How to Tame the Flood of Literature? A Round-up of Knee Surgery Research in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 37-40 |  Miten Sheth

Authors:  Miten Sheth [1].

[1] The Knee Clinic, First floor, Panchsheel Building, Paanch Rasta, Mulund West, Mumbai , India

Address of Correspondence
Dr Miten Sheth,
The Knee Clinic, First floor, Panchsheel Building, Paanch Rasta, Mulund West, Mumbai , India

There have been several interesting publications pertaining to the knee this year. Promising new technologies were described, contemporary implants and approaches were evaluated and conflicting evidence was deciphered through well-designed reviews and meta-analysis. We aim to summarize innovations, trends and consensuses in knee surgery with this article. There has been increased interest in the use of tranexamic acid (TXA) during total knee arthroplasty (TKA). The Michigan group [1] reported their experience of 23000 odd TKAs concluding that TXA use was associated with decreased blood loss and transfusion risk, without increased risk of complications. Researchers from Louisville [2] found topical TXA to be a safe and efficacious alternative to intravenous TXA. Xing et al [3] reported a meta-analysis of ten studies, including one study conducted this year at Bombay hospital [4], noting that the combination of intravenous and topical TXA reduced post-operative blood loss without increasing the risk of thromboembolism. There have been some high-profile papers concerning unicompartmental arthroplasty (UKA) recently. The Oxford UKA remains a slightly controversial intervention in the knee world. The Netherlands group [5] supported the use of Phase III mobile-bearing Oxford Knee in medial compartment osteoarthritis with 90.6% survival at fifteen years. The Texas group [6] showed 88% survivorship at ten years and excellent function. The Oxford group [7] themselves reported the largest ever single series of around 1000 UKAs with a ten-year cumulative survival rate of 93.2%. Notably, they mentioned that good results of UKAs can be achieved even by trainee surgeons, if performed at a high-volume centre. The anterior cruciate ligament (ACL) has always been an enigma and we seem to discover new things every year. Japanese surgeons from Kobe [8] evaluated factors affecting quadriceps strength recovery after ACL reconstruction with a hamstring tendon autograft. Pre-operative quadriceps strength, age, sex, and knee pain are independently associated with post-operative quadriceps strength recovery. Fink et al [9] prospectively studied acute and delayed ACL surgery patients for two years and found no impact of surgical timing on the objective and subjective outcomes. Cadaver research at Pittsburgh [10,11] concluded that the ACL isthmus is located almost half of the distance between the insertion sites. The cross-sectional area of the ACL at the isthmus is largest with the knee unloaded and at 90° of flexion, and the area decreases with extension and applied loads. ACL reconstruction with graft fixation and tension for anteromedial bundle – 45°/ 30N and posterolateral -15°/ 10N, most closely matched intact knee kinematics. Clinical research at Pittsburgh [12] revealed that increased slope of the lateral tibial plateau might be an important anatomical variable predicting high-grade rotatory laxity in patients with ACL injury. While there are raised expectations from newer approaches to ACL reconstruction like the “All-inside technique”, there is very little in the way of objective evidence to support it over the traditional methods. Surgeons from Vienna [13] and Hampshire [14] followed around 100 patients to a minimum of two years post-surgery. While both these studies reported improved functional outcomes and stability with a re-rupture rate of 12.7% and 6.5% respectively, French surgeons from Reims [15] found that a year after surgery, around 50% of patients had residual anterior tibial translation > 3 mm. Meniscal ramp and root lesions are a subject of increasing interest. Ramp lesions constitute a common but often missed entity in ACL deficient knees. Laprade et al [16] summarized the anatomy, biomechanics, diagnostic strategies, recommended treatment options, and post-operative protocol. A controlled laboratory study by Amis et al [17] proved that anterior and external rotational laxities were significantly increased after sectioning of the posteromedial menisco-capsular junction in an ACL deficient knee. These were not restored after ACL reconstruction alone but were restored by ACL reconstruction combined with posterior menisco-capsular repair. Sonnery-Cottet et al [18] classified these lesions and reported improved outcomes of ramp repair at a minimum two-year follow-up with a 6.8% failure rate. Our understanding of the meniscal root has evolved in the last five years. A critical analysis review of the evaluation, treatment and outcomes of meniscal root tears was done this year by the team from New York [19]. Mayo Clinic, Rochester [20] provided the natural history benchmark for clinical outcomes in patients undergoing non-operative treatment. Untreated root tears are associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at five year follow-up. Surgeons from Korea [21,22,23] reported favorable mid-term outcomes after pull-out fixation especially in patients with decreased meniscus extrusion at post-operative one year follow-up. Grade ≥ III chondral lesions, varus alignment, and older age were found to predict a poor prognosis after root fixation. A meta-analysis of case series showed that root repair resulted in significant improvements in the post-operative subjective scores. However, meniscus extrusion was not reduced and progression of arthrosis was not prevented completely. World literature is full of reports on osteoarthritis of the knee. However, there is little data to support decision making. A 3-year, double-blind, randomised, placebo-controlled trial of 500 odd patients studied the effect of vitamin D supplementation on knee osteoarthritis (VIDEO study) [24]. The authors concluded that vitamin D supplementation has no role in the management of knee OA. A Cochrane review by the team from Sao Paolo [25] could not draw definite conclusions to help us decide between micro fracture, drilling, mosaicplasty, and allograft transplantation for cartilage defects. Of note though, treatment failure, with recurrence of symptoms, occurred with both microfracture and mozaicplasty. Multi center trials threw light on some interesting facts this year. The Research in OsteoChondritis of the Knee (ROCK) study group [26] developed a classification system for arthroscopic evaluation of osteochondritis dissecans (OCD) of the knee that demonstrated excellent intra- and inter-observer reliability. The Multicenter Orthopaedic Outcomes Network (MOON) group [27,28] reported 32% incidence of high-grade pre-operative knee laxity in a cohort of around 2300 patients who underwent primary isolated ACL reconstruction. The presence of this laxity was associated with significantly increased odds of revision surgery but had no association with outcome scores at two years. Chronic ACL tears, generalized ligamentous laxity, and meniscus tears are associated with high-grade Lachman, pivot shift, and anterior drawer tests. Female patients and age younger than 20 years are associated with increased odds of a high-grade pivot-shift test. The Delaware-Oslo ACL cohort study [29] advised return to sports 9 months or later after ACL reconstruction, and more symmetrical quadriceps strength prior to return, to reduce the re-injury rate. The Multicenter ACL Revision (MARS) study [30] identified prior lateral meniscectomy and grade 3 to 4 changes of the trochlea as factors associated with worse outcomes after revision ACL reconstruction. Articles debating the existence of anterolateral ligament, efficacy of hyaluronic acid or platelet rich plasma, and nature of cartilage healing filled up world literature this year. Navigation, robotics and patient-specific instrumentation in total knee arthroplasty were discussed with caution, concern and confidence. In spite of the plethora of new information, a lot of questions remain unanswered yet. Original research, multi-centric collaboration and systematic analysis of published evidence are the key to better understanding of the knee.


1. Hallstrom B, Singal B, Cowen ME, Roberts KC, Hughes RE. The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty. J Bone Joint Surg Am. 2016 Oct 5;98(19):1646-1655.
2. Spanyer J, Patel J, Emberton E, Smith LS, Malkani AL. Topical Tranexamic Acid in Total Knee Arthroplasty Patients with Increased Thromboembolic Risk. J Knee Surg. 2016 Oct 5. [Epub ahead of print]
3. Yuan ZF, Yin H, Ma WP, Xing DL. The combined effect of administration of intravenous and topical tranexamic acid on blood loss and transfusion rate in total knee arthroplasty: Combined tranexamic acid for TKA. Bone Joint Res. 2016 Aug;5(8):353-61.
4. Jain NP, Nisthane PP, Shah NA. Combined Administration of Systemic and Topical Tranexamic Acid for Total Knee Arthroplasty: Can It Be a Better Regimen and Yet Safe? A Randomized Controlled Trial. J Arthroplasty. 2016 Feb;31(2):542-7.
5. Lisowski LA, Meijer LI, Bekerom MP, Pilot P, Lisowski AE. Ten- to 15-year results of the Oxford Phase III mobile unicompartmental knee arthroplasty: a prospective study from a non-designer group. Bone Joint J. 2016 Oct;98-B(10 Supple B):41-47.
6. Emerson RH, Alnachoukati O, Barrington J, Ennin K. The results of Oxford unicompartmental knee arthroplasty in the United States: a mean ten-year survival analysis. Bone Joint J. 2016 Oct;98-B(10 Supple B):34-40.
7. Bottomley N, Jones LD, Rout R, Alvand A, Rombach I, Evans T, Jackson WF, Beard DJ, Price AJ. A survival analysis of 1084 knees of the Oxford unicompartmental knee arthroplasty: a comparison between consultant and trainee surgeons. Bone Joint J. 2016 Oct;98-B(10 Supple B):22-27.
8. Ueda Y, Matsushita T, Araki D, Kida A, Takiguchi K, Shibata Y, Ono K, Ono R, Matsumoto T, Takayama K, Sakai Y, Kurosaka M, Kuroda R. Factors affecting quadriceps strength recovery after anterior cruciate ligament reconstruction with hamstring autografts in athletes. Knee Surg Sports Traumatol Arthrosc. 2016 Aug 23. [Epub ahead of print]
9. Herbst E, Hoser C, Gföller P, Hepperger C, Abermann E, Neumayer K, Musahl V, Fink C. Impact of surgical timing on the outcome of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 Aug 22. [Epub ahead of print]
10. Fujimaki Y, Thorhauer E, Sasaki Y, Smolinski P, Tashman S, Fu FH. Quantitative In Situ Analysis of the Anterior Cruciate Ligament: Length, Midsubstance Cross-sectional Area, and Insertion Site Areas. Am J Sports Med. 2016 Jan;44(1):118-25.
11. Sasaki Y, Chang SS, Fujii M, Araki D, Zhu J, Marshall B, Linde-Rosen M, Smolinski P, Fu FH. Effect of fixation angle and graft tension in double-bundle anterior cruciate ligament reconstruction on knee biomechanics. Knee Surg Sports Traumatol Arthrosc. 2016 Sep;24(9) 2892-8.
12. Rahnemai-Azar AA, Abebe ES, Johnson P, Labrum J, Fu FH, Irrgang JJ, Samuelsson K, Musahl V. Increased lateral tibial slope predicts high-grade rotatory knee laxity pre-operatively in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 May 6. [Epub ahead of print]
13. Schurz M, Tiefenboeck TM, Winnisch M, Syre S, Plachel F, Steiner G, Hajdu S, Hofbauer M. Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years’ Follow-up. Arthroscopy. 2016 Feb;32(2):332-7.
14. Yasen SK, Borton ZM, Eyre-Brook AI, Palmer HC, Cotterill ST, Risebury MJ, Wilson AJ. Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction. Knee. 2016 Sep 27.[Epub ahead of print]
15. Bressy G, Brun V, Ferrier A, Dujardin D, Oubaya N, Morel N, Fontanin N, Ohl X. Lack of stability at more than 12 months of follow-up after anterior cruciate ligament reconstruction using all-inside quadruple-stranded semitendinosus graft with adjustable cortical button fixation in both femoral and tibial sides. Orthop Traumatol Surg Res. 2016 Oct 4.[Epub ahead of print]
16. Chahla J, Dean CS, Moatshe G, Mitchell JJ, Cram TR, Yacuzzi C, LaPrade RF. Meniscal Ramp Lesions: Anatomy, Incidence, Diagnosis, and Treatment. Orthop J Sports Med. 2016 Jul 26;4(7).
17. Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA. Posteromedial Meniscocapsular Lesions Increase Tibiofemoral Joint Laxity With Anterior Cruciate Ligament Deficiency, and Their Repair Reduces Laxity. Am J Sports Med. 2016 Feb;44(2):400-8.
18. Thaunat M, Jan N, Fayard JM, Kajetanek C, Murphy CG, Pupim B, Gardon R, Sonnery-Cottet B. Repair of Meniscal Ramp Lesions Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 2-Year Follow-up. Arthroscopy. 2016 May 13.[Epub ahead of print]
19. Krych AJ, Reardon PJ, Johnson NR, Mohan R, Peter L, Levy BA, Stuart MJ. Non-operative management of medial meniscus posterior horn root tears is associated with worsening arthritis and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2016 Oct 19.[Epub ahead of print]
20. Strauss EJ, Day MS, Ryan M, Jazrawi L. Evaluation, Treatment, and Outcomes of Meniscal Root Tears: A Critical Analysis Review. JBJS Rev. 2016 Aug 9;4(8).
21. Chung KS, Ha JK, Ra HJ, Nam GW, Kim JG. Pullout Fixation of Posterior Medial Meniscus Root Tears: Correlation Between Meniscus Extrusion and Midterm Clinical Results. Am J Sports Med. 2016 Aug 24.[Epub ahead of print]
22. Chung KS, Ha JK, Ra HJ, Kim JG. Prognostic Factors in the Midterm Results of Pullout Fixation for Posterior Root Tears of the Medial Meniscus. Arthroscopy. 2016 Jul;32(7) 1319-27.
23. Chung KS, Ha JK, Ra HJ, Kim JG. A meta-analysis of clinical and radiographic outcomes of posterior horn medial meniscus root repairs. Knee Surg Sports Traumatol Arthrosc. 2016 May;24(5):1455-68.
24. Arden NK, Cro S, Sheard S, Doré CJ, Bara A, Tebbs SA, Hunter DJ, James S, Cooper C, O’Neill TW, Macgregor A, Birrell F, Keen R. The effect of vitamin D supplementation on knee osteoarthritis, the VIDEO study: a randomised controlled trial. Osteoarthritis Cartilage. 2016 Nov;24(11):1858-1866.
25. Gracitelli GC, Moraes VY, Franciozi CE, Luzo MV, Belloti JC. Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults. Cochrane Database Syst Rev. 2016 Sep 3;9:CD010675.
26. Carey JL, Wall EJ, Grimm NL, Ganley TJ, Edmonds EW, Anderson AF, Polousky J, Murnaghan ML, Nissen CW, Weiss J, Lyon RM, Chambers HG; Research in OsteoChondritis of the Knee (ROCK) Group. Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee: A Multicenter Reliability Study. Am J Sports Med. 2016 Jul;44(7):1694-8.
27. Magnussen RA, Reinke EK, Huston LJ; MOON Group, Hewett TE, Spindler KP. Effect of High-Grade Preoperative Knee Laxity on Anterior Cruciate Ligament Reconstruction Outcomes. Am J Sports Med. 2016 Aug 1.
28. Magnussen RA, Reinke EK, Huston LJ; MOON Group, Hewett TE, Spindler KP. Factors Associated With High-Grade Lachman, Pivot Shift, and Anterior Drawer at the Time of Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2016 Jun;32(6):1080-5.
29. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8.
30. MARS Group.. Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016 Jul;44(7) 1671-9.

How to Cite this article: Sheth M. How to Tame the Flood of Literature? A Round-up of Knee Surgery Research in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):37-40.

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