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.     

Posterior cruciate-retaining versus posterior stabilized total knee arthroplasty: a meta-analysis of randomized controlled trials

Purpose

To compare the outcomes between posterior cruciate-retaining and posterior stabilized total knee arthroplasty (TKA) in order to evaluate which approach is superior.

Methods

Randomized controlled trials (RCTs) comparing posterior cruciate-retaining with posterior stabilized TKA were reviewed which were published up to August 2011. Methodological quality of each included RCT was assessed using the Physiotherapy Evidence Database (PEDro) scale. The relevant data were analysed using Review Manager 5.1. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence.

Results

Eight RCTs involving 888 patients with 963 knee joints met predetermined inclusion criteria. The postoperative range of motion (ROM) and flexion angle were 11.07° and 2.88° higher for patients with a posterior stabilized TKA than those with a posterior cruciate-retaining TKA, respectively [weighted mean difference (WMD), ?11.07; 95 % confidence interval (CI), ?18.06 to ?4.08; p < 0.01 and WMD, ?2.88; 95 % CI, ?5.63 to ?0.12; p = 0.04]. No statistical differences were observed between the two designs for knee society pain score, extension angle, 2- and 5-year knee society score, 2- and 5-year knee society function score and complications after primary TKA.

Conclusion

Posterior cruciate-retaining and posterior stabilized TKA have similar clinical outcomes with regard to knee function, postoperative knee pain and the other complications. Prosthesis survivorship for both posterior cruciate-retaining and posterior stabilized TKA is satisfactory, and there are no differences between them at short- and middle-term follow-up.

Level of evidence

II.     

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.     

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.     

The relationship between patellofemoral and tibiofemoral morphology and gait biomechanics following arthroscopic partial medial meniscectomy

Purpose

To examine the relationship between tibiofemoral and patellofemoral joint articular cartilage and subchondral bone in the medial and gait biomechanics following partial medial meniscectomy.

Methods

For this cross-sectional study, 122 patients aged 30–55 years, without evidence of knee osteoarthritis at arthroscopic partial medial meniscectomy, underwent gait analysis and MRI on the operated knee once for each sub-cohort of 3 months, 2 years, or 4 years post-surgery. Cartilage volume, cartilage defects, and bone size were assessed from the MRI using validated methods. The 1st peak in the knee adduction moment, knee adduction moment impulse, 1st peak in the knee flexion moment, knee extension range of motion, and the heel strike transient from the vertical ground reaction force trace were identified from the gait data.

Results

Increased knee stance phase range of motion was associated with decreased patella cartilage volume (B = ?17.9 (95 % CI ?35.4, ?0.4) p = 0.045) while knee adduction moment impulse was associated with increased medial tibial plateau area (B = 7.7 (95 % CI 0.9, 13.3) p = 0.025). A number of other variables approached significance.

Conclusions

Knee joint biomechanics exhibited by persons who had undergone arthroscopic partial meniscectomy gait may go some way to explaining the morphological degeneration observed at the patellofemoral and tibiofemoral compartments of the knee as patients progress from surgery.

Level of evidence

III.     

Learning curves of two different techniques for the intra-articular injection of the knee joint under fluoroscopic guidance

Aim

The aim of the study was to compare the learning curves of three beginner operators using two different techniques of intra-articular injection of the knee under fluoroscopic guidance with a superolateral approach.

Materials and methods

In total, 177 consecutive patients (72 females (40.7%) and 105 males (59.3%), mean age 42.2 ± 15.0 years) scheduled for a computed tomography (CT) arthrography and without joint effusion on the lateral X-rays were enrolled. They underwent an intra-articular injection of the knee under fluoroscopic guidance with a superolateral approach. Patients were randomly assigned to three different operators, including a junior supervisor and two first-year residents in radiology who never performed an intra-articular injection of the knee before the present study. Procedures in lateral or supine position were randomly assigned to three operators.

Results

There was a higher rate of successful injections with the lateral position (92.1%) than with supine position (80.2%) (odds ratio (OR) 4.52, 95% confidence interval (CI) 1.46–14.0). A significant learning effect was observed for the supine position, while none was observed for the lateral position. Pain and time of fluoroscopy did not differ between the two procedures (p = 0.85 and p = 0.10, respectively). Junior supervisor had a higher rate of successful intra-articular injection compared with the other two operators (p = 0.0072). There was a statistically significant higher rate of extravasation with the supine position (66.3%) than with lateral position (19.7%) (p < 0.0001, OR 0.13, 95% CI 0.06–0.25).

Conclusion

The intra-articular injection of the knee under fluoroscopic guidance with the patient in lateral position is an easy technique for operators in training with a low rate of extravasation. Lateral position does not require a supplementary irradiation and does not increase the procedural pain. Personal operator’s skill is an independent factor in determining the success of the training.

     

Can standing knee radiographs predict chondral lesions in young- and middle-aged population?

Purpose

The aim of the study is to investigate the correlation between arthroscopic findings and joint space width on the standing knee radiographs at various flexion degrees in the young- and middle-aged patients with complaints of knee pain.

Methods

Middle-aged patients with complaint of knee pain ongoing more than 6 months and failure in conservative treatment methods were included. Weight-bearing full extension, 30 and 45° of flexion radiographs were obtained. Joint space width was calculated on radiograms. Arthroscopy was performed to evaluate the chondral pathologies. Correlation analysis was performed.

Results

Fourty-three patients (18 female, 25 male) with a mean age of 44.6 (20–63) were included. Mean joint space width was 4.87 mm ± 1.45 (2–10) mm in medial and 5.43 mm ± 1.47 (1–9) in lateral on standing extension radiographs. In 30° flexion radiographs, mean joint space width was 4.33 mm ± 1.25 (1.5–7.5) in medial and 5.36 mm ± 1.69 (1–9) in lateral. In 45° flexion radiographs, medial joint space was 4.28 mm ± 1.59 (2–9) in medial and 5.15 mm ± 1.59 (1.5–9) in lateral. In arthroscopic evaluation, one knee had grade 1 (2.3 %), three knees had grade 2 (7 %), nine knees had grade 3 (20.9 %), and twelve knees had grade 4 (27.9 %) lesions in the medial compartment. In the lateral compartment, two knees had grade 3 (4.7 %) and one knee had grade 4 lesion (2.3 %). Radiological data did not correlate with the arthroscopic findings.

Conclusion

Standing knee radiographs do not correlate with the arthroscopic findings in the middle-aged population with chondral lesions in knee joint.

Level of evidence

Case series with no comparison group, Level IV.     

No difference in clinical outcome between fixed- and mobile-bearing TKA: a meta-analysis

Purpose

To compare the clinical and radiographic results of fixed-bearing and mobile-bearing total knee arthroplasty (TKA).

Methods

We searched the PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases from 1966 to January 2012. No language restriction was applied. Reference lists of all the selected articles were hand-searched for any additional trials. Trial quality was assessed using the modified Jadad scale. Two authors independently extracted data from all eligible studies, including study design, participants, interventions, and outcomes (Knee Society Score, range of movement, radiolucent line, patient preference, walking support, pain score, and complications). The data were using fixed-effects or random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively.

Results

A total of 24 studies involving 2,799 patients were identified in this analysis. Meta-analysis showed lower pain score (OR, 0.66, 95 % CI 0.46, 0.94) in mobile-bearing TKA than fixed-bearing TKA. There was no significant difference between the two treatment groups regarding Knee Society Score (SMD, ?0.17, 95 % CI: ?0.60, 0.26), range of movement (SMD, ?0.05, 95 % CI: ?0.63, 0.53), radiolucent line (OR, 1.03, 95 % CI 0.74, 1.44), patient preference (OR, 1.15, 95 % CI 0.82, 1.61), walking support (OR, 1.07, 95 % CI 0.68, 1.70), and complications (OR, 0.85, 95 % CI 0.59, 1.21).

Conclusions

The available evidence suggested that there was no significant difference between clinical and radiographic results of fixed-bearing and mobile-bearing TKA except for pain score. Regarding clinical relevance, the less incidence of pain could be the advantage for selecting mobile-bearing TKA.

Level of evidence

II.     

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.     

The minimal clinically important difference in the Oxford knee score and Short Form 12 score after total knee arthroplasty

Purpose

The aim of this study was to identify the minimal clinically important difference (MCID) in the Oxford knee score (OKS) and Short Form (SF-) 12 score after total knee arthroplasty (TKA).

Methods

Prospective pre-operative and 1 year post-operative OKS and SF-12 scores for 505 patients undergoing a primary TKA for osteoarthritis were collected during a one-year period. Patient satisfaction with their (1) patient relief and (2) functional outcome was used as the anchor questions. Their response to each question was recorded using a 5-point Likert scale: excellent, very well, well, fair, and poor. Simple linear regression was used to calculate the MCID for improvement in the OKS and physical component of the SF-12 score according to the level of patient satisfaction with their pain relief and function.

Results

The OKS improved by 15.5 (95 % CI 14.7–16.4) points and the SF-12 physical component score improved by 10.1 (95 % CI 9.1–11.2) points for the study cohort. The level of patient satisfaction with their pain relief and function correlated with the improvement in the OKS (r = 0.56; p < 0.001, and r = 0.56; p < 0.001) and the physical component of the SF-12 score (r = 0.51; p < 0.001, and r = 0.60; p < 0.001), respectively. The MCID for the OKS was 5.0 (95 % CI 4.4–5.5) and 4.3 (95 % CI 3.8–4.8) points and for the physical component of the SF-12, it was 4.5 (95 % CI 3.9–5.2) and 4.8 (95 % CI 4.2–5.4) points for pain relief and function, respectively.

Conclusion

The MCID identified for the OKS and SF-12 physical component score after TKA is the best available estimate and can be used to power studies and ensure that a statistical difference is also recognised by a patient.

Level of evidence

Retrospective diagnostic study, Level III.     

Comparison of the recurrence risk of parameniscal cysts between patients treated with arthroscopic excision and arthroscopic decompression techniques

Purpose

To compare the recurrence risk of parameniscal cysts between arthroscopic meniscectomy with open cystectomy (arthroscopic excision) and entirely arthroscopic techniques with intra-articular cyst decompression (arthroscopic decompression).

Methods

A retrospective longitudinal study was conducted at a medical centre in Taiwan between 2002 and 2012. Patients with symptomatic parameniscal cysts undergoing either arthroscopic excision or arthroscopic decompression were included. Parameniscal cyst recurrence was evaluated every 3 months after surgery. The recurrence risk associated with treatment group, cyst volume, and meniscal tear circumference was investigated.

Results

This study included 241 young to middle-aged men and women. Of these, 112 underwent arthroscopic excision and 129 underwent arthroscopic decompression. During an average 26-month follow-up period, the arthroscopic decompression group had a sixfold higher recurrence risk [prevalence: 4 and 21 %, respectively; hazard ratio, HR 6.0 (95 % confidence interval, CI 2.3–15.6); p < 0.001] than the arthroscopic excision group. Furthermore, meniscal tears >12 mm in circumference and a cyst volume >2.4 cm³ conferred a fivefold higher recurrence risk than both lesions of smaller dimensions, both in the overall population and in the arthroscopic decompression group [HRs 5.3 (95 % CI 2.3–12.2) and 5.35 (95 % CI 2.2–13.3), respectively; p values <0.001 for both].

Conclusions

The suggestion of our study is that the recurrence of parameniscal cysts may be strongly related to large cystic lesions and large meniscal tears. Arthroscopic excision is preferable for treating parameniscal cysts, which are large cystic lesions with large meniscal tears, to reduce the recurrence risk.

Level of evidence

III.

     

An isolated rupture of the posterior cruciate ligament results in reduced preoperative knee function in comparison with an anterior cruciate ligament injury

Purpose

To investigate differences in preoperative knee function (Knee Injury and Osteoarthritis Outcome Score, KOOS), the time period from injury to surgery, and associated injuries when comparing primary isolated posterior cruciate ligament (PCL) and primary anterior cruciate ligament (ACL) reconstructions.

Methods

Isolated primary ACL and PCL reconstructions registered in the Norwegian National Knee Ligament Registry from 2004 through 2010 were included (n = 71 primary PCLs and 9,649 primary ACLs). Linear regression analysis was used to evaluate the preoperative KOOS subscale values.

Results

The preoperative KOOS in the PCL group (n = 71) and ACL group (n = 9,649) was significantly different for the subscales symptoms (mean difference, ?8.4; 95 % CI: ?12.8 to ?4.0), pain (mean difference, ?15.9; 95 % CI: ?20.3 to ?11.4), activities of daily living (mean difference, ?12.9; 95 % CI: ?17.4 to ?8.4), sport and recreation (mean difference, ?15.9; 95 % CI: ?22.6 to ?9.3), and quality of life (mean difference, ?7.9; 95 % CI: ?12.4 to ?3.5). The primary isolated PCL-reconstructed knees had a median time from injury to surgery of 21 months in comparison with 8 months for ACL injuries. The ACL-injured knees had more associated injuries (meniscus and full-thickness cartilage lesions) than the PCL-injured knees.

Conclusion

Surgically treated knees with an isolated rupture of the PCL exhibited worse knee function preoperatively compared with knees with an isolated ACL injury; in addition, the delay to surgery was longer. Meniscal lesions were found more frequently in ACL-injured knees.

Level of evidence

Prospective cohort study, evidence Level I.     

Reduced blood loss after intra-articular tranexamic acid injection during total knee arthroplasty: a meta-analysis of the literature

Purpose

The purpose of the study is to conduct a meta-analysis of randomized, controlled trials evaluating the efficacy and safety of intra-articular injection of tranexamic acid (TXA) for reducing blood loss and transfusion in patients undergoing total knee arthroplasty (TKA).

Methods

A meta-analysis was conducted of RCTs published before March 2013, identified from the PubMed, EMBase, Cochrane library, ScienceDirect, and other databases. Two independent reviewers assessed the methodological quality of the studies and performed data extraction. Mean difference in blood loss and blood transfusions, risk ratios of transfusion rates, and deep vein thrombosis (DVT) incidence in the TXA-treated group versus placebo group were pooled from the included studies. Data were analysed using Stata 11.0 software.

Results

Six studies were included, with a total sample size of 647 patients. The use of TXA significantly reduced total blood loss (mean difference: ?344.96; 95 % confidence interval (CI) ?401.20 to ?239.68; P < 0.01) and the proportion of patients requiring blood transfusions (risk ratios, 0.28; 95 % CI: 0.19–0.42; P < 0.01). There were no significant differences in the incidence of DVT, pulmonary embolism, or other complications between the study groups.

Conclusions

The present meta-analysis indicated that intra-articular injection of TXA in patients undergoing TKA may reduce total blood loss and the need for blood transfusions, particularly when a high dosage of TXA is used (≥30 mg/ml), without any increase in the risk of post-operative DVT.

Level of evidence

II.     

The efficacy comparison of on-demand boluses with and without basal infusion of 0.1 % bupivacaine via perineural femoral catheter after arthroscopic ACL reconstruction

Purpose

Optimal postoperative analgesia after anterior cruciate ligament repair remains challenging. The objective of this prospective experimental clinical study was to compare the postoperative analgesic efficacy of two infusion regimens of 0.1 % bupivacaine administered via perineural femoral catheter.

Methods

Forty adult ASA I and II patients undergoing anterior cruciate ligament reconstruction were enrolled. Surgery was performed under spinal anesthesia combined with femoral nerve block. A perineural femoral catheter was connected to the patient controlled analgesia infusion pump filled with 0.1 % bupivacaine for postoperative pain control. Subjects were assigned to one of two groups according to the bupivacaine infusion regimen: (1) 5 mL/h basal infusion with on-demand 5 mL boluses and 30-min refractive periods, and (2) only on-demand 5 mL boluses and 15-min refractive periods. Quality of postoperative analgesia, adjunctive analgesic consumption, and overall patient satisfaction were recorded for 48 h.

Results

Pain control was better in Group I on the day of surgery (P = 0.001) and on the first postoperative day at rest and during mobilization (P = 0.02 and P = 0.009). On the second postoperative day, only pain control during mobilization was better in Group I (P = 0.047). Adjunctive analgesic consumption and patient satisfaction were similar.

Conclusion

Perineural femoral infusion of on-demand 5 mL boluses of 0.1 % bupivacaine combined with 5 mL/h basal infusion was more efficient than on-demand regimen alone for postoperative pain management after reconstruction of anterior cruciate ligament of the knee.

Level of evidence

II.     

‘The Sneaky Plica’ revisited: morphology,pathophysiology and treatment of synovial plicae of the knee

Purpose

To comprise current knowledge on morphology, embryology and pathophysiology of synovial plicae as well as on clinical and therapeutic aspects of the plica syndrome.

Methods

Review of the literature combined with a meta-analysis of studies assessing the outcome of open or arthroscopic plica excision including the author’s own series.

Results

The term synovial plica has been devised to describe a number of intra-capsular folds thought to represent remnants of a membranous knee joint partition present during foetal development. Although four such folds have been defined, it is mainly the medial patellar plica which is implicated in carrying clinical significance as a potential cause of anteromedial knee pain particularly in adolescents. Blunt trauma, a sudden increase in athletic activity or any form of transient synovitis are associated with plica inflammation leading to tissue fibrosis and subsequent loss of elasticity. A plica affected in this way may impinge against intra-articular structures in its proximity, often creating localised chondromalacia particularly of the patello-femoral joint. The diagnosis is based on history and clinical examination although MRI can be of value. Twenty-three studies assessing the clinical out-come of 969 patients following open or arthroscopic plica excision were identified. The average age was 25 years with equal male-to-female ratio. Trauma was considered the cause in 57 %. At a mean follow-up of 27.5 months, 64 % of patients were symptom free, 26 % improved and 10 % considered failures.

Conclusion

Symptomatic plicae may initially be treated with physiotherapeutic measures and structured exercise regimes but success rates are generally low. Intra-plical or intra-articular corticosteriod injections may be beneficial if administered early in the disease process. Arthroscopic excision of the entire plical fold becomes indicated in recalcitrant cases and once a plica has undergone irrevocable morphological changes. The procedure carries low morbidity, and results are universally good especially if the plica is the sole pathology. Factors associated with a favourable outcome are young patient age, localised symptoms of short duration and absence of plica induced chondromalacia.

Level of evidence

Level IV.     

Youth baseball players with elbow and shoulder pain have both low back and knee pain: a cross-sectional study

Purpose

Serious arm injuries in youth baseball players have been increasing. Though a breakage in the kinetic chain could affect arm injuries, an association between arm injuries and insufficient support of the trunk and lower extremities is not well understood. The purpose of this study was to investigate the association of low back and knee pain with elbow and/or shoulder complaints among youth baseball players.

Methods

A self-administered questionnaire and document informed consent were mailed to youth athletes belonging to the Miyagi Amateur Sports Association. Multiple logistic regression analysis was used to examine the association of low back and knee pain with elbow and/or shoulder pain at the time of the questionnaire. Variables considered in the models were as follows: sex, age, BMI, years of athletic experience, position, team level, the amount of practice, participating day in team practice and game per week, frequency of participation in games, and practice intensity.

Results

The final study population was comprised 1582 youth baseball players (aged 6–15 years old, male 95.6 %) who had responded to the questionnaire. A total of 24.8 % (n = 381) had elbow and/or shoulder pain, whereas 8.5 % (n = 130) had low back pain and 13.1 % (n = 201) had knee pain. The prevalence of elbow and/or shoulder pain with concomitant low back and knee pain was 61.2 % (n = 82) and 51.9 % (n = 108) (p < 0.001), respectively. The presence of low back and knee pain was significantly associated with the prevalence of elbow and/or shoulder pain among youth baseball players [adjusted odds ratio (ORs): 4.31, 95 % confidence interval (95 % CI): 2.86–6.51, p < 0.001, and ORs: 2.92, 95 % CI: 2.09–4.09, p < 0.001, respectively]. For other variables, older age (10- and 11-year old: ORs: 1.73, 95 % CI 1.10–2.73, p = 0.018; 12–15 year old: ORs: 1.62, 95 % CI: 1.18–2.58, p = 0.006), pitcher (ORs: 1.46, 95 % CI: 1.10–1.94, p = 0.009), catcher (ORs: 1.69, 95 % CI: 1.24–2.31, p = 0.001,), and practice intensity (ORs: 1.58, 95 % CI: 1.22–2.06, p = 0.001) were significantly associated with elbow and/or shoulder pain.

Conclusion

Both low back and knee pain were significantly associated with elbow and/or shoulder pain in youth baseball players. Clinicians should check the complaints of the trunk and lower extremities as well as those of the elbow and shoulder for preventing severe injuries in youth baseball players. Level of Evidence III.

     

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.     

Intra-articular hylastan versus steroid for knee osteoarthritis

Purpose

To assess the efficacy and safety of one and two intra-articular (IA) injections of the new viscosupplement, hylastan, compared with a single IA corticosteroid injection for pain due to knee osteoarthritis (OA). Hylastan is a high-molecular-weight hyaluronan derivative prepared from bacterial fermented sodium hyaluronate that was developed to remain in the joint for longer than most other viscosupplements.

Methods

This 6-month, double-blind, randomized, parallel group, multicenter trial enrolled patients aged ≥40 years who met American College of Rheumatology criteria for knee OA and had continued pain despite conservative treatment. Patients were randomized 1:1:1 to one of three arms: 2 × 4 mL hylastan (n = 129; arthrocentesis then IA hylastan Day 0, same treatment Week 2); 1 × 4 mL hylastan (n = 130; arthrocentesis then IA hylastan Day 0, arthrocentesis only Week 2); steroid (n = 132; arthrocentesis then IA methylprednisolone acetate 40 mg Day 0, arthrocentesis only Week 2). Participants and evaluators were blinded to treatment. The primary clinical outcome measure was change from baseline in WOMAC A pain score over all postbaseline visits to Week 26.

Results

Statistically significant pain reduction was observed in all three arms, with similar mean (95 % CI) changes in WOMAC A: 2 × 4 mL hylastan ?0.9 (?1.0, ?0.7); 1 × 4 mL hylastan ?0.8 (?0.9, ?0.7); steroid ?0.9 (?1.0, ?0.8); all P < 0.0001 versus baseline. Changes in secondary outcomes (OMERACT-OARSI and WOMAC A responder rates, patient/clinical observer global assessments, and WOMAC A1 walking pain) were similar in all three arms. Target knee adverse events were comparable for all treatments.

Conclusions

Both IA hylastan injection regimens were effective in relieving pain with an acceptable safety profile. IA hylastan did not show a difference versus IA corticosteroid; therefore, the hypothesis of superior pain relief was not met. Further research is needed to compare the efficacy and safety of hylastan with other viscosupplements.

Level of evidence

Therapeutic study, Level I.     

Knee arthroplasty and bleeding: when to remove drainages

Purpose

The aim of this study is an attempt to clarify the productive time of drainages as we find that the use of drains in knee arthroplasty is controversial, and there is no consensus regarding their length–time maintenance. We analysed the survival curve of bleeding within three surgical techniques for knee arthroplasty and the effect of two variables on survival curve.

Methods

One hundred and eighty-eight out of 234 knees were included in the study, and patients were divided into three groups according to the surgical technique: conventional total knee arthroplasty (TKA), subvastus TKA and unicompartmental knee arthroplasty. Variables of study were type of surgery, number and placement of drains.

Results

Mean of survival curve for postoperative bleeding time was 16 h (95 % CI: 15.4; 16.6). The risk for longer bleeding increased 1.38-fold with each additional drain used (95 % CI 1.1; 1.8).

Conclusions

According to the present study, drains can be safely removed at around 17 h postoperative. Bleeding time reduces as less drains are applied.

Level of evidence

Therapeutic study, Level III     

Mid-term survival following primary hinged total knee replacement is good irrespective of the indication for surgery

Purpose

The use of ‘hinged’ knee prostheses for primary knee arthroplasty procedures is increasing. This analysis reports the rates of implant survival, modes of failure, revision details and functional outcomes with particular reference to the primary indication for surgery for a cohort of patients treated with primary hinged knee replacement.

Methods

Systematic review with supplementary analysis using data from the National Joint Registry and Department of Health. Analysis included 964 patients undergoing primary hinged knee replacement between April 2003 and December 2010. Survival at a maximum of 7 years was calculated for the group as a whole and dependent upon the indication for surgery (osteoarthritis vs. rheumatoid/inflammatory arthritis vs. post-traumatic arthritis). Functional outcomes (pre- and post-operative Oxford Knee and Euroqol-5D scores and post-operative satisfaction) were available for 46 patients.

Results

In total, 20 cases required revision. The 5-year survival rate (96.8 % [95 % CI 95.1–98.4 %]) was not dependent upon the primary surgical indication (p = n.s.). The commonest reasons for revision were infection (8 cases), peri-prosthetic fracture (4 cases) and aseptic loosening (3 cases). Patients reported substantial improvements in their Oxford Knee Score (mean improvement = 17.6, [95 % CI 14.4–20.8]) and EQ5D index (mean improvement = 0.357, [95 % CI 0.248–0.467]). Levels of post-operative satisfaction were high.

Conclusions

Hinged knee replacement can be considered as a viable alternative to more traditional unconstrained designs in the complex primary setting. These findings are clinically relevant as they support the increasing use of hinged knee replacements for the arthritic knee in which there is concomitant severe bone loss, deformity or instability. Surgeons using these implants can have confidence that their mid-term performance is comparable to more conventional knee designs.

Level of evidence

Prospective cohort study, Level II.