The Efficacy and Safety of Chinese Herbal Medicine in the Treatment of Knee Osteoarthritis: An Updated Systematic Review and Meta-Analysis of 56 Randomized Controlled Trials

Objective. This systematic review and meta-analysis were performed to investigate the efficacy and safety of Chinese herbal medicine (CHM) in the treatment of knee osteoarthritis (KOA). Methods. An electronic search was conducted in eight databases (PubMed, EMBASE, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese VIP Database, and Wanfang Database) from inception until December 2019. The risk of bias assessment of the included RCTs was evaluated by Cochrane collaboration’s tool. The inclusion criteria were RCTs that investigated the efficacy and safety of CHM in the treatment of KOA, with no restrictions on publication status or language. The exclusion criteria included nonrandomized or quasi-RCTs, no clear KOA diagnostic approach, combined Chinese medicinal herbs with other traditional Chinese medicine treatment modalities, and published using repeated data and missing data. We computed the relative risk (RR) and the standard mean difference (SMD) for dichotomous outcomes and continuous outcomes, respectively. When heterogeneity was detected or there was significant statistical heterogeneity ( P < 0.05 or I 2 > 50 % ), a random-effects model was employed, followed by further subgroup analysis and metaregression estimations to ascertain the origins of heterogeneity. Otherwise, we used a fixed-effects model ( P ≥ 0.05 or I 2 ≤ 50 % ). The primary outcome measures were visual analog score (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Lequesne index. Secondary outcome measures were the total clinical effective rate and adverse events. The meta-analysis was performed using the Stata 14.0 software. Results. A total of 56 RCTs comprising 5350 patients met the inclusion criteria. This meta-analysis showed that application of CHM as adjuvant therapy or monotherapy for KOA can significantly decrease VAS, WOMAC, and the Lequesne index and improve the Lysholm score as well as the total effective rate. In addition, this treatment has fewer adverse effects, suggesting that CHM is generally safe and well tolerated among patients with KOA. Conclusion. Our study offers supportive evidence that CHM, either adjuvant therapy or monotherapy, reduces the VAS, WOMAC, and Lequesne index and improves the Lysholm score and overall effective rate in patients with KOA. Additionally, CHM was well tolerated and safe in KOA patients. We found frequently used CHMs that might contribute to the formulation of a herbal formula that could be considered for further clinical use. However, given the heterogeneity and limited sample size in this study, larger multicenter and high-quality RCTs are needed to validate the benefits of CHM in the treatment of KOA.

Modified Langenskiöld Procedure for Congenital Patella Dislocations in Pediatric Patients

Background: Great difficulty and more failures were the descriptions of the treatment of congenital patella dislocation in pediatric patients. This study aims to evaluate the outcomes of patients with congenital patellar dislocations treated with the modified Langenskiöld procedure. Methods: The medical records of 16 knees in 11 patients with a diagnosis of congenital patella dislocation were collected from September 2016 to March 2019. They were treated with the modified Langenskiöld procedure. The mean follow-up period was 37.8 months. The outcome measures were the Lysholm score, Kujala score, patellar stability, and knee range of motion. Results: Eleven patients, namely, eight girls and three boys, with 16 knees were enrolled. The mean age at the time of operation was 3.1 years. The post-operative mean Lysholm score was 94.8 (SD 5.1; 87–100), whereas the Kujala score was 95 (SD 5.9; 86–100). There were no recurrent dislocations, and all patients had full extension postoperatively. Conclusion: The modified Langenskiöld procedure is a promising solution for the treatment of congenital patella dislocations. Level of evidence: Level IV; Case Series; Treatment Study

The Clinical Efficacy and Risk Factors after Revision and Reconstruction of Anterior Cruciate Ligament

The aim of this study was to study the clinical efficacy and prognostic factors after revision and reconstruction of anterior cruciate ligament. All the patients who underwent the first revision of anterior cruciate ligament (ACL) reconstruction in the department of sports medicine from January 2001 to December 2015 were collected. The demographic information, the first revision and reconstruction information of ACL, and the information during the first ACL reconstruction were collected. A total of 335 cases were included. Lysholm score, Tegner activity score, and IKDC subjective score at the last follow-up were significantly higher than those before operation. Compared with graft failure caused by sports injury, the postoperative scores of patients with revision due to life accidents or initial reconstruction techniques were significantly lower ( P < 0.05 ). The postoperative Lysholm score of patients with femoral canal drilling through the tibial canal was lower than that of patients with anterior internal approach. The postoperative IKDC score of patients who underwent medial meniscus suture at the same time was higher than that of patients without meniscus combined injury. ACL revision can improve the stability and function of knee joint. Compared with the revision caused by life accident or technical reasons of primary reconstruction surgery, the patients with graft failure caused by sports injury have better postoperative recovery. Medial meniscus suture and anterior internal approach drilling of the femoral bone canal have a statistically protective effect on the clinical function after ACL revision.

Internal Fixation of Lateral Trochlear Groove Osteochondritis Dissecans With Simultaneous Lateral Retinacular Lengthening in Adolescent Athletes

Background: The goals of operative treatment for the adolescent athlete with unstable osteochondritis dissecans (OCD) lesion are rigid fixation and prevention of recurrence. Purpose: To evaluate clinical and radiological outcomes of internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening. Study Design: Case series; Level of evidence, 4. Methods: Adolescent athletes who had undergone internal fixation and simultaneous lateral retinacular lengthening for an unstable OCD lesion of the lateral trochlear groove were retrospectively reviewed. Subjective assessments included the Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Tegner activity scale, and an athletic questionnaire. Functional tests included isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance. Pre- and postoperative radiographs and magnetic resonance images were reviewed. Results: The mean ± SD age of the 17 patients included in this study was 15.9 ± 0.9 years; last clinical follow-up duration was 37.7 ± 8.1 months. At the last follow-up, the Lysholm score improved from 68.7 ± 15.3 to 93.4 ± 12.4 and the IKDC subjective score from 60.2 ± 14.7 to 88.7 ± 12.7 ( P < .001). The mean Tegner activity scale score was 9.4 ± 0.5 before injury and 8.9 ± 1.2 at the last follow-up ( P = .059). The limb symmetry indices of isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance improved at the last follow-up; the mean limb symmetry index was ≥85% in each functional test. Regarding the athletic questionnaire, 16 (94.1%) patients were satisfied with the surgery. At the last follow-up, 2 patients had higher ability after returning to sports, 11 had the same ability, and 3 had lower ability than the preinjury level. Postoperative magnetic resonance imaging at 12-month follow-up showed that the OCD lesion appeared healed in 7 (41.2%) patients and partially healed in 9 (52.9%). Conclusion: Internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening in adolescent athletes achieved satisfactory clinical and radiological outcomes. Therefore, this combined surgical technique could be considered an effective treatment for lateral trochlear groove OCD, with a high rate of return to sport.

Lateral Capsular Stabilization in Lateral Meniscal Allograft Transplantation

Background: Stabilization of the lateral capsule to the tibial plateau may decrease midbody extrusion after lateral meniscal allograft transplantation (MAT). However, there is a paucity of literature reporting on postoperative magnetic resonance imaging (MRI) findings after lateral capsular stabilization (LCS) at the time of lateral MAT. Purpose/Hypothesis: The purpose was to describe MRI findings after LCS and compare postoperative extrusion between isolated lateral MAT and lateral MAT with LCS. It was hypothesized that allograft extrusion would be reduced after MAT with LCS but that the stabilized capsule would increase the risk of tears to the capsule or allograft. Study Design: Cohort study; Level of evidence, 3. Methods: Included were patients who underwent lateral MAT with 6-month follow-up MRI. Concomitant LCS was performed for patients with redundant lateral capsule displaced from the lateral tibial plateau as evident on coronal MRI or arthroscopic examination (MAT+LCS group); otherwise, patients underwent MAT only (isolated MAT group). The Lysholm score, Tegner score, and lateral joint space on radiographs were compared between the 2 groups at 2 years postoperatively, and the stabilized lateral capsule and allograft were evaluated using 6-month follow-up MRI. Extrusion, rotation, and position of the allograft bridge were compared between the 2 groups. Regression analysis was performed to identify factors predictive of degree of extrusion. Results: There were 10 patients in the MAT+LCS group and 13 patients in the isolated MAT group. No significant differences were found between groups in preoperative patient characteristics or postoperative Lysholm score, Tegner score, lateral joint space, or MRI parameters. Postoperative extrusion was not related to obliquity angle, position of the bony bridge, or presence of LCS. In the MAT+LCS group, 1 patient showed a tear of the lateral capsule and a radial tear of the allograft, and 3 patients had a meniscocapsular separation at the midbody of the allograft. In the isolated MAT group, 1 patient had a peripheral tear at the midbody, but there was no tear of the allograft in the other patients. Conclusion: LCS did not decrease extrusion of lateral meniscal transplantation, but it can lead to increased risk for graft or capsule tear.

Results of multiple ligament reconstruction after knee dislocation——A prospective study with 95 patients and minimum 2-year follow up

Background There is still a lack of clinical data in arthroscopic treatment for treating multiple ligament injuries. This study aims to evaluate the clinical outcomes of patients with multiple ligament injuries undergoing treatment based on the classification stage and type of injury. Methods A prospective, clinical trial on multiple ligament injuries was planned, which included 95 patients (58 men and 37 women; age: 42.8 ± 11.9 [range, 18–63] years) from October 2017 to June 2018. Injuries were classified into three stages (emergency stage < 24 h; acute stage: 24 h to 3 weeks, and chronic stage: > 3 weeks) and six types (KD I–VI) based on injuries time and structures, which indicated appropriate treatments. The clinical outcomes were evaluated at 2, 4, 6, 8, and 12 weeks and at 6, 9, 12 months and 24 months after surgery. The final choices in efficacy index included International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) score, and range of motion. Results During the follow-up, all patients exhibited statistically significant functional improvement in the injured limb compared with their preoperative situation. The mean postoperative scores of acute stage patients at 2-year follow-up were IKDC subjective score, 77.54 ± 11.53; Lysholm score, 85.96 ± 9.39; Tegner score, 4.13 ± 1.08; and VAS score, 1.21 ± 0.76. The mean postoperative scores of chronic stage patents at 2-year follow-up were IKDC subjective score, 74.61 ± 12.38; Lysholm score, 81.71 ± 10.80; Tegner score, 3.96 ± 1.14; and VAS score, 1.71 ± 0.60. The IKDC subjective score, Lysholm score, and Tegner score were significantly improved (P < 0.01) and the VAS score was significantly decreased (P < 0.01) at 2-year follow-up. Regarding the multiple ligament injuries classification, patients with more structural damage in stages V and VI showed less progress in functional recovery than those in stages I–IV. Conclusions This new classification with three stages and six types helps to identify the severity of injury and plan the management effectively. The outcomes were encouraging and the subjective functional results showed significant improvement at 2-year follow-up. Study design Prospective clinical trial. Level of evidence II

Comparison of Clinical Efficacy Between Arthroscopically Assisted Gracilis Autograft With Suture Reinforcement Technique and Transtibial Pull-out Technique in Treating Medial Meniscus Posterior Root Tears

Background: To compare the short-term efficacy of the transtibial pull-out technique and gracilis autograft with suture reinforcement technique in the treatment of medial meniscus posterior root tears. Methods: A total of 64 patients with medial meniscus posterior root tears received reconstruction of the posterior root of the meniscus attachment point through the tibial tunnel between June 2018 and April 2019 were included in this study, patients were divided into 2 groups (transtibial pull-out technique group: 35 cases; gracilis autograft with suture reinforcement technique group: 29 cases) according to the different posterior meniscus root tear repair methods. Clinical outcomes were evaluated by the visual analogue scale (VAS) and Lysholm score and IKDC score, and the demographics and functional recovery of the knee were compared between the two groups.Results: Intraoperative and postsurgical complications such as infection were not found in the two groups, and there was a statistically significant improvement in the Lysholm score，IKDC score and VAS score (P<0.001; respectively). All the patients were very satisfied with the function of their knee at the last follow-up. However, compared with the transtibial pull-out repair group, the reinforced medial meniscal root reconstruction technique with gracilis autograft group were significant improvement in the meniscus healing rates and Lysholm score, IKDC score and VAS score at the end of follow-up (P<0.05; respectively).Conclusions: Compared with the transtibial pull-out technique, the reinforced medial meniscal root reconstruction technique with gracilis autograft is advantageous for treating these patients because it is a minimally invasive procedure with superior clinical outcome and meniscus healing rates.Levels of Evidence: Ⅲ, Case-control study Retrospective comparative study

Surgical Treatment for Avulsion Fractures of the Anterolateral Ligament Associated with Periarticular Fractures of the Knee

The existence and anatomy of the anterolateral ligament (ALL) of the knee are a somewhat controversial topic in orthopaedic surgery. The fixation of the avulsion fracture of the ALL (Segond fracture), associated with periarticular knee fractures, is rarely given much consideration while the major fracture fragments are reconstructed. This study aims to confirm the existence of ALL and evaluate the clinical outcomes of surgical management for avulsion fractures, involving its insertion, when associated with periarticular knee fractures. Twenty-three patients (16 males and 7 females) with avulsion fractures of the ALL associated with periarticular knee fractures were fixed with a spider plate, cannulated screw, or suture anchor. Eight patients were diagnosed with distal femoral fracture, 10 with tibial plateau fracture, and 5 with tibial eminence avulsion fracture. All patients underwent X-rays at follow-up. Clinical and functional outcomes were assessed with the pivot-shift test, objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The ALL was found and identified as a distinct ligamentous structure in all patients. Prior to Segond repair, patients had significantly more instability, as determined by pivot-shift test, than seen postoperatively (p < 0.0001). At final follow-up, the mean subjective IKDC score was 83.2 ± 10.3. Fourteen patients were graded A, 6 were graded B, and 3 was graded C on the IKDC objective score. The mean Lysholm score was 85.4 ± 12.2. The mean Tegner score was 7.5 ± 1.2. This study confirmed that the ALL is a distinct structure in the anterolateral portion of the knee. The fixation of the avulsion fracture of the ALL associated with periarticular knee fractures can be an effective procedure without specific complications. Long-term and comparative follow-up studies are necessary to confirm the effects.

Effect of the amount of correction on posterior tibial slope and patellar height in open-wedge high tibial osteotomy

Objectives: To evaluate the effect of amount of correction on postoperative changes in PTS (posterior tibial slope), PH (patellar height), and clinical outcomes following biplanar OWHTO (open-wedge high tibial osteotomy). Method: This study included 79 knees (32 left and 47 right) of 79 patients (mean age 60.28 ± 4.2 years, 24 males, 55 females) with varus malalignment and symptomatic isolated medial joint osteoarthritis who underwent OWHTO. According to the amount of correction angles, all patients were divided into three groups: LCA (large correction angle) group (>14°), MCA (medium correction angle) group (10°–14°), and SCA (small correction angle) group (<10°). All patients were clinically assessed according to the Lysholm score, HSS (hospital for special surgery knee score), and KSS (knee society score) prior to and after surgery. For radiographic analysis, we measured the PTS, PH [ISI (Insall-Salvati index), and BPI (Blackburne-Peel index)]. The pre-post difference of PTS, ISI, and BPI was calculated by subtracting the post-OWHTO value to the pre-OWHTO value in three groups, respectively. The preoperative, postoperative, and difference of PTS, ISI, and BPI values were analyzed according to the correction angle. The mean follow-up period was 28.5 months (SD, 4.9; range 18–52 months). Results: Radiologically, PTS increased and PH decreased after surgery on the whole ( p < .05). The relationship between amount of correction and slope increase is significant ( p < .001). Furthermore, the pairwise difference between the LCA group and SCA group and MCA group is significant respectively ( p < .05). In terms of PH, the LCA group yielded ISI and BPI that were significantly different from baseline for the SCA group and MCA group. In addition, the pairwise difference between the SCA group and LCA group in ISI and BPI is significant ( p = .031). Clinically, significant improvements were observed in postoperative clinical scores of the Lysholm score, HSS, and KSS ( p < .05). Seventy-four patients (93.67%) reported satisfaction with surgery. However, no correlation was found between changes in PTS and PH with postoperative knee score. No severe adverse complications were observed. Conclusions: The amount of correction angle is a significant factor affecting the PTS and PH in OWHTO. With increased correction angle, the likelihood of increasing the PTS and decreasing the PH increases. Special attention should be paid to keep PTS and PH unchanged in cases where large corrections are required. Otherwise, closing wedge osteotomy or other intraoperative effective measures are supposed to be adopted.

Does posterior cruciate ligament sacrifice influence dynamic balance after total knee arthroplasty? Comparison of cruciate-retaining and cruciate-substituting designs in bilaterally operated patients

Purpose This study aimed to evaluate whether the posterior cruciate ligament sacrifice during total knee arthroplasty (TKA) has any effect on postoperative standing balance or not. Methods The patients who underwent bilateral TKA with either CR or PS design were analyzed. 30 patients (10 PS, 20 CR) were included for the final analysis. TKA designs were compared in terms of Lysholm score, range of motion, and balance characteristics including somatosensorial, vestibular, and visual balance scales, adaptation, limits of stability, and weight-bearing/squat tests by computerized dynamic posturography. Results The mean follow-up time was 59 months for CR, 49 months for PS group. The average Lysholm score values were 94 for CR and 95 for PS group, indicating functionally similar patient groups. The average knee flexion was found significantly higher in PS group (114°) compared to CR group (102°) ( p = 0.009). In the CR group, motor adaptation tests (toes up/toes down) were found to be better ( p = 0.034). In the on-axis velocity parameter (linear goal orientation) of limits of stability test, PS group patients were found to be more successful ( p = 0.035). Conclusions The use of CR implants can be recommended in patients with a high risk of falling since they provide better motor adaptation providing rapid reactions to rapid surface changes. Better linear goal orientation in PS group, providing a faster movement in an intended direction, should be considered when planning the ideal implant for the patients with relevant activities.