Rodilla / Knee: infiltración con anestésico local en la artroplastia de rodilla

Efficacy and safety of single-dose local infiltration of analgesia in total knee arthroplasty: A meta-analysis of randomized controlled trials

Chang-Peng Xua, 1, Xue Lib, 1, Zhi-Zhong Wangc, 1, Jin-Qi Songa, Bin Yua,

The Knee

Available online 13 March 2014

Abstract

Purpose

To examine the efficacy and safety of single-dose local infiltration of analgesia (LIA) for post-operative pain relief in total knee arthroplasty (TKA) patients.

Methods

A systematic electronic literature search (up to Aug 2013) was conducted to identify the RCTs that addressing the efficacy and safety of single-dose LIA in the pain management after TKA. Subgroup analysis was conducted to determine changes of visual analog scores (VAS) values at six different postoperative time points. Weighted mean differences or relative risks with accompanying 95% confidence intervals were calculated and pooled using a random effect model.

Results

Eighteen trials involving 1,858 TKA patients met the inclusion criteria. The trials were liable to medium risk of bias. The VAS values at postoperative 2h, 4h, 6h, 12h, 24h, 48h per patient were significantly lower in the LIA group than in the placebo group, and the former group also had less morphine consumption and better early functional recovery including range of motion, time to straight leg raise and 90° knee flexion than the latter group. No significant difference in length of hospital stay or side effects was detected between the two groups.

Conclusions

The current evidence shows that use of single-dose LIA is effective for postoperative pain management in TKA patients, with satisfactory short-term safety. More high-quality RCTs with long-term follow-ups are highly required for examining the long-term safety of single-dose LIA.

Level of evidence I, II.

Hombro / Shoulder: en la inestabilidad posterior hay riesgo de diagnosticar mal una lesión del labrum

Arthroscopic classification of posterior labrum glenoid insertion.

G Nourissat, C Radier, F Aim, S Lacoste

Orthopaedics & Traumatology, Surgery & Research: OTSR 2014 March 3

PURPOSE: We performed a prospective arthroscopic study to explore the variability of the posterior labrum glenoid insertion. We aimed to classify the insertions and to explore whether these insertions can be identified by pre-operative arthro-CT scan.

PATIENTS AND METHODS: From January to December 2011, 86 patients were prospectively included in the current study. During arthroscopy, anterior labrum was evaluated and posterior labrum was assessed in 3 different locations: superior, medial, and inferior. For each segment, the labrum was considered normally inserted (directly to the glenoid cartilage), medialized (inserted at the posterior part of the glenoid bone, without direct contact with the cartilage), torn (macroscopic degenerative changes, tears, fragments) or absent (agenesis). Imaging was analyzed segment by segment by an experienced osteoarticular radiologist, using the same classification.

RESULTS: Four types of posterior labrum insertions were identified. Type 1, 60% of the cases, corresponded to a posterior labrum totally inserted in the glenoid, with direct contact with the cartilage. Type 2, 20% of the cases, represented medialized insertion of the superior segment. Type 3, 15% of the cases, represented an associated medialization of the superior and medial segment of the posterior labrum. Type 4 is a medialized insertion of the all-posterior labrum. Fifty-six shoulders were used for arthro-CT and arthroscopy correlation: for the superior segment (n=22/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 68.18%, specificity 70.59%, positive predictive value (PPV) 60%, and negative predictive value (NPV) 77.42%. For the medial segment (n=16/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 81.25%, specificity 57.50%, PPV 43.33% and NPV 88.46%. For the inferior segment (n=5/56), the sensitivity was 100%, specificity 47.60%, PPV 15.63% and NPV 100%.

CONCLUSION: The current study points out the high variability of shoulder posterior labrum glenoid insertion, and thus the risk of misdiagnosis with posterior labral tears, especially in posterior instability and also the risk of considering as labral lesions some non-pathological aspects.

LEVEL OF EVIDENCE: Level III. Anatomic prospective study.

Cadera / Hip: el ángulo alfa puede que no refleje bien el cam

Correlations between the alpha angle and femoral head asphericity: Implications and recommendations for the diagnosis of cam femoroacetabular impingement.

Harris MD Kapron AL Peters CL Anderson AE

Eur J Radiol 2014 Feb 14.

Abstract

OBJECTIVE

To determine the strength of common radiographic and radial CT views for measuring true femoral head asphericity.

PATIENTS AND METHODS

In 15 patients with cam femoroacetabular impingement (FAI) and 15 controls, alpha angles were measured by two observers using radial CT (0°, 30°, 60°, 90°) and digitally reconstructed radiographs (DRRs) for the: anterior-posterior (AP), standing frog-leg lateral, 45° Dunn with neutral rotation, 45° Dunn with 40° external rotation, and cross-table lateral views. A DRR validation study was performed. Alpha angles were compared between groups. Maximum deviation from a sphere of each subject was obtained from a previous study. Alpha angles from each view were correlated with maximum deviation.

RESULTS

There were no significant differences between alpha angles measured on radiographs and the corresponding DRRs (p=0.72). Alpha angles were significantly greater in patients for all views (p≤0.002). Alpha angles from the 45° Dunn with 40° external rotation, cross-table lateral, and 60° radial views had the strongest correlations with maximum deviation (r=0.831; r=0.823; r=0.808, respectively). The AP view had the weakest correlation (r=0.358).

CONCLUSION

DRRs were a validated means to simulate hip radiographs. The 45° Dunn with 40° external rotation, cross-table lateral, and 60° radial views best visualized femoral asphericity. Although commonly used, the AP view did not visualize cam deformities well. Overall, the magnitude of the alpha angle may not be indicative of the size of the deformity. Thus, 3D reconstructions and measurements of asphericity could improve the diagnosis of cam FAI.

Tobillo / Ankle: puedes suturar o no el Aquiles, pero a mover pronto

Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures

Nilsson-Helander K, et al. Show all Journal

Am J Sports Med. 2010 Nov;38(11):2186-93

Clin J Sport Med. 2012 Mar;22(2):169-70.

Abstract

BACKGROUND: There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization.

PURPOSE: This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without surgery using early mobilization and identical rehabilitation protocols.

STUDY DESIGN: Randomized, controlled trial; Level of evidence, 1.

METHODS: Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), functional tests, and clinical examination at 6 and 12 months after injury.

RESULTS: There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P = .377). The mean 6- and 12-month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the 6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups.

CONCLUSION: The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains a subject of debate. Although the study met the sample size dictated by the authors' a priori power calculation, the difference in the rerupture rate might be considered clinically important by some.

Cadera / Hip: peores resultados postartroscopia en caso de choque femoroacetabular con espacio articular reducido

The Effect of Joint Space on Midterm Outcomes After Arthroscopic Hip Surgery for Femoroacetabular Impingement.

Skendzel JG, et al. Show all Am J Sports Med. 2014 Mar 7

Abstract

BACKGROUND: Excellent short-term results have been reported after hip arthroscopic surgery to address femoroacetabular impingement (FAI).

Purpose/ HYPOTHESIS: The purpose of this study was to determine if patients with narrow joint spaces had inferior outcomes at a postoperative minimum of 5 years and if they had a higher conversion rate to total hip arthroplasty (THA). The hypothesis was that patients with ≤2-mm joint spaces would report inferior outcomes and that patients with >2-mm joint spaces would have improved survivorship (no conversion to THA). 

STUDY DESIGN: Cohort study; Level of evidence, 3. 

METHODS: Between March 2005 and January 2008, prospectively collected data were analyzed for patients older than 18 years of age undergoing hip arthroscopic surgery for FAI. Radiographic measurements of joint space were collected, and hips were grouped as having preserved (>2 mm) or limited (≤2 mm) joint space. Outcome measures included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), modified Harris Hip Score (MHHS), Hip Outcome Score (HOS) for activities of daily living and sports, and Short Form-12 (SF-12). 

RESULTS: There were 559 patients included, 466 (83%) of whom were contacted. Fifty-four patients with limited joint spaces (86%) converted to THA, while only 63 patients with preserved joint spaces (16%) converted to THA. The mean survival time for patients with preserved joint spaces was 88 months (95% CI, 85-91 months), and the mean survival time for patients with limited joint spaces was 40.0 months (95% CI, 33.7-46.3 months) (P = .0001). Complete follow-up outcome data were available on 323 patients, none of whom had THA, with a mean follow-up of 73 months. The mean postoperative HOS for activities of daily living and sports were significantly better in patients with preserved joint spaces (82 vs 62 [P = .012] and 77 vs 47 [P = .003], respectively) compared with those with limited joint spaces at a mean of 73 months postoperatively (range, 60-97 months). 

CONCLUSION: Hip arthroscopic surgery for FAI resulted in significantly better outcomes and activity levels at minimum 5-year follow-up in patients with preserved joint spaces. Hips with limited joint spaces converted to THA earlier than did those with preserved joint spaces.

Rodilla / Knee: la lesión de la inserción meniscal como una meniscectomía total

Meniscal Root Tears: Significance, Diagnosis, and Treatment.

Bhatia S, et al. Show all

Am J Sports Med. 2014 Mar 12

Abstract

Meniscal root tears, less common than meniscal body tears and frequently unrecognized, are a subset of meniscal injuries that often result in significant knee joint disorders. The meniscus root attachment aids meniscal function by securing the meniscus in place and allowing for optimal shock-absorbing function in the knee. With root tears, meniscal extrusion often occurs, and the transmission of circumferential hoop stresses is impaired. This alters knee biomechanics and kinematics and significantly increases tibiofemoral contact pressure. In recent years, meniscal root tears, which by definition include direct avulsions off the tibial plateau or radial tears adjacent to the root itself, have attracted attention because of concerns that significant meniscal extrusion dramatically inhibits normal meniscal function, leading to a condition biomechanically similar to a total meniscectomy. Recent literature has highlighted the importance of early diagnosis and treatment; fortunately, these processes have been vastly improved by advances in magnetic resonance imaging and arthroscopy. This article presents a review of the clinically relevant anatomic, biomechanical, and functional descriptions of the meniscus root attachments, as well as current strategies for accurate diagnosis and treatment of common injuries to these meniscus root attachments.

Rodilla / Knee: Menos trombosis venosa profunda postartroscópica si hayprofilaxis

Deep Venous Thrombosis After Knee Arthroscopy: A Systematic Review and Meta-Analysis

Author(s): Ye Sun , Dongyang Chen , Zhihong Xu , Dongquan Shi , Jin Dai , Jianghui Qin , Jizhen Qin, Qing Jiang

Source:Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 30, Issue 3

Purpose

To establish a contemporary literature-based estimate of the incidence of deep venous thrombosis (DVT) after knee arthroscopic surgery.

Methods

We performed a systematic review and meta-analysis of the English language literature to assess the efficacy of prophylaxis to prevent DVT after knee arthroscopic surgery. Only randomized controlled trials (RCTs) or prospective studies were considered. Studies were excluded if they were not original prospective studies concerning DVT detected by imaging after knee arthroscopic surgery. We calculated pooled proportions of postoperative DVT and proximal DVT.

Results

Nine prospective uncontrolled studies and 4 RCTs were retrieved. Within them, the populations given low-molecular-weight heparin (LMWH) to prevent DVT had a 0.1% to 11.9% incidence of DVT, with an overall 36 DVTs identified (4 proximal), averaging 1.8%. One hundred thirty-six DVTs (29 proximal) were indicated in the populations without prophylaxis, and the DVT incidence varied from 1.8% to 41.2%, averaging 6.8%. Of the RCTs, the pooled risk ratio for DVT to develop was 0.180 (range, 0.065 to 0.499) for those who had LMWH as prophylaxis. An absolute risk reduction of 1.2%—from 1.5% to 0.3%—for the development of proximal DVT was observed.

Conclusions

Compared with patients who did not receive prophylaxis, the pooled risk ratio for the development of DVT was 0.18 for those who had LMWH prophylaxis. The incidence of proximal DVT is very low after arthroscopic surgery regardless of receiving prophylaxis (4 of 2,184) or not (29 of 1,814). The rate of proximal DVT in total DVT occurrence can be markedly reduced from 21.3% (29 of 136) to 11.1% (4 of 36).

Level of Evidence

Level IV. This study is a meta-analysis of RCTs and a systematic review of Level IV studies.