneration of the patellar tendon fibers causes microtears in...
Patellar tendinopathy is an overuse injury of the patella tendon common in jumping sports or activities. Degeneration of the patellar tendon fibers causes microtears in the tendon, leading to partial patellar tendon tears. If nonoperative treatment fails and the tears are mild, a debridement of the detached tissue with a patella tendon repair can help to reduce pain, promote healing, and improve function. However, if more than 50% of the patella tendon attachment to the inferior pole of the patella is detached, a debridement with a patellar tendon reconstruction is indicated to restore the strength of the patellar tendon. This reconstruction technique uses gracilis and semitendinosus autografts to surround and reconstruct the patellar tendon. Tunnels are drilled horizontally at the tibial tubercle and through the midpoint of the patella for graft passage. This technique can help to improve patient outcomes and reduce some of the risk of failure associated with performing only the debridement when significant partial patellar tendon tearing is present.
PubMed: 38835451
DOI: 10.1016/j.eats.2024.102931 -
The Knee Jun 2024Extensor mechanism (EM) disruption is a rare but severe complication of total knee arthroplasty (TKA) that can greatly impair function. Treatment options for chronic...
A unique case report of a revision extensor mechanism reconstruction using Marlex mesh in the setting of proximal tibial bone deficiency: The tantalum clamshell technique.
Extensor mechanism (EM) disruption is a rare but severe complication of total knee arthroplasty (TKA) that can greatly impair function. Treatment options for chronic patella tendon ruptures include primary repair, autograft augmentation, and reconstruction with allograft or synthetic material. Despite various techniques, failures can occur, and options for reconstruction after a failed allograft or mesh are limited, especially if the tibial component is well-fixed and cannot be easily removed, and if there is proximal tibial deficiency from a previous failed EM allograft. This case report presents a novel solution for revision EM reconstruction in a 72y.o. female patient with a history of multiple EM failures using an off-label Trabecular Metal Cone-Mesh-Cone (TM CMC) clamshell construct. The surgical procedure involved the removal of a non-viable allograft from the knee joint and the creation of a custom trabecular metal (TM) clamshell construct with a Marlex mesh graft in between the two TM implants. The customized TM cone was designed to cover the deficient anterior tibia and wrap around the ingrown TM cone. The Marlex mesh was cemented between the existing implant and the customized TM cone, and the construct was secured in place with two cancellous screws. The mesh was tunneled between soft tissue to prevent contact with the implant and rotated scar tissue was interposed to prevent abrasion of the mesh on the implant surfaces. The patient tolerated the procedure well and no complications were noted postoperatively. At a follow-up 12 months after the operation the patient remains satisfied with the result.
PubMed: 38833774
DOI: 10.1016/j.knee.2024.03.001 -
International Journal of Surgery... Jun 2024The demand for telesurgery is rapidly increasing. Augmented reality (AR) remote surgery is a promising alternative, fulfilling a worldwide need in fracture surgery....
BACKGROUND
The demand for telesurgery is rapidly increasing. Augmented reality (AR) remote surgery is a promising alternative, fulfilling a worldwide need in fracture surgery. However, previous AR endoscopic and Google Glass remotes remain unsuitable for fracture surgery, and the application of remote fracture surgery has not been reported. We aimed to evaluated the safety and clinical effectiveness of a new AR remote in fracture surgery.
MATERIALS AND METHODS
This retrospective non-inferiority cohort study was conducted at three centres. Between January 1, 2018, and March 31, 2022, 800 patients who underwent fracture surgery were eligible for participation. The study enrolled 551 patients with fractures (132 patellae, 128 elbows, 126 tibial plateaus, and 165 ankles) divided into an AR group (specialists used AR to remotely guide junior doctors to perform surgeries) and a traditional non-remote group (specialists performed the surgery themselves).
RESULTS
Among 364 patients (182 per group) matched by propensity score, seven (3.8%) in the AR group and four (3%) in the non-remote group developed complications. The 0.005 risk difference (95% confidence interval: -0.033 to 0.044) was below the pre-defined non-inferiority margin of a 10% absolute increase. A similar distribution in the individual components of all complications was found between the groups. Hierarchical analysis following propensity score matching revealed no statistical difference between the two groups regarding functional results at 1-year follow-up, operative time, amount of bleeding, number of fluoroscopies, and injury surgery interval. A Likert scale questionnaire showed positive results (median scores: 4-5) for safety, efficiency, and education.
CONCLUSION
This study is the first to report that AR remote surgery can be as safe and effective as that performed by a specialist in person for fracture surgery, even without the physical presence of a specialist, and is associated with improving the skills and increasing the confidence of junior surgeons. This technique is promising for remote fracture surgery and other open surgeries, offering a new strategy to address inadequate medical care in remote areas.
PubMed: 38833338
DOI: 10.1097/JS9.0000000000001662 -
Journal of Children's Orthopaedics Jun 2024The purpose of this study is to assess clinical and functional outcomes in separate cohorts of operatively and nonoperatively managed pediatric patella fractures.
PURPOSE
The purpose of this study is to assess clinical and functional outcomes in separate cohorts of operatively and nonoperatively managed pediatric patella fractures.
METHODS
A retrospective review was completed for patients aged 5-19 years treated for a unilateral patella fracture at a single pediatric level-1 trauma center. Patients were excluded for osteochondral fracture associated with patellar dislocation, polytrauma presentation with additional fractures, or <3 months of clinical follow-up. Functional outcomes were assessed via the Pediatric International Knee Documentation Committee form and the Marx Knee Activity Scale.
RESULTS
A total of 53 patients met inclusion criteria; 30 patients were treated operatively and 23 patients were treated nonoperatively. Patients with patellar sleeve/pole fractures were significantly younger by 5.2 years (p < 0.01) and presented with greater variability in mechanism of injury (p < 0.01). The nonoperative cohort achieved bony healing and returned to sports at a median (interquartile range) of 1.7 (1.2-2.3) months and 2.8 (2.3-3.3) months, respectively, post-injury. The operative group achieved bony healing and returned to sports at 2.8 (2.1-3.5) months and 5.9 (4.0-7.1) months, respectively, following surgery. Median (interquartile range) Pediatric International Knee Documentation Committee and Marx scores were 98 (89-100) and 14 (10-16), respectively, for the nonoperative group, and 92 (84-99) and 13 (12-16), respectively, for the operative group. No significant differences in patient-reported outcomes were observed between fracture patterns or treatment cohorts.
CONCLUSION
Pediatric and adolescent patients sustaining patella fractures reported long-term functional outcomes comparable to normative values, across multiple fracture patterns and with appropriate operative and nonoperative treatment. Fractures requiring surgery were expectedly associated with slower healing and return to sport timelines.
LEVEL OF EVIDENCE
Therapeutic Level III.
PubMed: 38831855
DOI: 10.1177/18632521241232301 -
Bone & Joint Open Jun 2024During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the...
The clinical and cost-effectiveness of elective primary total knee replacement with PAtellar Resurfacing compared to selective patellar resurfacing: a pragmatic multicentre randomized controlled Trial (PART).
AIMS
During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon's decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing.
METHODS
The PAtellar Resurfacing Trial (PART) is a patient- and assessor-blinded multicentre, pragmatic parallel two-arm randomized superiority trial of adults undergoing elective primary TKR for primary osteoarthritis at NHS hospitals in England, with an embedded internal pilot phase (ISRCTN 33276681). Participants will be randomly allocated intraoperatively on a 1:1 basis (stratified by centre and implant type (cruciate-retaining vs cruciate-sacrificing)) to always resurface or selectively resurface the patella, once the surgeon has confirmed sufficient patellar thickness for resurfacing and that constrained implants are not required. The primary analysis will compare the Oxford Knee Score (OKS) one year after surgery. Secondary outcomes include patient-reported outcome measures at three months, six months, and one year (Knee injury and Osteoarthritis Outcome Score, OKS, EuroQol five-dimension five-level questionnaire, patient satisfaction, postoperative complications, need for further surgery, resource use, and costs). Cost-effectiveness will be measured for the lifetime of the patient. Overall, 530 patients will be recruited to obtain 90% power to detect a four-point difference in OKS between the groups one year after surgery, assuming up to 40% resurfacing in the selective group.
CONCLUSION
The trial findings will provide evidence about the clinical and cost-effectiveness of always patellar resurfacing compared to selective patellar resurfacing. This will inform future NICE guidelines on primary TKR and the role of selective patellar resurfacing.
PubMed: 38828864
DOI: 10.1302/2633-1462.56.BJO-2023-0154 -
The American Journal of Sports Medicine Jun 2024Because of the increased prevalence of revision anterior cruciate ligament (ACL) reconstruction, there has been a desire to understand the role of posterior tibial slope...
BACKGROUND
Because of the increased prevalence of revision anterior cruciate ligament (ACL) reconstruction, there has been a desire to understand the role of posterior tibial slope on increased anterior tibial translation and increased ACL graft forces. One potential concern in supratubercle anterior closing wedge proximal tibial osteotomy (ACW-PTO) for decreasing the posterior tibial slope is the risk of altering the patellar height.
PURPOSE
To radiographically assess changes in (1) patellar height, (2) anterior tibial translation, and (3) posterior tibial slope after supratubercle ACW-PTO.
STUDY DESIGN
Case series; Level of evidence, 4.
METHODS
Patients who underwent supratubercle ACW-PTO by a single surgeon between July 2019 and June 2023 were included. Standardized lateral knee weightbearing radiographs to assess patellar height (via the Caton-Deschamps index), anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle, and posterior tibial slope were obtained at 4 time points (preoperatively and 1 day, 3 months, and 6 months postoperatively). Paired test was used to compare differences between preoperative, 1-day, and 3- and 6-month values for patellar height as measured using the Caton-Deschamps index and for posterior tibial slope. Paired test was also used to compare differences in the preoperative and 6-month postoperative values for anterior tibial translation.
RESULTS
In 20 patients after ACW-PTO, the Caton-Deschamps index demonstrated a significant increase in patellar height on postoperative day 1 ( < .001) but no significant differences at 3 ( = .057) and 6 ( = .176) months postoperatively. Anterior tibial translation on standing lateral knee radiographs was significantly decreased by a mean of 8.9 mm from preoperatively to 6 months postoperatively ( < .001). Posterior tibial slope was significantly decreased by a mean of 11.2° from preoperatively to 6 months postoperatively ( < .001).
CONCLUSION
Supratubercle ACW-PTO performed for ACL reconstruction failure in the setting of an increased posterior tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, after ACW-PTO, there was a significant decrease in anterior tibial translation and posterior tibial slope.
PubMed: 38828643
DOI: 10.1177/03635465241252982 -
Clinics in Orthopedic Surgery Jun 2024Treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments is a challenge. To treat this difficult fracture, we...
Articular Fragment Detachment and Separate Fixation for the Treatment of Comminuted Patellar Fractures with Coronal Split Articular Fragments: Articular Detachment Technique.
BACKGROUND
Treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments is a challenge. To treat this difficult fracture, we perform articular fragment detachment and separate fixation for coronal split articular and inferior pole fragments. We aimed to evaluate the radiological and clinical outcomes of our technique in comminuted patellar fractures at least 1 year after surgery.
METHODS
Between January 2019 and June 2022, 15 patients diagnosed with comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments based on preoperative computed tomography underwent surgery using the articular detachment technique. The key point of this technique was anatomical reduction and subchondral fixation of the coronal split articular fragment to the superior main fragment after complete detachment of the coronal split fragment from the inferior pole. The remaining inferior pole was fixed using a separate construct. Postoperative articular gap, articular step-off, and complications, including resorption, reduction loss, and avascular necrosis of fixed articular fragments, were evaluated as radiological outcomes. Range of motion and the Lysholm scores were used to evaluate clinical outcomes.
RESULTS
Among the 15 patients, the coronal split articular fragments were fixed using Kirschner wires in 13 patients and headless screws in 2 patients. The inferior poles were fixed using separate vertical wiring in 13 patients and tension-band wiring in 2 patients. A postoperative articular gap was noted in 7 patients, with an average articular gap of 1.0 mm (range, 0.7-1.6 mm). No articular step-off was observed. Bone union and normal range of motion were achieved in all patients. On the 1-year postoperative lateral radiograph, resorption of the articular fracture site was seen in 5 patients. There was no loss of reduction or avascular necrosis of the coronal split articular fragments. The average postoperative Lysholm score at 1 year was 89.3 ± 4.1 (range, 82-95).
CONCLUSIONS
The technique would be a reliable and safe option for the surgical treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments in terms of anatomical reduction and stable fixation of articular fragments without risk of avascular necrosis.
Topics: Humans; Fractures, Comminuted; Patella; Male; Female; Adult; Fracture Fixation, Internal; Middle Aged; Bone Wires; Retrospective Studies; Tomography, X-Ray Computed; Young Adult; Bone Screws; Fractures, Bone
PubMed: 38827765
DOI: 10.4055/cios23302 -
BioRxiv : the Preprint Server For... May 2024Neofunctionalization of duplicated gene copies is thought to be an important process underlying the origin of evolutionary novelty and provides an elegant mechanism for...
Neofunctionalization of duplicated gene copies is thought to be an important process underlying the origin of evolutionary novelty and provides an elegant mechanism for the origin of new phenotypic traits. One putative case where a new gene copy has been linked to a novel morphological trait is the origin of the arachnid patella, a taxonomically restricted leg segment. In spiders, the origin of this segment has been linked to the origin of the paralog , suggesting that a new gene facilitated the expression of a new trait. However, various arachnid groups that possess patellae do not have a copy of , disfavoring the direct link between gene origin and trait origin. We investigated the developmental genetic basis for patellar patterning in the harvestman , which lacks . Here, we show that the harvestman patella is established by a novel expression domain of the transcription factor . Leveraging this definition of patellar identity, we surveyed targeted groups across chelicerate phylogeny to assess when this trait evolved. We show that a patellar homolog is present in Pycnogonida (sea spiders) and various arachnid orders, suggesting a single origin of the patella in the ancestor of Chelicerata. A potential loss of the patella is observed in Ixodida. Our results suggest that the modification of an ancient gene, rather than the neofunctionalization of a new gene copy, underlies the origin of the patella. Broadly, this work underscores the value of comparative data and broad taxonomic sampling when testing hypotheses in evolutionary developmental biology.
PubMed: 38826321
DOI: 10.1101/2024.05.16.594547 -
Journal of Orthopaedic Surgery and... May 2024The patellar height index is important; however, the measurement procedures are time-consuming and prone to significant variability among and within observers. We...
BACKGROUND
The patellar height index is important; however, the measurement procedures are time-consuming and prone to significant variability among and within observers. We developed a deep learning-based automatic measurement system for the patellar height and evaluated its performance and generalization ability to accurately measure the patellar height index.
METHODS
We developed a dataset containing 3,923 lateral knee X-ray images. Notably, all X-ray images were from three tertiary level A hospitals, and 2,341 cases were included in the analysis after screening. By manually labeling key points, the model was trained using the residual network (ResNet) and high-resolution network (HRNet) for human pose estimation architectures to measure the patellar height index. Various data enhancement techniques were used to enhance the robustness of the model. The root mean square error (RMSE), object keypoint similarity (OKS), and percentage of correct keypoint (PCK) metrics were used to evaluate the training results. In addition, we used the intraclass correlation coefficient (ICC) to assess the consistency between manual and automatic measurements.
RESULTS
The HRNet model performed excellently in keypoint detection tasks by comparing different deep learning models. Furthermore, the pose_hrnet_w48 model was particularly outstanding in the RMSE, OKS, and PCK metrics, and the Insall-Salvati index (ISI) automatically calculated by this model was also highly consistent with the manual measurements (intraclass correlation coefficient [ICC], 0.809-0.885). This evidence demonstrates the accuracy and generalizability of this deep learning system in practical applications.
CONCLUSION
We successfully developed a deep learning-based automatic measurement system for the patellar height. The system demonstrated accuracy comparable to that of experienced radiologists and a strong generalizability across different datasets. It provides an essential tool for assessing and treating knee diseases early and monitoring and rehabilitation after knee surgery. Due to the potential bias in the selection of datasets in this study, different datasets should be examined in the future to optimize the model so that it can be reliably applied in clinical practice.
TRIAL REGISTRATION
The study was registered at the Medical Research Registration and Filing Information System (medicalresearch.org.cn) MR-61-23-013065. Date of registration: May 04, 2023 (retrospectively registered).
Topics: Deep Learning; Humans; Patella; Retrospective Studies; Male; Female; Automation; Radiography; Middle Aged; Adult
PubMed: 38822361
DOI: 10.1186/s13018-024-04809-6