Rodilla/Knee: Se supone que deberíamos avanzar

Are outcomes after total knee arthroplasty worsening over time? A time-trends study of activity limitation and pain outcomes

Singh JA, Lewallen DG

BMC Musculoskelet Disord 2014.:440.

Abstract

BACKGROUND

To examine whether function and pain outcomes of patients undergoing primary total knee arthroplasty (TKA) are changing over time.

METHODS

The Mayo Clinic Total Joint Registry provided data for time-trends in preoperative and 2-year post-operative activity limitation and pain in primary TKA patients from 1993-2005. We used chi-square test and analysis for variance, as appropriate. Multivariable-adjusted analyses were done using logistic regression.

RESULTS

In a cohort of 7,229 patients who underwent primary TKA during 1993-2005, mean age was 68.4 years (standard deviation (SD), 9.8), mean BMI was 31.1 (SD, 6.0) and 55% were women. Crude estimates showed that preoperative moderate-severe overall limitation were seen in 7.3% fewer patients and preoperative moderate-severe pain in 2.7% more patients in 2002-05, compared to 1992-95 (p < 0.001 for both). At 2-years, crude estimates indicated that compared to 1992-95, moderate-severe post-TKA overall limitation was seen in 4.7% more patients and moderate-severe post-TKA pain in 3.6% more patients in 2002-05, both statistically significant (p ≤ 0.018) and clinically meaningful. In multivariable-adjusted analyses that adjusted for age, sex, anxiety, depression, Deyo-Charlson index, body mass index and preoperative pain/limitation, patients had worse outcomes 2-year post-TKA in 2002-2005 compared to 1993-95 with an odds ratio (95% confidence interval (CI); p-value) of 1.34 (95% CI: 1.02, 1.76, p = 0.037) for moderate-severe activity limitation and 1.79 (95% CI: 1.17, 2.75, p = 0.007) for moderate-severe pain.

CONCLUSION

Patient-reported function and pain outcomes after primary TKA have worsened over the study period 1993-95 to 2002-05. This time-trend is independent of changes in preoperative pain/limitation and certain patient characteristics.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4301928/pdf/

Raquis/Spine: Tras la compresion vertebral el resultado no depende de la ortesis

Comparative Study of the Treatment Outcomes of Osteoporotic Compression Fractures without Neurologic Injury Using a Rigid Brace, a Soft Brace, and No Brace

A Prospective Randomized Controlled Non-Inferiority Trial

Ho-Joong Kim, MD; Je-Min Yi, MD; Hyeon-Guk Cho, MD; Bong-Soon Chang, MD; Choon-Ki Lee, MD; Jee Hyoung Kim, MD; Jin S. Yeom, MD

J Bone Joint Surg Am, 2014 Dec 03; 96 (23): 1959 -1966

Abstract

Background:
The efficacy of brace application for the treatment of osteoporotic compression fractures remains unclear. The purpose of this study was to compare the treatment outcomes in patients with osteoporotic compression fractures with regard to whether the patients had no braces, rigid braces, or soft braces.

Methods:
We randomly assigned sixty patients with acute one-level osteoporotic compression fractures within three days of injury to the no-brace, soft-brace, and rigid-brace groups through 1:1:1 allocation. The primary outcome was the baseline adjusted Oswestry Disability Index score at twelve weeks after compression fracture. The non-inferior margin of the Oswestry Disability Index was set at an average of 10 points.

Results:
The baseline adjusted Oswestry Disability Index score at twelve weeks after compression fracture in the no-brace group was not inferior to that in the soft-brace or rigid-brace groups. The mean adjusted Oswestry Disability Index score was 35.95 points (95% confidence interval, 25.42 to 46.47 points) in the no-brace group and 37.83 points (95% confidence interval, 26.77 to 48.90 points) in the soft-brace group, with a difference of −1.88 points (95% confidence interval, −7.02 to 9.38 points) between the groups. Similarly, the mean adjusted Oswestry Disability Index score was 35.95 points (95% confidence interval, 25.42 to 46.47 points) in the no-brace group and 33.54 points (95% confidence interval, 23.79 to 43.29 points) in the rigid-brace group, with a difference of 2.41 points (95% confidence interval, −7.86 to 9.27 points) between the groups. During the follow-up assessment period, there was no significant difference among the groups for the overall Oswestry Disability Index scores (p = 0.260), visual analog scale for pain scores for back pain (p = 0.292), and anterior body compression ratios (p = 0.237). However, the Oswestry Disability Index scores and the visual analog scale scores for back pain significantly improved with time after the fractures (p < 0.001), and the body compression ratios significantly decreased with time in all three groups (p < 0.001).

Conclusions:
The Oswestry Disability Index scores for the treatment of compression fractures without a brace were not inferior to those with soft or rigid braces. Moreover, the improvement in back pain and progression of anterior body compression were similar among the three groups.

Level of Evidence: Therapeutic Level I

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.

Trauma: Va bien la fijación con placas de ángulo fijo en la fractura declavicula lateral

Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates
Mark A. Fleming, Robert Dachs, Sithombo Maqungo, Jean-Pierre du Plessis, Basil C. Vrettos, Stephen J.L. Roche
Journal of Shoulder and Elbow Surgery
Published Online: October 29, 2014

Hypothesis

We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery.

Methods
We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport.

Results
Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities.

Conclusion
Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.

Level of evidence:
Level IV, Case Series, Treatment Study

General: Los residentes son como angelitos

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database.

Edelstein AI, Lovecchio FC, Saha S, Hsu WK, Kim JY.

J Bone Joint Surg Am. 2014 Aug 6;96(15):e131. [Epub ahead of print]

Abstract

BACKGROUND:

Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases.

METHODS:

We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement.

RESULTS:

Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles.

CONCLUSIONS:

Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients.

LEVEL OF EVIDENCE:

Therapeutic Level III. 

Rodilla/Knee/Knie: Hay que mejorar los resultados de la plastia de LCA

Nonsurgical or Surgical Treatment of ACL Injuries: Knee Function, Sports Participation, and Knee Reinjury: The Delaware-Oslo ACL Cohort Study.

J Bone Joint Surg Am. 2014 Aug 6;96(15):1233-1241. [Epub ahead of print]

Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA.

Abstract

BACKGROUND:

While there are many opinions about the expected knee function, sports participation, and risk of knee reinjury following nonsurgical treatment of injuries of the anterior cruciate ligament (ACL), there is a lack of knowledge about the clinical course following nonsurgical treatment compared with that after surgical treatment.

METHODS:

This prospective cohort study included 143 patients with an ACL injury. Isokinetic knee extension and flexion strength and patient-reported knee function as recorded on the International Knee Documentation Committee (IKDC) 2000 form were collected at baseline, six weeks, and two years. Sports participation was reported monthly for two years with use of an online activity survey. Knee reinjuries were reported at the follow-up evaluations and in a monthly online survey. Repeated analysis of variance (ANOVA), generalized estimating equation (GEE) models, and Cox regression analysis were used to analyze group differences in functional outcomes, sports participation, and knee reinjuries, respectively.

RESULTS:

The surgically treated patients (n = 100) were significantly younger, more likely to participate in level-I sports, and less likely to participate in level-II sports prior to injury than the nonsurgically treated patients (n = 43). There were no significant group-by-time effects on functional outcome. The crude analysis showed that surgically treated patients were more likely to sustain a knee reinjury and to participate in level-I sports in the second year of the follow-up period. After propensity score adjustment, these differences were nonsignificant; however, the nonsurgically treated patients were significantly more likely to participate in level-II sports during the first year of the follow-up period and in level-III sports over the two years. After two years, 30% of all patients had an extensor strength deficit, 31% had a flexor strength deficit, 20% had patient-reported knee function below the normal range, and 20% had experienced knee reinjury.

CONCLUSIONS:

There were few differences between the clinical courses following nonsurgical and surgical treatment of ACL injury in this prospective cohort study. Regardless of treatment course, a considerable number of patients did not fully recover following the ACL injury, and future work should focus on improving the outcomes for these patients.

LEVEL OF EVIDENCE:

Therapeutic Level II

Hombro / Shoulder / Schulter: Un repaso de las complicaciones de las PTHi

Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review

Matthias A. Zumstein, Miguel Pinedo, Jason Old, Pascal Boileau

The use of hemiarthroplasty in patients with an arthritic rotator cuff deficient shoulder has been shown to provide limited function and inconsistent pain relief.

The semiconstrained reverse shoulder prosthesis, designed by Grammont in the late 1980s, was invented based on 2 biomechanical concepts: lowering the humerus and medialization of the center of rotation at the glenoid component. This design has the dual advantage of tensioning the deltoid muscle to increase its functional strength, and decreasing mechanical torque at the glenoid component, thus avoiding glenoid loosening. The first series of reverse shoulder arthroplasty (RSA) with at least 2 years of follow-up confirmed the preliminary results, with excellent functional outcome and stable glenoid fixation. However, these series had a small numbers of patients and reported variable compli-cation and revision rates of 15% to 50% and reoperation rates of 4% to 40%. One reason for the high variability was unclear definitions of complications and revisions, which varied markedly between the series. Furthermore, it is difficult to draw conclusions from small numbers of patients.

The purpose of the present study was to determine the incidence and functional significance of adverse events after RSA, including problems, complications, reopera-tions, and revisions. We established a study design and specific objectives before commencing the literature research. These objectives were (1) to perform a systematic review of the published literature to determine the overall rates of problems, complications, reoperations, and revi-sions after RSA; (2) to compare their influence on the final functional outcome; and, (3) to analyze the different problems, complications, reoperations, and revisions based on the etiology of the RSA

Hombro / Shoulder / Schulter: El subescapular implicado en la inestabilidad de la PTHi

Instability after reverse total shoulder replacement.

Gallo RA, Gamradt SC, Mattern CJ, Cordasco FA, Craig EV, Dines DM, Warren RF

J Shoulder Elbow Surg 2011 Jun; 20(4):584-90.

Abstract

BACKGROUND

Despite advances in technique and implant design, instability after reverse total shoulder arthroplasty remains a challenging postoperative complication.

MATERIALS AND METHODS

We examined our institutions' first 57 reverse total shoulder arthroplasties performed during a 3-year period (2004-2006). There were 9 cases of instability, all occurring within the first 6 months after surgery.

RESULTS

All 9 patients had compromise of the subscapularis tendon at the time of initial reverse total shoulder implantation. With regard to implant positioning, 2 patients had superiorly inclined metaglenes and 3 had metaglenes positioned superior to the inferior glenoid. Each patient with a dislocation had at least 1 revision surgery, and 4 patients had underlying infection. At most recent follow-up, only 3 patients had a concentrically reduced reverse total shoulder arthroplasty in place whereas 3 remained explanted, 2 chronically dislocated, and 1 chronically subluxated.

CONCLUSIONS

Early instability after reverse total shoulder arthroplasty can be related to inadequate soft tissue, inadequate deltoid tension, malpositioned implants, and/or infection, and outcomes of treatment of early instability are generally poor.