Osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee: Results at 5 to 9 years

We evaluated short- and medium-term results of the treatment of articular cartilage defects of the knee with autogenous cylindrical osteochondral grafts (mosaicplasty) in 69 patients (median age 33 years) with symptomatic articular cartilage defects. Data of Lysholm score and visual analogue scale (VAS) of pain (0 = no pain; 100 = worst possible pain) were collected before the surgery, at 12 months postoperatively and 5 to 9 (median 7) years after the surgery. At the last follow-up the patients were also asked to state their degree of satisfaction with the outcome on a VAS (0 = not at all satisfied; 100 = completely satisfied), and to answer if they would have undergone the surgery again if necessary (yes or no). The mean Lysholm score and VAS of pain improved from 48 and 62, respectively, at the time of surgery to 81 and 24, respectively, at the 12-months follow-up (p < 0.001 for both comparisons). From 12 months postoperatively, the Lysholm score and VAS of pain deteriorated to 68 and 32, respectively at the 5- to 9-year follow-up (p < 0.001 and p = 0.018, respectively). The mean degree of satisfaction with the outcome was 70 (SD 28), and 61 patients (88%) stated that they would have undergone the surgery again. In conclusion, the mosaicplasty leads to improvement of symptoms and function at short- and medium-term follow-up. A deterioration of the results is observed from 12 months postoperatively to 5–9 years postoperatively.     

Comparison of the ceiling effect in the Lysholm score and the IKDC subjective score for assessing functional outcome after ACL reconstruction

BackgroundTo compare the ceiling effect of the Lysholm and IKDC subjective scores for assessing functional outcome after ACL reconstruction and evaluated the correlation with the one-leg hop test.MethodsA total of 134 patients who underwent ACL reconstruction between 2007 and 2011 were enrolled in this study. All patients fulfilled the postoperative 6- and 12-month evaluations. The ceiling effect of the Lysholm and IKDC subjective scores was assessed, and the correlations between two scales and one-leg hop test were analysed.ResultsFor the entire sample, the ceiling effect for the Lysholm score was 14.9% and 30.6% at 6 and 12 months postoperatively. The values for the IKDC subjective score were 5.2% and 17.2%, respectively. In all subjects, the correlation coefficients [95% confidence intervals] between the IKDC subjective score and one-leg hop test at 6 and 12 months (r = 0.492, [0.34 to 0.62]; r = 0.296, [0.12 to 0.46]) were higher than those for the Lysholm score (r = 0.355, [0.18 to 0.51]; r = 0.241, [0.06 to 0.41]), respectively.(p < 0.05).ConclusionWith regard to evaluating ACL reconstruction outcomes in patients, no significant difference between the IKDC subjective and the Lysholm scores exists in terms of the amount of ceiling effect and the correlation with the LSI. However, the concern that the ceiling effect of the Lysholm score was greater than the IKDC subjective score, should be addressed in assessing the patient's functional status postoperatively.Level of evidence: III, retrospective comparative study.     

Patterns of systemic lupus erythematosus expression in Europe

ObjectivesTo analyse the differences in disease expression of European SLE patients based on gender, age at diagnosis, and ethnicity.MethodsA two-year, retrospective, multicentre, observational study was carried out in five countries (France, Germany, Italy, Spain and the UK). Patients' clinical manifestations including disease activity, organ involvement, organ damage and flares were analysed.ResultsThirty-one centres enrolled 412 consecutive eligible patients (90.5% of women), with active disease, stratified by disease severity (half severe and half non-severe).Baseline characteristics included; mean (SD) age: 43.3 (13.6) years, SLE duration: 10.7 (8.0) years and age at disease diagnosis: 32.6 (13.0) years old. The mean (SD) SELENA-SLEDAI and SLICC/ACR scores were: 8.1 (6.7) and 0.82 (1.36), respectively. Over half of patients experienced flares (54.9%). The average number of annual flares was 1.01 (0.71) flares/year.In males compared to females, the renal system was more frequently active (53.8% vs 30.0%, p = 0.002), the mean SLICC/ACR score was higher (1.15 vs 0.79, p = 0.039) and the pulmonary system was more likely to be damaged (12.8% vs 3.8%, p = 0.010). Furthermore, patients diagnosed at younger age displayed more renal system activity (young: 56.3% vs adult: 33.4% vs elder: 8.9%, p < 0.001) and renal damage (25.0% vs 6.9% vs 2.2%, p = 0.018) compared to the others. The annual number of flares (1.13 vs 1.05 vs 0.81 flares/year, p < 0.0001), including the occurrence of severe flares (0.58 vs 0.51 vs 0.20, p < 0.0001), was also higher in these patients.Conversely, greater organ damage was observed in patients diagnosed at an older age compared to the others. The mean SLICC/ACR score was higher (1.31 vs young: 0.88 and adult: 0.78, p < 0.001) in patients diagnosed in the older age groups. The pulmonary (13.3% vs younger: 0% vs adult: 3.7%, p = 0.030) and cardiovascular (17.8% vs younger: 0% vs adult: 2.9%, p < 0.001) systems were more frequently damaged in these patients.Black African descents showed greater disease activity compared to Caucasian patients. They flared more often (77.1% vs 48.6%, p = 0.001) and experienced a greater number of annual flares (1.57 vs 0.89 flares/year, p < 0.0001), mainly more severe flares (0.89 vs 0.38/year, p < 0.0001). They also were more likely to experience renal system damage.ConclusionThe study showed clearly two patient subsets. The disease was the most active in Black African descents, and this phenomenon has never been described before in continental Europe. The disease was also more active in patients diagnosed at a younger or adult. Greater disease damage was observed in males and in patients diagnosed at an older age.     

Comparison of second-look arthroscopic findings and clinical results according to the amount of preserved remnant in anterior cruciate ligament reconstruction

BackgroundAlthough ACL reconstruction is prevalent, the most effective method for ACL reconstruction still remains controversial. The purpose of this study was to evaluate the effect of the preserved remnant in ACL reconstruction on graft morphology at second-look arthroscopy and clinical outcomes.Methods66 consecutive patients who underwent a second-look arthroscopy after a remnant-preserving ACL reconstruction were enrolled. The patients were divided into two groups according to whether the remnant ACL fibers could be preserved by over 50% (Group I) or not (Group II). The Lysholm score, IKDC subjective score, Tegner activity score, pivot-shift test, and KT-2000 arthrometric findings were evaluated preoperatively and just prior to the second-look arthroscopy to assess clinical outcomes. At second-look arthroscopy, graft morphology was evaluated using hypertrophy rate and synovialization.ResultsAt second-look arthroscopy, the hypertrophy rate of Group I (42.1%) was higher than Group II (25.1%), which was statistically significant (p = 0.002). In graft synovialization, there was a statistically significant difference between the two groups (p < 0.001). The IKDC subjective score improved from 42.9, 43.1 to 77.8, 75.0 for Group I and Group II, respectively (p = 0.025). For the Lysholm score, Group I and Group II improved from 55.4 and 55.7 to 87.8 and 84.9 (p = 0.031). There was also a significant difference between the pivot shift tests between the groups (p = 0.039). Other clinical tests showed no statistically significant differences.ConclusionPreserving the remnant ACL tissue during ACL reconstruction could have a positive effect on graft hypertrophy, synovialization and clinical outcomes.Level of evidenceIII, retrospective comparative study.     

Efficacy and safety of paliperidone extended-release in schizophrenia patients with prominent affective symptoms

BackgroundThis post-hoc analysis evaluated the effects of paliperidone extended-release (ER) in patients with schizophrenia and prominent affective symptoms.MethodsPooled data from three 6-week, randomized, double-blind, placebo-controlled studies were analyzed. Subjects received fixed doses of paliperidone ER 3–12 mg/day or placebo. Prominent affective symptoms were defined as depressive (Positive and Negative Syndrome Scale [PANSS] depression item score of ≥ 5 [moderately severe]) and/or manic (PANSS grandiosity score of ≥ 4 [moderate], plus a score of ≥ 4 [moderate] on at least 1 PANSS item for excitement, hostility, uncooperativeness, or poor impulse control). Assessments included PANSS, Clinical Global Impressions-Severity (CGI-S), Personal and Social Performance (PSP) scale, and adverse events (AEs).ResultsAmong 193 patients with prominent affective symptoms, 140 received paliperidone ER and 53 received placebo. Paliperidone ER showed significant mean (SD) improvements vs. placebo in PANSS total (? 20.5 [23.8] vs. ? 6.3 [27.2]; p < 0.001, respectively) and all factor scores (p < 0.01). Significant mean (SD) improvements were observed in PSP (7.2 [15.8] vs. 0.4 [14.6]; p = 0.004) and CGI-S (? 0.9 [1.2] vs. ? 0.3 [1.2]; p < 0.001) scores. Most common AEs with paliperidone ER vs. placebo: headache (16.4% vs. 13.2%), insomnia (7.9% vs. 9.4%), akathisia (7.1% vs. 1.9%), sedation (7.1% vs. 3.8%).LimitationsThese studies were not designed to examine patients with prominent affective symptoms. Authors' clinical judgment was used to define prominent affective symptoms, using relevant PANSS items.ConclusionsPaliperidone ER was well tolerated and associated with significantly greater improvements in symptomatology, functioning, and overall clinical status vs. placebo in patients with schizophrenia and prominent affective symptoms.     

Long term outcome following knee replacement in patients with juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is a disabling and destructive condition that commonly affects the knee during childhood. Our study aimed to look at the outcome of knee replacement in this uncommon group, set a benchmark for survival and determine predictors of functional results.Patients were identified from a regional specialist rheumatology clinic set up for the care of adult patients with JIA. Outcome was assessed using Stanford HAQ 20-item disability scale, patient administered WOMAC questionnaire and Knee society score.This retrospective cohort includes 34 knee replacements in 20 patients with JIA performed at a median age of 35 years with median follow up of 16 years. Median WOMAC and Knee society score at last follow up were 61.7 and 60.8 respectively. The pain component of the scores was significantly (p < 0.001) better than functional component. Strong negative correlation (R = ? 0.79, p < 0.001) was noted between Knee society function score and HAQ score. Moderate negative correlation (R = ? 0.42; p = 0.02) was noted between Knee society function score and age at onset of the disease. Multiple stepwise regression analysis to estimate the predictors of functional results showed that the only significant (p < 0.001) predictor for functional outcome was disease activity, as predicted by the HAQ score. Kaplan Meier survival analysis revealed an estimated survival of 58.5% at 20 years.Knee replacement is a satisfactory pain relieving procedure in JIA patients, although survival may be poor. Disease activity as determined by HAQ score, may predict functional results.     

Early postoperative predictors of satisfaction following total knee arthroplasty

BackgroundDespite the excellent total knee arthroplasty (TKA) results reported using traditional outcome measures, dissatisfaction rates of up to 30% are reported following surgery. Although several preoperative factors have been identified as possible predictors of satisfaction, there is conflicting evidence. Identification of dissatisfaction in the early postoperative assessment may therefore be an alternative consideration.MethodsWe examined the relationship between 12-month satisfaction, and early post-operative outcomes in a cohort of 486 TKA patients. Preoperative, and postoperative outcome measures at 3- and 12-months (Oxford knee score, pain score, SF12, and knee motion), were analysed and compared between patients who were satisfied and dissatisfied at 12-months following TKA. Mean scores, and postoperative change in scores were calculated. Postoperative outcomes were examined for correlation with satisfaction, and multivariate logistic regression models used to identify potential predictors of dissatisfaction.ResultsOverall satisfaction was 77.0%. No preoperative differences were observed between groups. Dissatisfaction was associated with worse postoperative status across all outcome measures (p < 0.001), except the 3-month SF12-physical component (p = 0.052). Dissatisfied patients demonstrated minimal further improvement or even worsening of outcome scores between 3- and 12-months postoperatively (p < 0.02). Both the 3-month OKS (OR = 1.15, p < 0.001), and knee flexion (OR = 1.03, p = 0.009) were significant predictors of subsequent 12-month satisfaction.ConclusionsDissatisfaction following TKA is associated with worse outcomes as early as 3 months following surgery, with minimal further improvement subsequently achieved at 12-months. Early postoperative assessment following TKA should therefore be considered, including clinical assessment, to identify those patients at risk of dissatisfaction.     

L’âge des culots globulaires transfusés influence-t-il toujours le pronostic des patients en réanimation ?

ObjectiveFew studies have shown that aged packed red blood cells (RBC) transfusion negatively influenced the outcome of ICU patients, probably related to storage lesions which could be decreased by leukodepletion of RBC. The purpose of this study was to evaluate the impact of aged leukodepleted-RBC pack, on the outcome of ICU patients.DesignRetrospective, observational, cohort study in a Medical Intensive Care Unit.PatientsConsecutive patients admitted during the years 2005 and 2006, and requiring a transfusion. We recorded patient's demographic data, number of RBC unit and age of each RBC, length of ICU, mortality during ICU stay.ResultsFive hundred and thirty-four patients were included with global mortality was 26.6%, length of stay in ICU six days (3–14) and SAPS II 48 (35–62). RBC equaling to 5.9 were transfused per patients (22.7% < 14 days and 57.3% < 21 days). The number of RBC was significantly higher in the dead patients group, but the rate of RBC stored less than 21 days was not different (54% versus 60%; p = 0.21). In a multivariate logistic model, independent predictors of ICU death were SAPS II (OR = 1.02 per point, p < 0.001), number of RBC (OR = 1.08 per RBC, p < 0.001), length of stay in ICU (p < 0.001). Similar results were obtained while introducing the age of RBC as time dependent covariates in a multivariate Cox's model.ConclusionsRBC transfused in our ICU are old. The ICU outcome is independently associated with the number of leucodepleted RBC transfused, but not with their age.     

Specifying the effects of physician's communication on patients’ outcomes: A randomised controlled trial

ObjectiveTo experimentally test the effects of physician's affect-oriented communication and inducing expectations on outcomes in patients with menstrual pain.MethodsUsing a 2 × 2 RCT design, four videotaped simulated medical consultations were used, depicting a physician and a patient with menstrual pain. In the videos, two elements of physician's communication were manipulated: (1) affect-oriented communication (positive: warm, emphatic; versus negative: cold, formal), and (2) outcome expectation induction (positive versus uncertain). Participants (293 women with menstrual pain), acting as analogue patients, viewed one of the four videos. Pre- and post video participants’ outcomes (anxiety, mood, self-efficacy, outcome expectations, and satisfaction) were assessed.ResultsPositive affect-oriented communication reduced anxiety (p < 0.001), negative mood (p = 0.001), and increased satisfaction (p < 0.001) compared to negative affect-oriented communication. Positive expectations increased feelings of self-efficacy (p < 0.001) and outcome expectancies (p < 0.001), compared to uncertain expectations, but did not reduce anxiety. The combination of positive affect-oriented communication and a positive expectation reduced anxiety (p = 0.02), increased outcome expectancies (p = 0.01) and satisfaction (p = 0.001).ConclusionBeing empathic and inducing positive expectations have distinct and combined effects, demonstrating that both are needed to influence patients’ outcomes for the best.Practice implicationsContinued medical training is needed to harness placebo-effects of medical communication into practice.     

Clinical outcomes after arthroscopic treatment of knee osteoarthritis

PurposeThe aim of this study was to describe the clinical outcomes of patients with knee osteoarthritis (OA) treated with arthroscopic surgery, documenting the associated injuries and defining the type of treatment selected for OA patients with different symptoms.HypothesisKnee arthroscopy is effective for treating patients with symptomatic OA and mechanical symptoms.MethodsThis was a prospective, consecutive series of 100 patients with a clinical and radiological diagnosis of OA who were treated with knee arthroscopy. The average follow-up time was 35.9 months (25–71), and the average age was 60.1 years (50–83). Inclusion criteria: > 50 years of age, a clinical imaging diagnosis of knee OA with an Ahlbäck I–III classification. Exclusion criteria: < 50 years of age, Ahlbäck IV, pathologic lower limb mechanical axis and inflammatory joint diseases. The IKDC and Lysholm scores were assessed before and after surgery.ResultsThe preoperative average scores were as follows: Lysholm, 56.9 ± 13.5 points (22–71); IKDC, 59.4 ± 21.7 points (45–80). The postoperative average scores were as follows: Lysholm, 86.9 points (22–87); IKDC, 79.5 points (45–100). Regarding the Lysholm scores, 76% were good and excellent results and 24% were moderate (p = 0.045). The associated injuries included 48% of chondral and 36% of unstable meniscal injuries. Good or excellent results were observed in 76% of the meniscal injury cases according to the Lysholm scores, while only 84.6% of the cases with unstable chondral lesions had good or excellent results (p = 0.035).ConclusionMost patients with knee OA associated with unstable cartilage or meniscal injuries reported good-to-excellent symptomatic results at the short- and mid-term follow-ups.Level of evidenceIII     

Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block

BackgroundWe report a prospective blinded randomised trial of local infiltration versus femoral nerve block in patients undergoing primary total knee replacement (TKR), in accordance with the CONSORT statement 2010.MethodsFifty patients in a teaching hospital were consented for the study. The study arms were intraoperative local anaesthesia (150 ml 0.2% ropivacaine/1 ml 1:1000 adrenaline/30 mg ketolorac) and femoral nerve block (30 ml 0.2% ropivacaine) with a primary outcome of pain score at 4 h post operatively. Secondary outcomes were pain at 2 h, pain scores before and after physiotherapy on day one, total opiate administered, time to physiotherapy goals and length of stay. Randomisation was by sealed envelope. The assessor was blinded and the patients partially blinded to the intervention.ResultsTen patients were excluded, eight before randomisation. The trial is complete. Forty patients were analysed for the primary outcome measure. The local infiltration group had significantly lower pain scores at 4 h post-operatively; mean [SD] score 2.1 [2.6] versus 6.8 [3.2], p < 0.00001 and on post-operative day one prior to physiotherapy; mean score 2.4 [2.3] versus 4.4 [2.3], p < 0.05. Total opiate use was also significantly lower in the local infiltration group; mean total 115 [50.3] mg versus 176.5 [103.5] mg, p < 0.01. There was no difference in any other outcome. There were no harms as a result of either intervention.ConclusionIntraoperative local infiltration gives superior pain relief compared to single shot femoral nerve block over the first 24 h following primary TKR and minimises post-operative opiate use.     

Performance of a rapid antigen test (Binax NOW® RSV) for diagnosis of respiratory syncytial virus compared with real-time polymerase chain reaction in a pediatric population

BackgroundInfants from Alaska's Yukon–Kuskokwim Delta (YKD) have a high respiratory syncytial virus (RSV) hospitalization rate (104/1000/yr). Appropriate patient management requires rapid and accurate RSV diagnosis. Antigen-based methods are often used in clinical settings, but these tests can lack sensitivity.ObjectiveWe compared Binax NOW^® RSV (BN) used for RSV diagnosis in the YKD hospital with a real-time polymerase chain reaction assay (RT-qPCR) used for viral surveillance.Study designBetween October 2005 and September 2007 we obtained nasopharyngeal washes (NPW) from children <3 years hospitalized with a lower respiratory tract infection. The NPW were tested using BN and RT-qPCR.Results79/311 (25%) children had RSV infection as determined by RT-qPCR. As compared with RT-qPCR, sensitivity and specificity of BN were 72% and 97%, respectively. The sensitivity of BN was higher in children <1 year compared with children ≥1 year (79% vs. 52%; p = 0.025), children with bronchiolitis compared with children without bronchiolitis (89% vs. 38%; p < 0.001), and children with a shorter duration of symptoms before testing (0–1 (92%) vs. 2–4 (78%) vs. 5+ (65%) days; p = 0.04). The median RSV viral load in NPW positive by BN and RT-qPCR was 1.01 × 10⁹ copies/mL vs. a median of 5.25 × 10⁷ copies/mL for NPW positive by RT-qPCR only (p < 0.001).ConclusionRT-qPCR is more sensitive than BN in detecting RSV infection. BN sensitivity is high in children with bronchiolitis, but the sensitivity is low when children present with a non-bronchiolitis illness, especially after a longer duration of symptoms before testing.     

Walking shoes and laterally wedged orthoses in the clinical management of medial tibiofemoral osteoarthritis: A one-year prospective controlled trial

The purpose of the study was to examine the clinical efficacy of individually prescribed laterally wedged orthoses and walking shoes in the treatment of medial knee osteoarthritis using a prospective, single-blind, block-randomized controlled design.Sixty-six subjects (29 males, 37 females, mean age 62.4 years, mean BMI 33.0 kg/m²) were block-randomized to a lateral wedge (treatment) or neutral (control) orthotic group. Both groups were issued a standardized walking shoe for use with the orthoses. Primary outcome measures included the pain, stiffness, and functional limitations subscales of the Western Ontario and McMaster Universities index. Secondary outcome measures included the 6-minute walk distance and pain change, and stair negotiation time and pain change.A significant interaction (p = 0.039) favoring the treatment group was observed for pain change during the 6-minute walk. The treatment group demonstrated significant improvements at both 1 month (p < 0.001) and 1 year (p < 0.001) compared to baseline. The control group only demonstrated significant improvements at 1 year (p = 0.017). No other interactions were observed. Both groups were improved at each follow-up in the WOMAC subscales for pain (p < 0.001), stiffness (p < 0.001), and physical function (p < 0.001). Both groups also improved in 6-minute walk test distance (p < 0.001), stair negotiation test time (p = 0.004), and stair negotiation test pain change (p < 0.001).The results suggest that both neutral and laterally wedged orthoses may be beneficial in the management of medial knee osteoarthritis when used with walking shoes. However, the addition of lateral wedging was associated with early improvements in 6-minute walk test pain change not seen in the control group.     

Effects of supervised whole body vibration exercise on fall risk factors,functional dependence and health-related quality of life in nursing home residents aged 80+

ObjectiveTo test the feasibility and effectiveness of whole-body vibration (WBV) therapy on fall risk, functional dependence and health-related quality of life in nursing home residents aged 80+ years.DesignTwenty-nine 80–95 years old volunteers, nursing home residents were randomized to an eight-week WBV intervention group) (n = 15) or control group (n = 14). Functional mobility was assessed using the timed up and go (TUG) test. Lower limb performance was evaluated using the 30-s Chair Sit to Stand (30-s CSTS) test. Postural stability was measured using a force platform. The Barthel Index was used to assess functional dependence and the EuroQol (EQ-5D) was used to evaluate Health-Related Quality of Life. All outcome measures were assessed at baseline and at a follow-up after 8 weeks.ResultsAt the 8-week follow up, TUG test (p < 0.001), 30-s CSTS number of times (p = 0.006), EQ-5Dmobility (p < 0.001), EQ-5DVAS (p < 0.014), EQ-5Dutility (p < 0.001) and Barthel index (p = 0.003) improved in the WBV intervention group when compared to the control group.ConclusionsAn 8-week WBV-based intervention in a nursing home setting is effective in reducing fall risk factors and quality of life in nursing home residents aged 80+.     

Aortic elastic properties and cognitive function in elderly individuals: The Ikaria Study

BackgroundThe aim of this work was to evaluate the association between aortic elastic properties and cognitive function in elderly individuals, permanent inhabitants of Ikaria Island.MethodsIn 535 individuals (75 ± 6 years, 53% males) aortic distensibility (AoD) was non-invasively calculated from the aortic diameters measured with echocardiography and brachial artery pressure using the formula by Stefanadis et al.; cognitive status was evaluated using the Mini Mental State Examination (MMSE).Results88% of the elders had normal values of MMSE score (i.e., ≥24). Elders who achieved MMSE score ≥24 had higher values of AoD (1.90 ± 2.06 vs. 1.08 ± 1.42, p < 0.001), as well as were more physically active (85% vs. 69%, p = 0.05), had higher educational status (8.5 ± 2.8 years vs. 6 ± 2 years, p = 0.001), higher creatinine clearance levels (70 ± 21 vs. 63 ± 23, p = 0.05) and lower pulse pressure (PP) values (63 ± 16 vs. 68 ± 18, p = 0.06), as compared with those individuals with MMSE < 24. Logistic regression analysis showed that for every unit increase in AoD there was a 25% higher likelihood of having MMSE ≥ 24 (OR per 1000 × mmHg^?1 = 1.25, 95%CI 0.99–1.58), after adjustments for age, gender, current smoking, cardiovascular disease, creatinine clearance, hypertension, diabetes mellitus, obesity, physical activity status and education status. Furthermore having PP levels in the upper tertile (>70 mmHg), increases by 55% the likelihood of having MMSE < 24 (OR for above 70 mmHg = 0.45, 95%CI 0.22, 0.92), after the same adjustments were made.ConclusionArterial aging seems to affect cognitive function; a finding that states a novel research hypothesis about the pathophysiological mechanisms of mental functioning.     

Promising short-term results following selective bundle reconstruction in partial anterior cruciate ligament tears

BackgroundThe different functions of the two anterior cruciate ligament (ACL) bundles have increased interest in tears of only one of these two bundles. The purpose of this study was to assess the outcome of selective reconstruction of an injured bundle of isolated anteromedial bundle (AMB) or posterolateral bundle (PLB) tears.MethodsConsecutive series of 147 ACL reconstructions was prospectively analyzed. Patients with partial ACL tears who underwent selective bundle reconstructions were studied. Stability was assessed with the Lachman, anterior-drawer and pivot-shift tests and KT-1000. Functional assessment was performed with Lysholm and Tegner questionnaires. The preoperative MRI was analyzed to detect differences from arthroscopic findings.ResultsTwenty-eight patients (19%) were included. The minimum follow-up period was 30 months. Eighteen had AMB and 10 PLB tears. Only 19% of their MRI's were categorized as partial ACL tears.The Lysholm score improved from 66.1/65.5 to 96.6/95.2 in the AMB/PLB groups, respectively (p < 0.001). The same or no more than one level lower Tegner score was restored. The pivot-shift, Lachman and anterior-drawer tests were negative in all cases (p < 0.001). Two reconstructed AMBs developed extension loss due to Cyclops lesions and were resolved surgically.ConclusionsThe technique provided excellent functional scores with normalized stability and a return to previous level of activity with a low rate of minor complications at a minimum 2.5 years' follow-up. Arthroscopic examination was the most reliable tool for properly diagnosing and treating a condition observed in almost one out of every five ACL reconstructed knee in this series.Level of evidenceTherapeutic case series; level 4.     

Diabetes does not influence the early outcome of total knee replacement: A prospective study assessing the Oxford knee score,short form 12, and patient satisfaction

BackgroundThere is conflicting evidence as to whether diabetes mellitus influences the functional outcome and patient satisfaction after a total knee replacement (TKR). The aim of this study was to assess the effect of diabetes upon the Oxford knee score (OKS), short form (SF)-12, and patient satisfaction after TKR.MethodsProspective pre- and post-operative (one year) OKS and SF-12 scores for 2389 patients undergoing primary TKR were compiled, of which 275 (12%) patients suffered with diabetes. Patient satisfaction was assessed at one year.ResultsPatients with diabetes were more likely to have a greater level of comorbidity (p < 0.001), and a worse pre-operative OKS and SF-12 score (p < 0.02), compared to those patients without diabetes. Diabetes was not a significant (p > 0.41) independent predictor of post-operative OKS or the SF-12 physical score on multivariable analysis. Although, factors more prevalent within the diabetic cohort (heart disease, vascular disease, liver disease, anaemia, depression, back pain, worse pre-operative OKS and SF-12 score) were found to be independent predictors of post-operative OKS and SF-12 physical score. Interestingly, diabetes was associated with a significantly greater improvement in mental wellbeing (SF-12 mental component), which was confirmed on multivariable analysis. Patient satisfaction was not influenced by a concomitant diagnosis of diabetes (p = 0.57).ConclusionThe outcome of TKR as assessed by the OKS, SF-12, and overall patient satisfaction rates are not influenced by diabetes per se, although factors more prevalent within this population result in a worse post-operative outcome.Level of evidence: prospective cohort study, level III.     

Five-year follow-up of minimally invasive computer assisted total knee arthroplasty (MICATKA) versus conventional computer assisted total knee arthroplasty (CATKA) — A population matched study

BackgroundMinimally invasive surgery (MIS) has perceived advantages in the early post-operative stage such as reduced blood loss, decreased pain, earlier return to function and earlier discharge. The aim of our study was to confirm that longer term clinical outcome of TKA is not compromised when MIS is combined with computer assisted surgery.MethodsEighty patients matched for age, gender, pre-operative Knee Society Score (KSS) and mechanical axis were prospectively studied. Forty patients underwent minimally invasive computer assisted total knee arthroplasty (MICATKA) and 40 patients underwent conventional computer assisted TKA (CATKA). Functional scores were determined at 6 weeks, 6, 12, 18, and 24 months and 5 years post-surgery. Long-leg alignment views were obtained 3 months post-operatively.ResultsKSSs in the short term were significantly better in the MICATKA group than in the CATKA group (p < 000.1). Tourniquet-time was 58 min in the MICTKA group and 60 min in the CATKA group (p = 0.3). Straight leg raise was achieved by day one in 93% of the MICATKA group compared to 30% of the CATKA group (p < 0.001). Length of stay for the MICATKA group has a mean of 3.25 days and a mean of 6 days for the CATKA group (p < 0.001). KSSs up to 2-years were significantly better in the MICTKA group (p < 0.001). At 5-years there was no significant difference in KSSs (p = 0.46) in the MICATKA and CATKA groups.ConclusionWe confirm that the use of navigation in minimally invasive TKA permits a number of early post-operative advantages and that longer-term functional outcome is not compromised with its usage.Level of evidenceLevel II     

Long-term clinical outcomes following the use of synthetic hydroxyapatite and bone graft in impaction in revision hip arthroplasty

Impaction grafting using morsellised allograft bone restores bone stock, but carries the potential for transmission of infection. Synthetic bone graft substitutes can eliminate this risk but may, however, influence outcome. In this study we tested the hypothesis that a 50/50 mix of hydroxyapatite and allograft does not affect long-term function, survival or radiological outcome. Sixty-five patients had revision hip arthroplasty using impaction grafting with either pure allograft (42 patients) or a 50/50 mixture of allograft and solid particulate hydroxyapatite. Harris hip scores were assessed pre-operatively and annual intervals thereafter. Function was analyzed using multilevel modeling, the Kaplan–Meier method used for survival analysis and graft incorporation was assessed radiologically. The hip score improved in both groups but showed a small annual decline (average 1.2/year, p < 0.01). This decline was higher for females (average 3.4, p = 0.025) and significantly related to pre-op scores (p < 0.001). After adjusting for these, allograft patients had marginally higher scores (difference = 3.1, p = 0.3). The majority of revisions were for aseptic loosening. At 13 years survival in the allograft group was 84%, and 82% in the mixture group (p = 0.96, log rank test). Radiologically the graft incorporation was similar in both groups (p = 0.62). We conclude that long-term prosthesis survival and function following revision arthroplasty with a 50/50 mixture of allograft and hydroxyapatite are comparable to allograft alone.     

Inflammatory predictors of ongoing pain 2 years following knee replacement surgery

IntroductionThe prevalence of unrelieved pain following total knee arthroplasty (TKA) is substantial.ObjectiveWe asked if cytokine markers of inflammation in preoperative serum or knee synovial fluid (SF) would predict pain 2 years following TKA.MethodsDemographic data and functional outcomes were recorded at baseline and 2 years with the WOMAC index. Serum and SF tissue samples were collected at the time of surgery. Linear regression modeling was used to determine the relationship between SF/serum inflammatory markers and a lesser improvement in self reported pain at two years follow-up.ResultsOf our 28 patient cohort, significant correlations between serum and SF levels were found for IL-1β (p < 0.002), MIP-1β (p < 0.001), adiponectin (p < 0.001) and leptin (p < 0.001). Adjusted analysis showed that greater SF concentrations of TNF-α, MMP-13 and IL-6 were independent predictors of less pain improvement at two years follow-up (p < 0.05).ConclusionsThose patients, having ongoing pain despite no clinical or radiological cause, may have an inflammatory profile characterizing a predisposition to ongoing pain after TKA.Level of EvidencePrognosis study, Level 2.