General: Mosaicoplastia en condropatías pequeñas

Systematic Review of Autogenous Osteochondral Transplant Outcomes

T. Sean Lynch M.D.Ronak M. Patel M.D.Anthony Miniaci M.D.

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Available online 21 January 2015, doi:10.1016/j.arthro.2014.11.018

Purpose

The goal of this systematic review was to present the current best evidence for clinical outcomes of osteochondral autograft transplantation to elucidate the efficacy of this procedure.

Methods

PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials were searched (key terms “knee,” “osteochondral autograft transfer,” or “mosaicplasty”) to identify relevant literature between 1950 and 2013 in the English language. This evaluation included studies in pediatric and adult patients with grade 3 or 4 articular cartilage injuries; the studies had a minimum of 25 patients and at least 12 months of follow-up and compared osteochondral autograft transfers/mosiacplasty with another treatment modality. Articles were limited to full-text randomized controlled trials or cohort studies. Main outcomes studied were patient-reported and functional outcome, with secondary outcomes including effect of lesion size, return to sport and sport function, radiographic outcomes, and reoperation rates.

Results

There were a total of 9 studies with 607 patients studied in this systematic review. When osteochondral autologous transfer/mosaicplasty (OATM) was compared with microfracture (MF), patients with OATM had better clinical results, with a higher rate of return to sport and maintenance of their sports function from before surgery. Meanwhile, patients who underwent MF trended toward more reoperations, with deterioration around 4 years after surgery. When compared with autologous chondrocyte implantation (ACI), clinical outcome improvement was not conclusive; however, at 10-year follow-up, a greater failure rate was found to be present in the OATM group.

Conclusions

Current evidence shows improved clinical outcomes with OATM when compared with preoperative conditions. These patients were able to return to sport as early as 6 months after the procedure. It could be suggested from the data that OATM procedures might be more appropriate for lesions that are smaller than 2 cm2 with the known risk of failure between 2 and 4 years. Further high-quality prospective studies into the management of these articular cartilage injuries are necessary to provide a better framework within which to target intervention.

Level of Evidence

Level II, systematic review of Level I and II studies.

Tobillo/Ankle: Es preferible tratar las fracturas estables con ortesis

The Effects of Shared Decision Making in the Conservative Management of Stable Ankle Fractures
R.H. Hutchinson, J.L. Barrie
Injury; Published Online: January 17, 2015
DOI: http://dx.doi.org/10.1016/j.injury.2015.01.013

Abstract

Introduction

The majority of ankle fractures seen in clinic are stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable ankle fractures are advised that they need a cast. In this study we counselled patients regarding the different options for conservative management of their stable ankle fracture. We then encouraged them to make an informed decision on which method of treatment they would like to pursue.

Materials & Methods
We analysed eight years of a single consultant's fracture clinic. 163 patients were offered a choice of: a weight bearing below knee cast; a functional ankle brace; or a regime of rest, ice, compression bandage and elevation (“RICE” regime). All patients were advised to mobilise on the injured ankle as their pain allowed.

Results
163 patients were suitable for all 3 treatment options. 82% (133/163) chose an ankle brace, 15% (25/163) opted for a RICE regime and 3% (5/163) chose a below knee cast. Of these only one returned to clinic complaining of increased pain, however after further discussion the patient opted to continue with his RICE regime as planned.

Discussion
A conservative approach to these injuries is now common practice; however there is a wide variation in what type of conservative management is given. Recent studies suggest orthopaedic surgeons are still treating the majority of these injuries with a weight-bearing cast despite risks of stiffness, skin damage and thromboembolism. This study showed when the patient is given opportunity to make an informed choice the vast majority opt not to have a cast. The study suggests management of these injuries should be decided via a two-way conversation between patient and practitioner.

Conclusions
Using a shared decision making approach to these injuries is a useful method of providing patients with the most suitable treatment for their personal treatment goals.

Cadera/Hip: extracto de gambas para curar el cartílago

Arthroscopic Treatment of Hip Chondral Defects With Bone Marrow Stimulation and BST-CarGel
Marc Tey, Jesús Mas, Xavier Pelfort, Joan Carles Monllau
Arthroscopy Techniques, available online 19 January 2015
doi:10.1016/j.eats.2014.10.002

Abstract

Microfracture, the current standard of care for the treatment of non-degenerative chondral lesions in the hip joint, is limited by the poor quality of the filling fibrocartilaginous tissue.

BST-CarGel (Piramal Life Sciences, Laval, Quebec, Canada) is a chitosan-based biopolymer that, when mixed with fresh, autologous whole blood and placed over the previously microfractured area, stabilizes the blood clot and enhances marrow-triggered wound-healing repair processes. BST-CarGel has been previously applied in the knee, with statistically significant greater lesion filling and superior repair tissue quality compared with microfracture treatment alone. In this report we describe the application of BST-CarGel for the arthroscopic treatment of hip chondral lesions.

Our preliminary data suggest that our BST-CarGel procedure provides high-quality repair tissue and therefore may be considered a safe, cost-efficient therapeutic choice for the treatment of hip chondral defects.

Rodilla/Knee: Más bien, rotando hacia afuera

Influence of tibial rotation in total knee arthroplasty on knee kinematics and retropatellar pressure: an in vitro study
Arnd Steinbrück, Christian Schröder, Matthias Woiczinski, Tatjana Müller, Peter E Müller, Volkmar Jansson, Andreas Fottner
Knee Surg Sports Traumatol Arthrosc. 2015 Jan 11. [Epub ahead of print]

PURPOSE: Although continuous improvements have been made, there is still a considerable amount of unsatisfied patients after total knee arthroplasty (TKA). A main reason for this high percentage is anterior knee pain, which is supposed to be provoked by post-operative increased retropatellar peak pressure. Since rotational malalignment of the implant is believed to contribute to post-operative pain, the aim of this study was to examine the influence of tibial component rotation on knee kinematics and retropatellar pressure.

METHODS: Eight fresh-frozen knee specimens were tested in a weight-bearing knee rig after fixed-bearing TKA under a loaded squat from 20° to 120° of flexion. To examine tibial components with different rotations, special inlays with 3° internal rotation and 3° external rotation were produced and retropatellar pressure distribution was measured with a pressure-sensitive film. The kinematics of the patella and the femorotibial joint were recorded with an ultrasonic-based motion analysis system.

RESULTS: Retropatellar peak pressure decreased significantly from 3° internal rotation to neutral position and 3° external rotation of the tibial component (8.5 ± 2.3 vs. 8.2 ± 2.4 vs. 7.8 ± 2.5 MPa). Regarding knee kinematics femorotibial rotation and anterior-posterior translation, patella rotation and tilt were altered significantly, but relative changes remained minimal.

CONCLUSION: Changing tibial rotation revealed a high in vitro influence on retropatellar peak pressure. We recommend the rotational alignment of the tibial component to the medial third of the tibial tuberosity or even more externally beyond that point to avoid anterior knee pain after TKA.

Rodilla/Knee: Ojo con la gonartritis séptica posoperatoria

Joint infection after knee arthroscopy: Medicolegal aspects
S. Marmora, T. Farmanb, A. Lortat-Jacobc
Orthopaedics & Traumatology: Surgery & Research (2009) 95, 278—283

Summary

Introduction:
Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients’ functional prognosis and engage surgeon’s liability. This study ana- lyzes the context of such infection occurrences, their management as well as their medicolegal consequences.

Patients and methods:
Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medi- cal liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrol- ysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy.

Results:
Clinical signs of septic arthritis appeared after a median interval of 8 days (0—37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1—9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0—20), a total temporary work incapacity of 120 days (40—790), a suffering burden averaging 3 out of 7 (0—4,5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation.

Discussion:
Some risk factors of articular infection are known and well-identified. They can be linked to the patient’s condition (addiction to smoking, surgical history, professional activity)
or to medical management (intra-articular corticoid injections, interventions under oral anti- coagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid’s inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic manage- ment of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner.

Level of evidence: Level IV; economic and decision analysis, retrospective study

Hombro/Shoulder: No te contentes con la primera impresión

Identification and treatment of existing copathology in anterior shoulder instability repair.Forsythe B, Frank RM, Ahmed M, Verma NN, Cole BJ, Romeo AA, Provencher MT, Nho SJ
Arthroscopy. 2015 Jan;31(1):154-66. doi: 10.1016/j.arthro.2014.06.014

Recurrent anterior instability is a common finding after traumatic glenohumeral dislocation in the young, athletic patient population.

A variety of concomitant pathologies may be present in addition to the classic Bankart lesion, including glenoid bone loss; humeral head bone loss; rotator interval pathology; complex/large capsular injuries including humeral avulsions of the glenohumeral ligaments (HAGL lesions), SLAP tears, near circumferential labral tears, and anterior labral periosteal sleeve avulsions (ALPSA lesions); and rotator cuff tears. Normal anatomic variations masquerading as pathology also may be present. Recognition and treatment of these associated pathologies are necessary to improve function and symptoms of pain and to confer anterior shoulder stability.

This review will focus on the history, physical examination findings, imaging findings, and recommended treatment options for common sources of copathology in anterior shoulder instability repair.

Rodilla/Knee: Si el menisco se lesiona, se resentirá el cartílago

Quantitative MRI T2 Relaxation Time Evaluation of Knee Cartilage: Comparison of Meniscus-Intact and -Injured Knees After Anterior Cruciate Ligament Reconstruction.
Li H, Chen S, Tao H, Chen S
Am J Sports Med. 2015 Jan 14. pii: 0363546514564151. [Epub ahead of print]


Abstract

BACKGROUND:
Associated meniscal injury is well recognized at anterior cruciate ligament (ACL) reconstruction, and it is a known risk factor for osteoarthritis.

PURPOSE:
To evaluate and characterize the postoperative appearance of articular cartilage after different meniscal treatment in ACL-reconstructed knees using T2 relaxation time evaluation on MRI.

STUDY DESIGN: Cohort study; Level of evidence, 3

METHODS:
A total of 62 consecutive patients who under ACL reconstruction were recruited in this study, including 23 patients undergoing partial meniscectomy (MS group), 21 patients undergoing meniscal repair (MR group), and 18 patients with intact menisci (MI group) at time of surgery. Clinical evaluation, including subjective functional scores and physical examination, was performed on the same day as the MRI examination and at follow-up times ranging from 2 to 4.2 years. The MRI multiecho sagittal images were segmented to determine the T2 relaxation time value of each meniscus and articular cartilage plate. Differences in each measurement were compared among groups.

RESULTS:
No patient had joint-line tenderness or reported pain or clicking on McMurray test or instability. There were also no statistically significant differences in functional scores or medial or lateral meniscus T2 values among the 3 groups (P > .05 for both). There was a significantly higher articular cartilage T2 value in the medial femorotibial articular cartilage for the MS group (P < .01) and the MR group (P < .05) compared with that of the MI group, while there was no significant difference in articular cartilage T2 value between the MS and MR groups (P > .05) in each articular cartilage plate. The medial tibial articular cartilage T2 value had a significant positive correlation with medial meniscus T2 value (r = 0.287; P = .024)

CONCLUSION:
This study demonstrates that knees with meniscectomy or meniscal repair had articular cartilage degeneration at 2 to 4 years postoperatively, with higher articular cartilage T2 relaxation time values compared with the knees with an intact meniscus.

General: por muy mayor que seas, haz ejercicio

Older people's perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature

Franco MR, Tong A, Howard K, Sherrington C, Ferreira PH, Pinto RZ, Ferreira ML
Br J Sports Med. 2015 Jan 13
doi: 10.1136/bjsports-2014-094015

BACKGROUND:

Physical inactivity accounts for 9% of all deaths worldwide and is among the top 10 risk factors for global disease burden. Nearly half of people aged over 60 years are inactive. Efforts to identify which factors influence physical activity behaviour are needed.

OBJECTIVE:

To identify and synthesise the range of barriers and facilitators to physical activity participation.

METHODS:

Systematic review of qualitative studies on the perspectives of physical activity among people aged 60 years and over. MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched. Independent raters assessed comprehensiveness of reporting of included studies. Thematic synthesis was used to analyse the data.

RESULTS:

From 132 studies involving 5987 participants, we identified six major themes: social influences (valuing interaction with peers, social awkwardness, encouragement from others, dependence on professional instruction); physical limitations (pain or discomfort, concerns about falling, comorbidities); competing priorities; access difficulties (environmental barriers, affordability); personal benefits of physical activity (strength, balance and flexibility, self-confidence, independence, improved health and mental well-being); and motivation and beliefs (apathy, irrelevance and inefficacy, maintaining habits).

CONCLUSIONS:

Some older people still believe that physical activity is unnecessary or even potentially harmful. Others recognise the benefits of physical activity, but report a range of barriers to physical activity participation. Strategies to enhance physical activity participation among older people should include (1) raising awareness of the benefits and minimise the perceived risks of physical activity and (2) improving the environmental and financial access to physical activity opportunities.

Rodilla/Knee: Sin diferencias de riesgo de revisión con distintos polietilenos

Is There a Difference in Total Knee Arthroplasty Risk of Revision in Highly Crosslinked versus Conventional Polyethylene?

Paxton EW, Inacio MC, Kurtz S, Love R, Cafri G, Namba RS.

Clin Orthop Relat Res. 2015 Jan 8. [Epub ahead of print]

Abstract

BACKGROUND: 

Highly crosslinked polyethylene (HXLPE) was introduced to reduce wear and associated osteolysis in total knee arthroplasty (TKA). However, there is limited clinical evidence that HXLPE is more effective than conventional polyethylene (CPE) in TKA.

QUESTIONS/PURPOSES: 

(1) Do primary TKAs with HXLPE tibial inserts have a lower risk of revision (all-cause, aseptic, and septic) than TKAs with CPE tibial inserts? (2) In NexGen TKA (Zimmer Inc, Warsaw, IN, USA) bearings, do HXLPE tibial inserts have a lower risk of revision (all-cause, aseptic, and septic) than CPE tibial inserts? (3) In Press-Fit Condylar TKA (PFC or PFC Sigma; DePuy Inc, Warsaw, IN, USA), do HXLPE tibial inserts have a lower risk of revision (all-cause, aseptic, and septic) than procedures performed with CPE tibial inserts?

METHODS: 

The Kaiser Permanente Total Joint Replacement Registry was used to identify primary TKAs (N = 77,084) performed during the study period (April 2001 to December 2011) with cobalt-chromium alloy on CPE (CoCr-CPE) and CoCr-HXLPE bearings. The registry has 95% voluntary participation and less than 9% were loss to followup during the 10-year study period. A total of 60,841 (79%) had CoCr-CPE bearings, 11,048 (14%) had CoCr-HXLPE bearings, and 5195 (7%) were unknown. Specific knee implant designs (NexGen, Zimmer and PFC-Sigma, DePuy Inc) were also evaluated. These implants represented 41% (31,793) and 49% (37,457), respectively, of the 77,084 TKAs of known implant types registered during that period; implant selection was at the discretion of the attending surgeon. Descriptive statistics and marginal Cox regression models with propensity score adjustments were applied to compare risk of revision for CoCr-CPE versus CoCr-HXLPE TKA bearings.

RESULTS: 

At 5 years followup, cumulative incidence of revision for CoCr-CPE and CoCr-XLPE were 2.7% and 3.1%, respectively. Adjusted risks of all-cause (hazard ratio [HR], 1.05; 95% confidence interval [CI], 0.86-1.29; p = 0.620), aseptic (HR, 1.01; 95% CI, 0.77-1.32; p = 0.954), and septic revision (HR, 1.11; 95% CI, 0.81-1.51; p = 0.519) did not differ in patients with CoCr-XLPE bearings compared with CoCr-CPE. Within TKAs with NexGen components, the adjusted risks of all-cause (HR, 1.14; 95% CI, 0.86-1.51; p = 0.354), aseptic (HR, 1.14; 95% CI, 0.79-1.65; p = 0.493), and septic revision (HR, 1.14; 95% CI, 0.76-1.73; p = 518) were similar in patients with CoCr-XLPE compared with those with CoCr-CPE bearings. Finally, within the TKAs with PFC components, the adjusted risks of all-cause (HR, 0.80; 95% CI, 0.49-1.30; p = 0.369), aseptic (HR, 0.62; 95% CI, 0.62-1.14; p = 0.123), and septic revision (HR, 0.97; 95% CI, 0.51-1.85; p = 0.929) were also similar in patients with CoCr-XLPE compared with those with CoCr-CPE bearings.

CONCLUSIONS: 

In this large study, we did not find differences in risk of revision for CoCr-HXLPE compared with CoCr-CPE bearings at 5 years followup. In selecting HXLPE in TKA, clinicians should consider the increased cost and lack of available evidence of performance for greater than 10 years followup. Future studies are necessary to evaluate longitudinal outcomes of CoCr-HXLPE versus conventional TKA bearings.

LEVEL OF EVIDENCE: 

Level III, therapeutic study. 

Trauma: menos "sensibilidad" quirúrgica en las fracturas de húmero

Nonoperative treatment of humeral shaft fractures revisited.

Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L

J Shoulder Elbow Surg 2014 Jul 31.

PURPOSE

The purpose of this study was to examine the union rate of humeral shaft fractures treated nonoperatively and to establish whether a particular fracture type is more likely to go on to nonunion.

METHODS

Radiographs and patient records of 207 humeral shaft fractures occurring during 5 years were retrospectively reviewed. All patients were initially managed nonoperatively and placed in a U-slab on diagnosis in the emergency department; this was converted to a functional humeral brace at 7 to 10 days after injury. Fracture location, morphology and comminution were assessed radiologically. Union was defined as the absence of pain and movement at the fracture site in the presence of radiographic callus formation. Nonunion was defined as no evidence of bone union by 1 year after injury or fractures requiring delayed fixation, defined as operative fixation undertaken more than 6 weeks after injury.

RESULTS

The study included 138 humeral shaft fracture patients; 18 patients (11%) were lost to follow-up, and 24 went on to nonunion, giving an overall union rate of 83%. Of the 24 nonunions, 15 underwent delayed operative fixation at an average of 8.3 months after injury. The union rate for proximal-third fractures was 76% compared with 88% for middle-third fractures and 85% for distal-third fractures. Comminuted fractures (defined as 3+ parts) had a 89% union rate regardless of position.

CONCLUSION

A lower threshold for surgical intervention may be considered in proximal-third, two-part spiral-oblique humeral shaft fractures. Brace therapy can be the optimal treatment regimen, but it is not the only option.