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Introduction: To achieve the most desirable post-operative results, operation techniques and procedures for total knee arthroplasty (TKA) are highly standardized. However, debates persist whether patients having undergone a gap balancing technique (GB) perform better than those having undergone measured resection (MR) technique. Therefore, a meta-analysis study was conducted to investigate advantages of GB compared to the MR. The focus of the present study was on clinical and functional scores, radiological measurements and further complications., Materials and Methods: The present meta-analysis was conducted according to the PRISMA checklist. In November 2019, literature search was performed. All clinical studies comparing measured resection technique versus gap balancing technique for primary total knee arthroplasty were considered for inclusion. Only articles reporting quantitative data under the outcomes of interest were eligible for inclusion. The methodological quality assessment and statistical analyses were performed through the Review Manager Software version 5.3 (The Cochrane Collaboration, Copenhagen)., Results: Data from 25 clinical trials (2971 procedures) were collected. Patient baseline demonstrated a good comparability. No difference among the two cohorts was found in terms of SF-12 Mental and Physical, ROM, KSS, KSS Function, OKS, WOMAC. No difference was found in the alignment of mechanical axis and femoral rotation. During the knee motion, no difference was found between the medial and lateral gaps among the two techniques. The GB showed a significant elevated joint line (P < 0.0001), along with a longer duration of the operating time (P = 0.001). No differences were found in terms of revision surgery, aseptic loosening or prosthetic infections., Conclusion: GB and MR achieve similar outcomes for TKA. In the GB group, a proximalisation of the joint line and extended operating time was detected. Regarding the additional outcomes of interest, the present analysis showed comparability between both groups, MR and GB.

Introduction: Alternatives to the classical medial parapatellar (MPP) approach for total knee arthroplasty (TKA) include the mini-medial parapatellar (MMPP), mini-subvastus (MSV), mini-midvastus (MMV) and quadriceps-sparing (QS) approaches. The best approach has been not fully clarified. The purpose of the present study was to conduct a Bayesian network meta-analysis comparing these approaches., Materials and Methods: The present analysis was carried out according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. The databases search was performed in October 2019. All clinical trials comparing two or more approaches for primary TKA were considered for inclusion. The baseline comparability was evaluated through the analysis of variance (ANOVA) test. The statistical analysis was performed through the STATA software/MP. A Bayesian hierarchical random-effects model analysis was adopted in all the comparisons., Results: Data from 52 articles (4533 patients) were collected. The mean follow-up was 20.38 months. With regard to diagnosis, gender, age and BMI, adequate baseline comparability was detected. The MSV approach ranked better concerning clinical scores (the lowest visual analogic scale, the higher KSS and KSFS) and functional outcomes (the shortest straight leg raise, the greatest degree of flexion and range of motion). Concerning perioperative data, the MSV evidenced the shortest hospital stay, while the MPP the shortest surgical duration and lowest estimated blood loss., Conclusion: According to the main findings of the present study, the mini-subvastus approach for total knee arthroplasty demonstrated superior overall compared to the other approaches. Orthopaedic surgeons should consider this approach in the light of the evidence and limitations of this Bayesian network meta-analysis.

Rationale and Objectives: Up to now, the diagnosis of tendinopathies is based on conventional B-mode-ultrasound (B-US), Power Doppler-ultrasound (PD-US), and magnetic resonance imaging. In the past decade, Shear Wave Elastography (SWE) has been introduced in tendon imaging, for example in athletes or patients suffering from tendinopathy. SWE allows real-time quantification of tissue stiffness, and, by this, the assessment of the mechanical properties of a tendon and its changes during acute disease and tendon healing. So far there are no ultrasound-based studies that have evaluated postoperative tendon changes, anatomical and mechanical properties and tendon healing of the patellar, and quadriceps tendon following Total Knee Arthroplasty (TKA). The purpose of this prospective study was two-fold: first to analyze morphologic, vascular, and mechanical properties of patellar and quadriceps tendons in patients following TKA; and, second to evaluate possible changes thereof and their visibility in the course of time., Materials and Methods: Observational cross-sectional, IRB-approved study in 63 postoperative patients with a total of 76 total knee arthroplasties (50 unilateral, 13 bilateral) and 50 nonoperated knees for comparison, resulting in 152 postoperative patellar- and quadriceps and 100 nonoperated patellar- and quadriceps-tendons for comparative analysis. For further examination, we divided the 63 patients into two groups according to the duration since surgery (group A < 24 months; group B > 24 months). All patients completed a standardized questionnaire, furthermore the Knee Society score and the Knee Society function score. The amount of experienced pain was assessed using the ordinal numeric rating scale and the presence of anterior knee pain was examined. Subsequently every participant underwent a standardized multimodal ultrasound protocol consisting of B-US, PD-US, and SWE of the left and right patellar and quadriceps tendons., Results: Using the different US-modalities, operated patellar, and quadriceps tendons (n = 152) were significantly more frequent classified as pathological (B-US) (p < 0.001), the mean Ohberg score was significantly higher (PD-US) (p < 0.001), and the tendons were significantly softer (SWE) than their nonoperated counterparts (n = 100). Mean SWE-value of postoperative patellar tendons was 45.66 ± 14.84 kPa versus 60.08 ± 19.13 kPa in nonoperated knees (p < 0.001). Mean SWE-value of postoperative quadriceps tendons was 35.73 ± 15.66 kPa versus 52.69 ± 16.20 kPa in nonoperated knees (p < 0.001). Comparing the two postoperative groups (group A and B), we recognized a significant decrease of pathologically classified patellar and quadriceps tendons (B-US and PD-US) in group B. The early postoperatively reduced SWE values slightly increased during the course of time., Conclusion: After TKA, patellar, and quadriceps tendons show significant measurable alterations in B-US, PD-US, and SWE. Especially a significant decrease of tendon stiffness in operated knees, as assessed by SWE, might be a surrogate marker for changed mechanical properties. These alterations improve, the longer ago the surgery was. The quantitative information obtained by SWE could be of particular interest in follow-up and therapy monitoring after TKA. Knowledge about tendon stiffness and it's varieties in different population groups (e.g. athletes, elderly, postoperative patients) is crucial to sonographically rate a tendon as "healthy" or "diseased.", (Copyright © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Purpose: Dissatisfaction and an impaired quality of life after total knee arthroplasty (TKA) is often associated with postsurgical anterior knee pain (AKP). The underlying pathological mechanisms are not yet fully understood. Therefore, a multifactorial approach encompassing clinical and radiological parameters seemed reasonable and promising to investigate postsurgical AKP., Methods: In this cross-sectional study, 25 patients without and 25 patients with postsurgical AKP after unilateral TKA were randomly recruited from a larger cohort of patients. Multiple clinical and radiological parameters-including real-time shear wave elastography (SWE) to measure the patellar and quadriceps tendon elasticity-were acquired and subsequently associated with AKP. For statistical analysis, SPSS (IBM, version 25) was used., Results: In total 50 participants (58.0% men, mean age 63.42 years, mean body mass index 29.75 kg/m 2 ), having different prosthetic designs implanted, were included. Independently of key covariates, the strength of the quadriceps muscle ( p = 0.021), a thinner inlay ( p = 0.041), and a lower position of the patella ( p = 0.041) were associated with AKP. Although no correlation with AKP was found ( p = 0.346, resp. p = 0.154), we observed significantly decreased Young's modulus of the patellar and quadriceps tendons for the involved knee compared to the uninvolved knee ( p < 0.001)., Conclusion: In conclusion, quadriceps muscle strength, inlay thickness, and the patella position might be of particular relevance in avoiding postsurgical AKP. Future studies with larger sample sizes are needed to clarify the impact of quadriceps muscle strength and the postoperative patella position as well as the role of SWE as a personalized modifiable prediction marker.

Introduction: The aim of multidisciplinary rehabilitation after total knee replacement (TKA) is to reduce postoperative complications and costs and enable faster convalescence. The goals of fast-track rehabilitation, as a multidisciplinary concept, are to reduce the length of hospital stay and achieve early functional improvements by optimizing the perioperative setting., Method: A literature review was carried out for the years 1960-2013. The search terms were: "rehabilitation", "training", "physiotherapy", "physical therapy", "recovery", "exercise program", "knee surgery", "TKA", "total knee replacement", "arthroplasty", "intensive", "multidisciplinary", "accelerated", "rapid" or "fast track". Only randomized controlled trials and metaanalyses were included. A survey was also performed to assess care as actually offered in orthopaedic rehabilitation clinics in North Rhine-Westphalia., Results: A total of 729 articles were identified of which 11 studies were included. Fast-track rehabilitation can significantly reduce both the duration of hospital stay and costs after TKA. Current studies showed that a better short-/middle-term clinical outcome might be achieved with multidisciplinary rehabilitation. However, a difference in the long-term outcome could not be observed. Our survey shows that most patients are admitted to a rehabilitation clinic in a state of poor general condition as well as decreased mobility and knee range of motion., Conclusions: Fast-track rehabilitation facilitates a shortened hospital stay as well as cost saving. It probably can be used to optimize the condition of the patient before admission to a rehabilitation facility., (© Georg Thieme Verlag KG Stuttgart · New York.)