Background: Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue–based stabilization. Purpose: To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations. Results: Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%). Conclusion: TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.
Background: Meniscal extrusion has become increasingly utilized when evaluating meniscus root abnormalities. However, no consensus definition or approach exists on how to measure extrusion. Purpose/Hypothesis: The purpose of this study was to evaluate the extent of heterogeneity in meniscal extrusion measurement techniques and reported extrusion values in knees with posterior medial meniscus root tears (PMMRTs). We hypothesized that meniscal extrusion measurement techniques would vary considerably throughout reported studies, with resultant wide-ranging published extrusion values. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The inclusion criteria consisted of all clinical and cadaveric studies reporting on meniscal extrusion after PMMRTs, excluding studies lacking data in full extension, those presenting only semiquantitative analyses, articles reporting only differences in meniscal extrusion, and review articles. Results: A total of 45 studies were included. Imaging modality types included magnetic resonance imaging (89%), 3-dimensional reconstruction with computed tomography (7%), linear displacement transducers (2%), and a combination of magnetic resonance imaging and ultrasound (2%). The 3 most commonly used landmarks to acquire coronal images for meniscal extrusion measurements were the medial collateral ligament (38%), the midpoint of the anterior-posterior length of the medial meniscus (23%), and the middle of the medial femoral condyle (19%). The pooled mean extrusion values according to the measurement location were 3.5 ± 0.7 mm, 3.9 ± 0.8 mm, and 4.5 ± 2.1 mm, respectively, with no significant differences noted between the modality types ( P = .23). The pooled mean meniscal extrusion from all included studies was 3.2 ± 2.0 mm. Conclusion: Substantial variation exists in measurement techniques for meniscal extrusion, particularly as it relates to the coronal cross-sectional reference location. Further studies should aim to provide clear descriptions of the measurement method and have uniform measurement methodology to allow comparisons and pooling between studies.
Periprosthetic infections occur in approximately 0.8% to 1.9% of all total knee arthroplasties (TKAs). Even with these low rates, it is rare to find a zoonotic bacterium causing a periprosthetic infection. In this case report, the authors identify the second documented case of a total joint infection with Francisella tularensis in the world and the first in the United States. A 58-year-old man underwent a left TKA in 1994 and a right TKA in 1997 for severe primary bilateral knee osteoarthrosis. In 2015, he underwent polyethylene exchange for polyethylene wear. Subsequently, he developed repeated effusion without fever or constitutional signs of infection. One aspiration was sent for culture and grew F tularensis . He was treated with doxycycline for chronic suppression and currently has no signs of infection. Total joint implantation rates are expected to rise, with 3.5 million procedures projected to be performed annually by the year 2030 vs 450,000 procedures performed in 2005. With the increased number of operations, it is likely that zoonotic infections will increase as well. Thus, rare zoonotic bacterial infections as well as chronic outdoor exposure in the presence of persistent joint swelling should be considered when obtaining a patient history. [ Orthopedics . 2020; 43(1):e54–e56.]
Background: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. Purpose: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. Results: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. Conclusion: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.
The fracture of the femoral component is a rare complication of a total knee arthroplasty (TKA). This article presents a case in which a 70-year-old man underwent a left press-fit Advance Medial-Pivot Knee System TKA (MicroPort Orthopedics, Arlington, TN) in 2000. Twenty years later, he experienced a nontraumatic onset of knee pain after standing up from a lunge position. Radiographs and CT scans revealed a complete fracture of the medial condyle of the femoral component. Revision surgery was performed confirming the broken component. A cemented Triathlon Total Stabilizer (Stryker Orthopedics, Kalamazoo, MI) prosthesis was used for the revision. The authors recommend that surgeons maintain a high level of suspicion of component fracture when patients present with persistent severe knee pain and instability after a TKA.
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