Preoperative lateral subluxation of the patella is a predictor of poor early outcome of Oxford phase-III medial unicompartmental knee arthroplasty

Background and purpose

There is disagreement in the literature about the importance of patellofemoral joint degeneration and knee pain for the outcome of unicompartmental knee arthroplasty (UKA). We therefore investigated the importance of selected predictors including patellofemoral joint degeneration and the location of preoperative knee pain for the early outcome of UKA.

Patients and methods

The study group comprised 260 consecutive patients from 5 hospitals who underwent Oxford UKA for anteromedial osteoarthritis. Data were collected at baseline and included pain location, radiologically observed degeneration of the patellofemoral joint including subluxation of the patella, intraoperative cartilage status of the patellofemoral joint, disease-specific knee status, and Oxford knee score (OKS). Outcomes were evaluated after 1 year using the OKS, global patient satisfaction, and global patient result.

Results

The average OKS score at baseline was 24 (SD 7), and it was 40 (SD 8) at the 1-year follow-up. 94% of the patients claimed improvement after the operation and 90% were satisfied with the UKA. Lateral subluxation of the patella was a predictor of poor outcome, and the preoperative OKS score was also a predictor of outcome. Full-thickness cartilage loss at any location gave a similar outcome to that with a normal or near-normal joint surface, and likewise, preoperative anterior knee pain was not a predictor of outcome.

Interpretation

We conclude that the good early outcome after UKA in this study is in line with the best reported results. Patellofemoral degeneration should not be considered a contraindication to Oxford UKA. Patients with lateral subluxation of the patella have an increased risk of a poor result after UKA and should preferably be offered a total knee replacement.There is no consensus about the indications for choosing unicompartmental knee arthroplasty (UKA) instead of total knee arthroplasty. Kozinn and Scott (1989) accepted only minor degenerative changes in the patellofemoral joint, and anterior knee pain—thought to be a sign of significant patellofemoral involvement—has also been an exclusion criterion (Stern et al. 1993). Berger et al. (2004) stated that patients with clinical, radiographic, or intraoperative evidence of patellofemoral arthrosis are not appropriate candidates for unicompartmental knee arthroplasty. However, the Oxford Group recommended that the state of the patellofemoral joint should be ignored when deciding whether or not to use UKA (Goodfellow et al. 1986, 2006). A recent paper by the Oxford group (Beard et al. 2007a) demonstrated that anterior knee pain or damage to the patellofemoral joint (provided that there is not bone loss and grooving of the lateral facet) is not a contraindication for Oxford UKA, while caution should be observed in cases with lateral patellofemoral joint degeneration. In these cases, a TKR should be preferred to avoid clinical failure.Here we describe early outcome after Oxford phase-III UKA. We also investigated the importance of selected predictors—including patellofemoral joint degeneration, subluxation of the patella, and the location of preoperative knee pain—for early outcome.     

Combining magnetic and optical tracking for computer aided therapy

A fast and accurate magnetic tracking system was developed for applications in real-time tumor tracking, computer-aided surgery, and endoscopy. The tracking is based on the application of miniaturized sensors. Once implanted in the patient, the sensors receive signals from an external field generator. The fast evaluation of the signals allows the online determination of position and orientation of each sensor. With the help of optical tracking, the sensor coordinates are transformed in the reference system used by the clinician. The effects of eddy currents in nearby electrically-conducting objects are taken into account using special computational methods. The present paper presents the results of a first experiment in a canine model.     

Endothelial catabolism of extracellular adenosine during hypoxia: the role of surface adenosine deaminase and CD26

Extracellular levels of adenosine increase during hypoxia. While acute increases in adenosine are important to counterbalance excessive inflammation or vascular leakage, chronically elevated adenosine levels may be toxic. Thus, we reasoned that clearance mechanisms might exist to offset deleterious influences of chronically elevated adenosine. Guided by microarray results revealing induction of endothelial adenosine deaminase (ADA) mRNA in hypoxia, we used in vitro and in vivo models of adenosine signaling, confirming induction of ADA protein and activity. Further studies in human endothelia revealed that ADA-complexing protein CD26 is coordinately induced by hypoxia, effectively localizing ADA activity at the endothelial cell surface. Moreover, ADA surface binding was effectively blocked with glycoprotein 120 (gp120) treatment, a protein known to specifically compete for ADA-CD26 binding. Functional studies of murine hypoxia revealed inhibition of ADA with deoxycoformycin (dCF) enhances protective responses mediated by adenosine (vascular leak and neutrophil accumulation). Analysis of plasma ADA activity in pediatric patients with chronic hypoxia undergoing cardiac surgery demonstrated a 4.1 +/- 0.6-fold increase in plasma ADA activity compared with controls. Taken together, these results reveal induction of ADA as innate metabolic adaptation to chronically elevated adenosine levels during hypoxia. In contrast, during acute hypoxia associated with vascular leakage and excessive inflammation, ADA inhibition may serve as therapeutic strategy.     

Impaired T cell death and lupus-like autoimmunity in T cell-specific adapter protein-deficient mice

T cell-specific adaptor protein (TSAd) is a T lineage-restricted signaling adaptor molecule that is thought to participate in the assembly of intracellular signaling complexes in T cells. Previous studies of TSAd-deficient mice have revealed a role for TSAd in the induction of T cell interleukin 2 secretion and proliferation. We now show that TSAd-deficient mice are susceptible to lupus-like autoimmune disease. On the nonautoimmune-prone C57BL/6 genetic background, TSAd deficiency results in hypergammaglobulinemia that affects all immunoglobulin (Ig)G subclasses. Older C57BL/6 TSAd-deficient mice (1 yr of age) accumulate large numbers of activated T and B cells in spleen, produce autoantibodies against a variety of self-targets including single stranded (ss) and double stranded (ds) DNA, and, in addition, develop glomerulonephritis. We further show that immunization of younger C57BL/6 TSAd-deficient mice (at age 2 mo) with pristane, a recognized nonspecific inflammatory trigger of lupus, results in more severe glomerulonephritis compared with C57BL/6 controls and the production of high titer ss and ds DNA antibodies of the IgG subclass that are not normally produced by C57BL/6 mice in this model. The development of autoimmunity in TSAd-deficient mice is associated with defective T cell death in vivo. These findings illustrate the role of TSAd as a critical regulator of T cell death whose absence promotes systemic autoimmunity.     

Influence of iterative image reconstruction on CT-based calcium score measurements

Iterative reconstruction techniques for coronary CT angiography have been introduced as an alternative for traditional filter back projection (FBP) to reduce image noise, allowing improved image quality and a potential for dose reduction. However, the impact of iterative reconstruction on the coronary artery calcium score is not fully known. In 112 consecutive stable patients with suspected coronary artery disease, the coronary calcium scores were assessed. Comparisons were made between the Agatston, volume and mass scores obtained with traditional FBP, and by using adaptive statistical iterative reconstruction (ASIR). A significant reduction of the Agatston score, volume score and mass score was observed for ASIR when compared to FBP, with median differences of resp. 26, 5 mm³ and 1 mg. Using the ASIR reconstruction, the number of patients with a calcium score of zero increased by 13 %. Iterative CT reconstruction significantly reduces the Agatston, volume and mass scores. Since the calcium score is used as a prognostic tool for coronary artery disease, caution must be taken when using iterative reconstruction.     

Cross-national variation of gender differences in adolescent subjective health in Europe and North America

The cross-national consistency and variation of gender differences in subjective health complaints was examined in a sample of 125732 11- to 15-year-olds from 29 European and North American countries, participating in the WHO collaborative study 'Health behaviour in school-aged children (HBSC) 1997/98'. Health complaints were measured with the Health Behaviour in School-aged Children Symptom Checklist. Gender differences in health complaints were analysed through multilevel logistic regression analysis. The results indicated a very robust pattern of increasing gender differences across age, with 15-year-old girls as a group at increased risk for health complaints across all countries. The magnitude of gender differences varied across countries, with some countries showing a consistently strong gender difference across age group and different health complaints, and other countries showing a consistently weak gender difference. The gender difference in health complaints was stronger in countries with a low gender development index score. The findings underscore the need to incorporate socio-contextual factors in the study of gender health inequalities during adolescence.     

Results of spot-scanning proton radiation therapy for chordoma and chondrosarcoma of the skull base: the Paul Scherrer Institut experience

PURPOSE: To assess the clinical results of spot scanning proton beam radiation therapy (PT) in the treatment of skull base chordomas and low-grade chondrosarcomas (CS). METHODS AND MATERIALS: Between October 1998 and October 2003, 29 patients (median age, 39 years) with chordomas (n = 18) and CS (n = 11) were treated at the Paul Scherrer Institut (PSI) with protons using the main 510-MeV cyclotron. Tumor conformal application of proton beams was realized by spot scanning technology. The median chordoma and CS dose was 74 and 68 cobalt Gy equivalent, respectively (cobalt Gy equivalent = proton Gy x 1.1). Median gross tumor volumes (GTV) were 16.4 mL (range, 1.8-48.1 mL) and 15.2 mL (range, 2.3-57.3 mL) for chordoma and CS, respectively. Late toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE, v3.0) grading system. The median follow-up time was 29 months (range, 6-68 months). RESULTS: Actuarial 3-year local control rates were 87.5% and 100% for chordoma and CS, respectively. We observed one surgical pathway and one marginal failure in patients with chordomas. No regional failure or distant metastasis was observed. At 3 years, actuarial PFS and OS for the entire cohort was 90% and 93.8%, respectively. Actuarial 3-year complication-free survival was 82.2%. Radiation-induced pituitary dysfunction was observed in 4 (14%) patients (CTCAE Grade 2). No patient presented with post-PT brainstem or optic pathways necrosis or dysfunction. In univariate analysis, age < or =40 years at the time of PT affected favorably on PFS (p = 0.09). CONCLUSION: Spot-scanning PT offers high tumor control rates of skull base chordoma and CS. These results compare favorably to other combined proton-photon or carbon ion irradiation series. Observed toxicity was acceptable. Younger age (< or =40 years) was a favorable prognostic factor of PFS. These preliminary results are encouraging but should be confirmed during a longer follow-up.