Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection

Purpose

The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection.

Method

Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems.

Results

In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher (P < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher (P < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems (P < 0.001).

Conclusion

Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone.

Level of evidence

Randomized, controlled trial, Level I.     

Arthroscopy combined with hardware removal for chronic pain after ankle fracture

Purpose

The purpose of this study was to evaluate the effectiveness of arthroscopy combined with hardware removal for chronic pain after satisfactory healing of an ankle fracture. We hypothesized that combining hardware removal with arthroscopy for the intra-articular pathology would improve residual complaints more so than hardware removal alone.

Methods

The outcomes of the 53 young male patients with chronic pain after healed ankle fracture treated with two different therapeutic plans: (1) conservative treatment after hardware removal (group A) and (2) arthroscopic intervention with hardware removal (group B) were prospectively studied. Patients were reviewed preoperatively and 6 and 12 months postoperatively using American Foot and Ankle Society (AOFAS) scale.

Results

Median AOFAS scores improved from 74 (66–80) points to 76 (73–92) points in group A and from 75 (64–80) points to 85 (72–100) points in group B, and this improvement was significantly higher for patients in group B (p = 0.001).

Conclusions

This study supports the notion that when there is a definite diagnosis such as loose body, bony impingement, or anterolateral soft-tissue impingement causing chronic pain after healed ankle fracture, arthroscopic treatment with hardware removal is a better treatment option than hardware removal and conservative treatment.

Level of evidence

Prospective comparative study, Level II.     

Arthroscopic autologous chondrocyte implantation in the ankle joint

Purpose

Autologous chondrocyte implantation (ACI) is an established procedure in the ankle providing satisfactory results. The development of a completely arthroscopic ACI procedure in the ankle joint made the technique easier and reduced the morbidity. The purpose of this investigation was to report the clinical results of a series of patients who underwent arthroscopic ACI of the talus at a mean of 7 ± 1.2-year follow-up.

Methods

Forty-six patients (mean age 31.4 ± 7.6) affected by osteochondral lesions of the talar dome (OLT) received arthroscopic ACI between 2001 and 2006. Patients were clinically evaluated using AOFAS score pre-operatively and at 12, 36 months and at final follow-up of 87.2 ± 14.5 months.

Results

The mean pre-operative AOFAS score was 57.2 ± 14.3. At the 12-month follow-up, the mean AOFAS score was 86.8 ± 13.4 (p = 0.0005); at 36 months after surgery, the mean score was 89.5 ± 13.4 (p = 0.0005); whereas at final follow-up of 87.2 ± 14.5 months it was 92.0 ± 11.2 (p = 0.0005). There were three failures. Histological and immunohistochemical evaluations of specimens harvested from failed implants generally showed several aspects of a fibro-cartilaginous tissue associated with some aspects of cartilage tissue remodelling as indicated by the presence of type II collagen expression.

Conclusion

This study confirmed the ability of arthroscopic ACI to repair osteochondral lesions in the ankle joint with satisfactory clinical results after mid-term follow-up.

Level of evidence

IV, retrospective case series.     

Anterior fibrous bundle: a cause of residual pain and restrictive plantar flexion following ankle sprain

Purpose

To describe anterior fibrous bundle as an intra-articular residual disorder following ankle sprain.

Methods

Between January 1998 and January 2009, we performed arthroscopy on 10 patients (7 males, 3 females; median age, 25 years; age range, 17–43 years) who had the uncommon problem of anterior ankle pain accompanied by restriction of plantar flexion following an ankle sprain. Pre-operative magnetic resonance imaging revealed osteochondral lesions (OCLs) of the talar dome in 3 patients, but no other findings that could explain restricted plantar flexion. All patients underwent arthroscopy for investigation and treatment of the cause of symptoms, and the 3 patients with OCL underwent additional arthroscopic drilling. Outcome was measured using the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score, Visual Analogue Scale (VAS) for pain and active plantar flexion angle.

Results

In all patients, an anterior fibrous bundle was confirmed under arthroscopic investigation as the cause of symptoms and was resected arthroscopically. Median AOFAS and VAS scores improved significantly from 65 (range 61–82) and 70 (range 50–85) pre-operatively to 95 (range 84–100) and 4 (range 0–15) at final follow-up, respectively (p < 0.001). In addition, median active plantar flexion angle improved significantly from 40° (range 35–40) pre-operatively to 55° (range 45–55), (p < 0.01).

Conclusions

An anterior fibrous bundle is one of the intra-articular residual disorders after ankle sprain that can cause restriction of plantar flexion.

Level of evidence

Therapeutic case series, Level IV.     

Indications and limitations of osteochondral autologous transplantation in osteochondritis dissecans of the talus

Purpose

Osteochondral autologous transplantation (OAT) from the ipsilateral femoral lateral condyle in osteochondritis dissecans (OD) of the talus has shown good clinical results in the past. To further define, indications and limitations of OAT various factors have been discussed which might influence the clinical outcome.

Methods

In this study, the clinical outcome of OAT of 32 patients (mean follow-up 29 months) was evaluated by means of the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, ankle pain on the visual analogue scale (VAS), and Hospital for Special Surgery (HSS) Patella score. We then analysed the statistical correlation between clinical outcome and various variables such as age, pre-existing osteoarthritis, or size of the lesion.

Results

Median AOFAS score was 86 (range 68–100), median ankle pain on VAS was 2.0 (range 0–5.5), and median HSS Patella score was 95 (range 35–100). Advanced age (above 40 years of age) was associated with a significantly lower HSS Patella score (80 vs. 97.5, p = 0.035). None of the other variables (obesity, pre-existing osteoarthritis, size of the lesion, necessity of malleolar osteotomy, localization of the lesion, and number of previous surgeries) influenced the clinical outcome adversely.

Conclusions

Osteochondral autologous transplantation in OD of the talus is a safe procedure with good clinical results. As advanced age is associated with higher donor-site morbidity, indication for OAT in older patients should be carefully considered. As none of the other variables affected the clinical outcome of OAT adversely, there is no contraindication for OAT, for example, in osteochondral lesions requiring more than one osteochondral grafts, lateral lesions, patients with BMI >25, pre-existing osteoarthritis, or failed previous surgery.

Level of evidence

IV.     

Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement

Purpose

Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). However, little is known whether the type of response correlates with the post-operative functional outcomes. The purpose of this study is to document the ability of a diagnostic hip injection to predict short-term functional outcomes following arthroscopic surgical management.

Methods

A prospective cohort of 52 patients diagnosed with FAI who had an intra-articular hip injection prior to arthroscopic surgery was evaluated. A pain diary was used during the 2 weeks after hip injection to document response. In addition, the modified Harris Hip Score (mHHS) was administered preoperatively and 6 months post-operatively to assess functional outcomes. The relationship between response to an intra-articular hip injection and mHHS scores 6 months after FAI surgery was evaluated.

Results

Overall, 42 of 52 (81 %) patients diagnosed with FAI achieved pain relief from the hip injection. Outcomes according to mHHS scores improved significantly at the 6-month follow-up visit (19 points, 95 % CI 15–24, p = 0.001). The therapeutic utility of the hip injection suggested that lack of pain relief predicted a lack of functional improvement following arthroscopic surgery.

Conclusion

In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery.

Level of evidence

Level II.     

Quantitative magnetic resonance imaging (MRI) evaluation of cartilage repair after microfracture (MF) treatment for adult unstable osteochondritis dissecans (OCD) in the ankle: correlations with clinical outcome

Objectives

To quantitatively evaluate cartilage repair after microfracture (MF) for ankle osteochondritis dissecans (OCD) using MRI and analyse correlations between MRI and clinical outcome.

Methods

Forty-eight patients were recruited and underwent MR imaging, including 3D-DESS, T2-mapping and T2-STIR sequences, and completed American Orthopaedic Foot and Ankle Society (AOFAS) scoring. Thickness index, T2 index of repair tissue (RT) and volume of subchondral bone marrow oedema (BME) were calculated. Subjects were divided into two groups: group A (3–12 months post-op), and group B (12–24 months post-op). Student’s t test was used to compare the MRI and AOFAS score between two groups and Pearson’s correlation coefficient to analyse correlations between them.

Results

Thickness index and AOFAS score of group B were higher than group A (P?<?0.001, P?<?0.001). T2 index and BME of group B were lower than group A (P?<?0.001, P?=?0.012). Thickness index, T2 index and BME were all correlated with AOFAS score (r?=?0.416, r?=??0.475, r?=??0.353), but BME was correlated with neither thickness index nor T2 index.

Conclusions

Significant improvement from MF can be expected on the basis of the outcomes of quantitative MRI and AOFAS score. MRI was correlated with AOFAS score. BME is insufficient as an independent predictor to evaluate repair quality, but reduction of BME can improve the patient’s clinical outcome.

Key Points

? Patients with unstable ankle OCD had satisfactory clinical outcome after MF. ? Quantitative MRI correlates with clinical outcome after MF for ankle OCD. ? The reduction of subchondral BME will improve the patient’s clinical outcome. ? Quantitative MRI can monitor the process of cartilage repair over time.     

The effects of arthroscopic joint debridement in the knee osteoarthritis: results of a meta-analysis

Purpose

Knee osteoarthritis is one of the most common orthopaedic diseases. Therapeutic options for this disease include conservative treatments and arthroscopic debridement and partial or complete replacement. This meta-analysis aimed to collect and analyse the available information on the effects of arthroscopic joint debridement related to the clinical outcomes, the required conversion to replacement and the factors for patient selection.

Methods

A search for publications was performed in the PubMed, Cochrane and EMBASE medical databases. The primary search resulted in a total of 1,512 citations. The results from 30 papers were included in this study. The extracted dates were listed in a standardised protocol. The statistical evaluation was performed using Comprehensive Meta-analysis software (V2 Biostat, Englewood, NJ, USA).

Results

No randomised study that compared conservative and arthroscopic treatments for knee osteoarthritis was found. Most studies reported middle-term results after arthroscopic operations. The results of these studies showed excellent or good outcomes in more than 60 % of all patients. These results were correlated with a significant increase in the knee scores from baseline to follow-up; the standardised difference in means was 2.3 (CI 95 % 1.5–3.0, p < 0.001). The required conversion rate to replacement increased as the follow-up interval increased. The rates were as follows: 1 year—6.1 % (CI 95 %, 2.1–16.6 %), 2 years—16.8 % (CI 95 %, 10.2–26.3 %), 3 years—21.7 % (CI 95 %, 15.5–29.1 %) and 4 years—34.1 % (CI 95 %, 22.8–47.6 %). The mean survival time was 42.7 (CI 95 %, 14.5–71.1) months. Numerous factors influenced the outcome, including the radiological stage of the osteoarthritis and individual patient factors (e.g. time of history of osteoarthritis, weight and smoking). The local knee findings, such as axial dysalignment, missing effusion and massive crepitus, were also correlated with patient outcome.

Conclusion

Arthroscopic joint debridement is a potential and sufficient treatment for knee osteoarthritis in a middle-term time interval. This procedure results in an excellent or good outcome in approximately 60 % of patients in approximately 5 years.

Level of evidence

Systematic review of studies, Level III.     

Increased cartilage volume after injection of hyaluronic acid in osteoarthritis knee patients who underwent high tibial osteotomy

Purpose

High tibial osteotomy (HTO) is a surgical procedure used to correct abnormal mechanical loading of the knee joint; additionally, intra-articular hyaluronic acid injections have been shown to restore the viscoelastic properties of synovial fluid and balance abnormal biochemical processes. It was hypothesized that combining HTO with intra-articular hyaluronic acid injections would have benefit to improve the cartilage volume of knee joints.

Methods

Forty patients with medial compartment knee osteoarthritis (OA) were randomly placed into 1 of 2 groups. The study group (n = 20) received 2 cycles (at 6-month intervals) of 5 weekly intra-articular hyaluronic acid injections after HTO operation. The control group (n = 20) did not receive any intra-articular injections after HTO surgery. Cartilage volume (primary outcome) was assessed by magnetic resonance imaging (MRI) pre-operatively and 1 year post-operatively. Treatment efficacy (secondary outcomes) was evaluated with the Western Ontario and McMaster Universities OA Index (WOMAC) and by the comparison of the total rescue medication (paracetamol/diclofenac) used (weeks 6, 12, 24, 48).

Results

MRI studies showed a significant increase in total cartilage volume (p = 0.033), lateral femoral cartilage volume (p = 0.044) and lateral tibial cartilage volume (p = 0.027) in the study group. Cartilage volume loss was detected at the lateral tibial plateau in the control group. There were significant improvements after surgery in both groups for all subscales of WOMAC scores (p < 0.001) compared to the baseline. However, no difference was found between the two groups. The study group had significantly lower amounts of diclofenac consumption (p = 0.017).

Conclusion

Based on the findings of the present study, intra-articular hyaluronic acid injections may be beneficial for increasing total cartilage volume and preventing the loss of lateral tibiofemoral joint cartilage after HTO.

Level of evidence

Therapeutic study, Level I.     

Treatment of osteochondral defects of the talus in children

Purpose

Osteochondral talar defects are infrequent in children, and little is known about the treatment and clinical outcome of these defects. The purpose of this study was to evaluate the clinical and radiographic outcomes of conservative and primary surgically treated osteochondral talar defects in skeletally immature children.

Methods

Thirty-six (97 %) of 37 eligible patients with a symptomatic primary osteochondral talar defect were evaluated after a median follow-up of 4 years (range 1–12 years). Clinical assessment included the Berndt and Harty outcome question, Ogilvie-Harris score, Visual Analog Scale pain score (at rest, during walking and during running), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the SF-36. Weight-bearing radiographs were compared with preoperative radiographs with the use of an ankle osteoarthritis classification system.

Results

Ninety-two per cent of the initially conservatively treated children [mean age 13 years (SD 2)] were eventually scheduled to undergo surgery. After fixation of the fragment, seven cases (78 %) reported a good Berndt and Harty outcome, and two cases (22 %) a fair outcome; the median AOFAS score was 95.0 (range 77–100). After debridement and bone marrow stimulation, 13 cases (62 %) reported a good Berndt and Harty outcome, three cases (14 %) a fair outcome, and five cases (24 %) a poor outcome; the median AOFAS score was 95.0 (range 45–100). No signs of degenerative changes were seen in both groups at follow-up.

Conclusions

Fixation and debridement and bone marrow stimulation of an osteochondral talar defect are both good surgical options after failed conservative treatment.

Level of evidence

Retrospective case series, Therapeutic, Level IV.     

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies

Purpose

To determine the technical feasibility and preliminary clinical efficacy of performing simultaneous arthroscopic management in cases with combined posterior and anterior ankle pathologies utilizing previously described standard arthroscopic procedures within a single surgical sitting.

Methods

Nineteen consecutive patients with combined anterior and posterior ankle pathologies were included in the current study, after at least 6 months of failed conservative managements. Combined standard posterior and anterior ankle arthroscopy was performed in all patients within the same surgical session; first with the patient in the prone position, then with the patient turned onto the supine position to perform the anterior procedure.

Results

All patients were available for the follow-up; the median follow-up period was 33 months (range 22–61 months). No persistent neurological deficits or infections were recorded. The American Orthopedic Foot and Ankle Society Ankle and Hind foot Scale score significantly improved from 70.2 ± 15.2 points preoperatively to reach 93.0 ± 5.4 points at 1 year post-operatively (p < 0.001). Sixteen patients (84.2 %) returned to their previous activity levels.

Conclusions

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies within the same surgical session is initially clinically encouraging; it allows for an earlier return to activities of daily living without a significantly added morbidity.

Level of evidence

Case series, Level IV.     

Critical three-dimensional factors affecting outcome in osteochondral lesion of the talus

Purpose

This study aimed to investigate the relationship between clinical outcomes, patient demographics and the 3D-geometric profiles of the osteochondral lesion of the talus (OLT) following arthroscopic debridement and bone marrow stimulation.

Methods

Between 2005 and 2011, arthroscopic debridement and bone marrow stimulation were performed on 50 ankles with OLT mean age of 36.0 (19.1) years and mean follow-up time of 35.5 (20.2) months. Clinical data were assessed using validated Japanese Society of Surgery of the Foot scoring. An outcome was deemed unsatisfactory if the JSSF score was less than 80. Magnetic resonance imaging and X-rays were used to assess the 3D-geometric profiles of the OLT.

Results

The mean preoperative and postoperative scores were 73.4 (13.6) and 89.6 (11.5), respectively (p < 0.001). Unsatisfactory outcomes were identified in 12 % of patients. Linear regression analyses showed that lesion depth and patient age were significantly negatively correlated with postoperative scores (p < 0.001). High prognostic significances were attributed to defect depth and age of patient, and cut-off values of 7.8 mm and 80 years, respectively, were recommended to avoid a postoperative score less than 80. No significant correlations between poor clinical outcome and the other lesion profiles or demographic factors were identified.

Conclusion

Using 3D-geometric and demographic profiles, defect depth and age of patient are essential prognostic factors in OLT and may act as a basis for preoperative surgical decisions. A lesion depth ≥7.8 mm and age ≥80 years predict an unsatisfactory outcome following arthroscopic debridement and bone marrow stimulation.

Level of evidence

Retrospective comparative study, Level III.     

Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up

Purpose

The aim of this prospective randomized intervention study was to evaluate the outcome at a 2 and 5 year follow-up whether combined arthroscopic surgery followed by exercise therapy was superior to the same exercise therapy alone when treating non-traumatic, degenerative medial meniscal tears.

Methods

Ninety-six middle-aged patients with MRI-verified degenerative medial meniscus tear and radiographic osteoarthritis grade ≤1 (Ahlbäck) participated in the study. Radiographic examination was done before randomization and after 5 years. The patients were randomly assigned to either arthroscopic treatment followed by exercise therapy for 2 months or to the same exercise therapy alone. At the start of the study and at the follow-ups at 24 and 60 months the patients answered three questionnaires KOOS, Lysholm Knee Scoring Scale and Tegner Activity Scale and made pain ratings on the Visual Analogue Scale (VAS).

Results

Both groups showed highly significant clinical improvements from baseline to the follow-ups at 24 and 60 months on all subscales of KOOS, Lysholm Knee Scoring Scale and VAS (p < 0.0001). No group differences were found at any of the testing occasions. One third of the patients that were treated with exercise therapy alone did not feel better after the treatment but were improved after arthroscopic surgery. According to radiographic findings two patients from each group had a slight progression of their osteoarthritis after 5 years.

Conclusion

The findings indicate that arthroscopic surgery followed by exercise therapy was not superior to the same exercise therapy alone for this type of patients. Consequently, exercise therapy can be recommended as initial treatment. However, one third of the patients from the exercise group still had disabling knee symptoms after exercise therapy but improved to the same level as the rest of the patients after arthroscopic surgery with partial meniscectomy.

Level of evidence

I.     

Modest mid-term outcomes after isolated arthroscopic debridement of acetabular labral tears

Purpose

Currently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2-year follow-up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).

Methods

The records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2-year follow-up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.

Results

Fifty-nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow-up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.

Conclusions

Isolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.

Level of evidence

Retrospective case series, Level IV.     

Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cruciate Ligament Register

Purpose

To investigate and analyse outcomes of patients over the age of 40 who had undergone anterior cruciate ligament (ACL) reconstruction and to compare them to their younger counterparts. We analysed patient-reported outcomes measured using the knee injury and osteoarthritis outcome score (KOOS) as well as aetiology of injury, concomitant intra-articular injuries and time from injury to surgery.

Methods

Data were extracted from the Swedish National Knee Ligament Register during the period of 2005 through 2012. The following data were extracted and analysed: patient age, gender, activity at the time of injury, time between injury and reconstruction, concomitant intra-articular injuries, graft size used for reconstruction and KOOS measured pre-operatively as well as 1, 2 and 5 years post-operatively. The cohort was stratified into age groups of 0–19, 20–29, 30–39 and ≥40 years of age.

Results

Pivoting sports were dominating as the cause of ACL injury in the younger age groups (up to 39 years). Alpine skiing and other non-specified activities were the most common causes in the older age group (≥40 years). Pre-operative KOOS was significantly lower in older age groups (p < 0.01). Post-operative KOOS regarding all subscales was significantly better in the older age group. The improvement in KOOS was significant with increasing age (p < 0.01). Older patients exhibited the greatest improvement in KOOS for all subscales at 1, 2 and 5 years post-operative follow-ups compared with pre-operative values (p < 0.01). Older patients had more cartilage injuries pre-operatively compared with younger patients. The same trend was observed in the older group for meniscus injury with and without cartilage injuries. The diameter of the graft used for ACL reconstruction was significantly larger in the older age groups and largest in the age group ≥40 years (p < 0.01). Older patients waited significantly longer for surgery after the ACL injury (p < 0.01).

Conclusion

In the older age groups, patients reported lower pre-operative KOOS compared with their younger counterparts. At follow-up, KOOS was similar in all age groups. From these results, we can therefore conclude that our hypothesis confirmed that optimal surgical results can in fact be achieved even in older patients.

Level of evidence

II.     

Arthroscopic single-bundle ACL reconstruction with modified double-layer bone-patellar tendon-bone allograft

Purpose

The objective of present study was to introduce a modified double-layer bone-patellar tendon-bone (BPTB) allograft for arthroscopic single-bundle ACL reconstruction and investigate the clinical outcomes.

Methods

From 2007 to 2009, a total of 136 patients underwent arthroscopic single-bundle ACL reconstructions with BPTB allograft. Of which, 66 patients were with double-layer BPTB allograft (Group 1), and 70 patients were with conventional BPTB allograft (Group 2). Clinical outcomes including Lachman and pivot-shift tests, KT-1000 arthrometer measurements, and Lysholm and Tegner activity scores were compared between the two groups at a 2-year minimum follow-up.

Results

Forty-six patients in each group were at a two-year minimum follow-up. The mean side-to-side difference on the KT-1000 arthrometer was 1.2 ± 1.2 mm for group 1 and 2.1 ± 1.9 mm for group 2, with significant difference between the two groups (p = 0.017). The knee function was significantly better for group 1 than for group 2, because the mean Lysholm score was 94.2 ± 4.8 points versus 86.6 ± 7.1 points (p = 0.000), and the median Tegner score was 8 (range 5–10) points versus 6 (range 4–10) points (p = 0.001).

Conclusions

On the basis of the KT-1000 arthrometer evaluation and clinical measures, single-bundle ACL reconstruction with double-layer BPTB allograft achieves significantly lesser anterior laxity and better knee function than a single-layer allograft reconstruction.

Level of evidence

Therapeutic, retrospective comparative study, Level III.     

Arthroscopic management of late complications of calcaneal fractures

Purpose

To review retrospectively the results of arthroscopic management of late complications of calcaneal fractures.

Methods

Fifty patients (32 males, 18 females) with late complications of calcaneal fractures were managed arthroscopically. The median age at the time of arthroscopic surgery was 45 (19–63) years old. Detailed history taking, physical examination, standing lateral radiograph of the foot and axial view of the calcaneus and computed tomogram study were performed in all of the patients in order to identify the sources of symptoms. The arthroscopic treatment was then planned accordingly. The patients were assessed according to the AOFAS ankle-hindfoot score and the standing radiographs of the foot and ankle, both preoperatively and at the latest follow-up consultation.

Result

A median of 1 arthroscopic procedure was performed for each patient (range, 1–4). The median follow-up after the latest arthroscopic surgery was 49 (range, 24–85 months) months. In all of the cases, the symptoms improved after the arthroscopic surgery and all the arthrodesis sites healed. The overall median preoperative AOFAS ankle-hindfoot score was 60.5 (27–75). The overall median AOFAS ankle-hindfoot score at the time of latest follow-up was 90 (73–100).

Conclusions

The arthroscopic approach focuses on the patient’s symptoms. It is a feasible approach to alleviate patient’s symptoms. Detailed history taking and clinical examination to determine the sources of the patient’s symptoms are the keys to success.

Level of evidence

Therapeutic level IV.     

Treatment of isolated patellofemoral osteoarthritis with lateral facetectomy plus Insall’s realignment procedure: long-term follow-up

Purpose

To assess the long-term results of lateral facetectomy plus Insall’s realignment procedure to treat isolated patellofemoral osteoarthritis.

Methods

All consecutive patients undergoing this procedure with a follow-up between 10 and 14 years were included in this study. Subjects were excluded if they had previous patellar dislocation, patellar fracture, tibiofemoral osteoarthritis (except mild cases) or follow-up <10 or >14 years. Failure cases (need for total knee arthroplasty) of this surgical procedure before 10 years of follow-up were considered in the overall failure rate. Clinical, functional and radiographic outcomes were obtained at baseline and compared to postoperative values.

Results

Forty-three patients (mean (SD) age 59.7 (8.1) years) had a follow-up between 10 and 14 years and were finally included in this study. The failure rate in the whole series and included patients was 26.4 and 16.3 %, respectively, for a mean (SD) follow-up of 9.2 (3.2) years and 11.7 (1.4) years, respectively. Patellofemoral pain (p < 0.0001), need for NSAIDs (p < 0.0001), longitudinal (p < 0.0001) and transversal (p < 0.0001) patellar glide tests, Zholen’s sign (p = 0.0007) and knee effusion (p = 0.02) significantly improved in the follow-up. Postoperative Knee Society Score (KSS) anatomical (p < 0.0001), functional (p < 0.0001) and total (p < 0.0001) scores and Kujala’s score (p = 0.001) were significantly higher compared to preoperative values. The patellar tilt (p = 0.001) and shift (p = 0.04) significantly improved postoperatively, whereas the patellofemoral osteoarthritis was not modified (n.s.) with respect to preoperative assessment.

Conclusions

The lateral facetectomy plus Insall’s realignment procedure was a successful treatment for isolated patellofemoral osteoarthritis from a clinical, functional and radiographic point of view in the long-term follow-up.

Level of evidence

Prospective case series, Level IV.     

Single-dose intra-articular bupivacaine after knee arthroscopic surgery: a meta-analysis of randomized placebo-controlled studies

Purpose

The purpose of this meta-analysis was to examine the efficacy and safety of single-dose intra-articular bupivacaine in the management of pain after knee arthroscopic surgery.

Method

The comprehensive literature search, using MEDLINE, the Cochrane Central Register of Controlled Trials, and Embase databases, was conducted to identify randomized controlled trials that used single-dose intra-articular bupivacaine for postoperative pain. The relative risk (RR), weighted mean difference (WMD), and their corresponding 95 % confidence intervals (CIs) were calculated using RevMan^® statistical software.

Result

Twenty-three studies (n = 1287) were included (647 subjects in bupivacaine group and 640 subjects in the control group). Statistically significant differences were observed in the VAS values (WMD ?1.1; 95 % CI ?1.7 to ?0.5), number of patients requiring supplementary analgesia (RR 0.83; 95 % CI 0.74–0.94), and time to first analgesic request (WMD 129.3; 95 % CI 15.4–243.1) among the bupivacaine group when compared to the control group. However, short-term side effects had no significant difference between these two groups (RR 0.73; 95 % CI 0.44–1.24).

Conclusions

On the basis of the currently available literature, single-dose intra-articular bupivacaine was shown to be significantly better than placebo at relieving pain after knee arthroscopic surgery. More high-quality randomized controlled trials with long follow-up are highly required for examining the safety of single-dose intra-articular bupivacaine. Besides, routine use of single-dose intra-articular bupivacaine is still an effective way for pain management after knee arthroscopic surgery.

Level of evidence

II.     

Intra-articular clonidine for post-operative analgesia following arthroscopic knee surgery: a systematic review and meta-analysis

Purpose

To assess the efficacy and safety of a single dose of intra-articular clonidine for post-operative pain following arthroscopic knee surgery by analyzing relevant randomized controlled trials (RCTs).

Methods

PubMed, EMBASE, Cochrane Library, ISI Web of knowledge, Chinese Biomedical Literature Database, Google Scholar and other databases were searched for RCTs comparing a single dose of intra-articular clonidine with placebo for post-operative pain following arthroscopic knee surgery. Risk of bias of included studies was assessed by Cochrane Collaboration’s tool, and data were analyzed by RevMan 5.1 software. Pain intensity, supplementary analgesic use and side effects were evaluated as the outcomes.

Results

Seven RCTs were included, and the results of the meta-analysis showed that intra-articular clonidine reduced the pain intensity for the first 4 h after surgery, reduced the risk of using rescue analgesics and the incidence of post-operative nausea, but increased the risk of hypotension after surgery.

Conclusions

A single dose of intra-articular clonidine has a definite analgesic effect, but the analgesic effect is mild and short lasting, which is just for 4 h after injection, and intra-articular clonidine alone could not provide sufficient post-operative analgesia following arthroscopic knee surgery. Post-operative hypotension may be the side effect that should be paid the most attention in the ambulatory setting.

Level of evidence

II.