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Evidence-Based Practice Should Supersede Evidence-Based Medicine Through Consideration of Clinical Experience and Patient Characteristics in Addition to the Published Literature. Arthroscopy 2023; 39:903-907. [PMID: 36872029 DOI: 10.1016/j.arthro.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 03/07/2023]
Abstract
On the surface, the benefits of evidence-based medicine (EBM) seem self-evident. However, reliance on the scientific literature alone has limitations. Studies may be biased, statistically fragile, and/or not reproducible. Reliance solely on EBM may ignore physician clinical experience and individual patient characteristics and input. Reliance solely on EBM may overvalue quantitative, statistical significance, resulting in a false sense of certainty. Reliance solely on EBM may fail to consider lack of generalizability of published studies to individually unique patients. The concept of evidence-based practice goes beyond EBM and incorporates (1) EBM, (2) clinical expertise, and (3) individual patient characteristics, values, and preferences. Even if branded as evidence-based, a suggested treatment may not be the best treatment. Evidence-based practice must be considered before determining what is best for our patients.
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Muacevic A, Adler JR, Hussain A, Raddy KG, Divekar AB, Shrivastava R, Relwani J. Arthroscopic Debridement and Lavage for Osteoarthritis of the Knee: Results From a Low-Resource Setting. Cureus 2022; 14:e31750. [PMID: 36569725 PMCID: PMC9771083 DOI: 10.7759/cureus.31750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Osteoarthritis of the knee is a highly prevalent disease globally, causing strain on healthcare resources and leading to a reduced quality of life. There are many treatments proposed for this condition, from conservative measures like analgesics and physiotherapy to surgical options like arthroscopy and total knee arthroplasty (TKA). Arthroscopic debridement and lavage provide significant improvement in a cohort of patients with particular features and can be a temporizing measure before TKA. This study aimed to investigate the results of this procedure, in a case series in the short-term and mid-term, in a low-resource setting. Methods This was a case series of 20 patients, who presented with clinical and radiographic features of mild to moderate (Kellgren-Lawrence grades I-III) primary osteoarthritis of the knee. Arthroscopic debridement and lavage were performed and the Knee Society Score (KSS) was recorded pre-operatively and post-operatively in the short and mid-term at one month, three months, and twelve months. Statistical analyses was done for correlation, with different variables such as the presence of meniscal pathology, loose bodies, grade of osteoarthritis, malalignment, and body mass index (BMI). Results The KSS improved at one month, three months, and twelve months for all the patients. The improvement in the KSS scores was associated with varus malalignment of less than 10 degrees, a BMI of less than 25, and the presence of loose bodies. There were no adverse events or complications from this study. Conclusions There was a significant improvement in a patient cohort with malalignment of less than 10 degrees, BMI of less than 25, meniscal pathology, and loose bodies. We can therefore recommend arthroscopic debridement and lavage as a temporizing measure before TKA in this particular cohort.
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Lubowitz JH, Brand JC, Rossi MJ. Stop Overtreatment, Overdiagnosis, and the Medicalization of "Normal" to Improve Health Care Outcomes. Hippocrasy: The Book. Arthroscopy 2022; 38:2361-2364. [PMID: 35940733 DOI: 10.1016/j.arthro.2022.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/04/2022] [Indexed: 02/02/2023]
Abstract
In the 21st century, physician adherence to the Hippocratic Oath "to treat the ill to the best of one's ability" may require improving our entire health care system. As a result of a wide range of problems, including but not limited to overtreatment, overdiagnosis, inattention to warmth and sympathy, and medicalizing normal, as well failure to attend to prevention, treating the problem, and recognizing what is not known, efficient care delivery and best outcomes may be compromised. A recent book, cleverly titled Hippocrasy: How Doctors Are Betraying Their Oath, courageously calls out evidence of hypocrisy in the health care status quo and, most importantly, includes proposals suggesting how health care might be improved. While the book would benefit from more balance and less bias, improving patient outcomes is a worthwhile goal that readers of Arthroscopy inevitably share.
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Brand JC, Rossi MJ, Lubowitz JH. Internet and Social Media Contribute to Medical Research Journal Growth. Arthroscopy 2022; 38:2111-2114. [PMID: 35809973 DOI: 10.1016/j.arthro.2022.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 02/02/2023]
Abstract
In 2010, our editorial team wrote about the Internet's inarguable role in overloading information on our readers. In this editorial, we reflect on insights gained, mostly in the past decade, regarding the Internet and social media. Medical and surgical information online is easy to obtain, but it varies from platform to platform, is low in quality and reliability, and overestimates the public's ability to decipher the information. Physicians do not use social media enough, or well. Social media can engage patients and can inform patients about the quality of medical and surgical information online. Physicians, themselves, can provide reliable information that informs patients and eases their minds. Physician-authors can use social media to develop communities with shared interests in research; members of these communities can post research findings and highlight the publications in which they find them. Discussion of research online increases the likelihood that it will be cited. It is no surprise that the Internet and social media have contributed to the growth of Arthroscopy; Arthroscopy Techniques; and Arthroscopy, Sports Medicine, and Rehabilitation.
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Reito A, Harris IA, Karjalainen T. Arthroscopic partial meniscectomy: did it ever work? Acta Orthop 2021; 93:1-10. [PMID: 34605736 PMCID: PMC8815409 DOI: 10.1080/17453674.2021.1979793] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Arthroscopic partial meniscectomy (APM) is one the most common orthopedic surgical procedures. The most common indication for APM is a degenerative meniscal tear (DMT). High-quality evidence suggests that APM does not provide meaningful benefits in patients with DMTs and may even be harmful in the longer term. This narrative review focuses on a fundamental question: considering the history and large number of these surgeries, has APM ever actually worked in patients with DMT? A truly effective treatment needs a valid disease model that would biologically and plausibly explain the perceived treatment benefits. In the case of DMT, effectiveness requires a credible framework for the pain-generating process, which should be influenced by APM. Basic research, pathoanatomy, and clinical evidence gives no support to these frameworks. Moreover, treatment of DMT with an APM does not align with the traditional practice of medicine since DMT is not a reliable diagnosis for knee pain and no evidence-based indication exists that would influence patient prognosis from APM. A plausible and robust explanation supported by both basic research and clinical evidence is that DMTs are part of an osteoarthritic disease process and do not contribute to the symptoms independently or in isolation and that symptoms are not treatable with APM. This is further supported by the fact that APM as an intervention is paradoxical because the extent of procedure and severity of disease are both inversely associated with outcome. We argue that arthroscopic treatment of DMT is largely based on a logical fallacy: post hoc ergo propter hoc.
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Affiliation(s)
- Aleksi Reito
- Department of Orthopaedics and Traumatology, Tampere University Hospital, and Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Australia
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Agarwalla A, Gowd AK, Liu JN, Amin NH, Werner BC. Rates and Risk Factors of Revision Arthroscopy or Conversion to Total Knee Arthroplasty Within 1 Year Following Isolated Meniscectomy. Arthrosc Sports Med Rehabil 2020; 2:e443-e449. [PMID: 33134979 PMCID: PMC7588599 DOI: 10.1016/j.asmr.2020.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 04/17/2020] [Indexed: 02/01/2023] Open
Abstract
Purpose To identify the rates of and risk factors for revision arthroscopy and conversion to total knee arthroplasty (TKA) within 1 year of isolated meniscectomy. Methods Humana and Medicare national insurance databases were queried for patients who underwent isolated meniscectomy. Patients who underwent revision arthroscopy or TKA within 1 year postoperatively were identified by International Classification of Diseases Procedural Codes, Ninth Revision, and Current Procedural Terminology codes. Multivariate binomial logistic regression analysis was used to identify risk factors, and adjusted odds ratios (ORs) and 95% confidence intervals (Cis) were calculated, with P < .05 considered significant. Results A total of 13,142 patients and 407,888 patients underwent isolated meniscectomy in the Humana and Medicare databases, respectively. Of the patients, 395 (3.01%) and 3,770 patients (0.92%) underwent revision arthroscopy, and 629 patients (4.79%) and 38,630 patients (9.47%) underwent TKA within 1 year of meniscectomy in the Humana and Medicare databases, respectively. Obesity (Humana: OR = 1.33, P = 0.003; Medicare: OR = 1.10, P < 0.001) and age < 20 years (Humana: OR = 2.64, P = 0.022), 20-29 years (Humana: OR = 3.30, P = 0.002), 40-49 years (Humana: OR = 3.80, P < 0.001), 50-59 years (Humana: OR = 1.99, P = 0.027), and < 64 years (Medicare: OR = 1.74, P < 0.001) were risk factors for revision arthroscopy. Obesity (Humana: OR = 1.64, P < 0.001; Medicare: OR = 1.37, P < 0.001), morbid obesity (Medicare: OR = 1.20, P < 0.001), age 70-74 (Medicare: OR = 1.12, P < 0.001), 75-79 (Medicare: OR = 1.25, P < 0.001), 80-84 (Medicare: OR = 1.20, P < 0.001), and concomitant osteoarthritis (Humana: OR = 1.42, P < 0.001; Medicare: OR = 1.46, P < 0.001) were risk factors for conversion to TKA. Conclusions Medicare and Humana databases showed that 0.92%-3.01% and 4.79%-9.47% of patients undergo revision arthroscopy or conversion to TKA within a year of isolated meniscectomy. Obesity was a risk factor for early revision arthroscopy and conversion to TKA, whereas concomitant osteoarthritis was a risk factor for conversion to TKA. Level of Evidence Level III, retrospective comparative trial.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, New York, U.S.A
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
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Navarro RA, Adams AL, Lin CC, Fleming J, Garcia IA, Lee J, Black MH. Does Knee Arthroscopy for Treatment of Meniscal Damage with Osteoarthritis Delay Knee Replacement Compared to Physical Therapy Alone? Clin Orthop Surg 2020; 12:304-311. [PMID: 32904116 PMCID: PMC7449858 DOI: 10.4055/cios19114] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUD To determine patient factors that lead to treatment of meniscal tears with osteoarthritis (OA) with knee arthroscopy (KA) or physical therapy only (PT-only); and to assess differences in clinical outcomes including the time to knee arthroplasty. METHODS Patients aged ≥ 45 years with OA at meniscal tear diagnosis were followed up from the date of surgery (KA) or first PT visit (PT-only) until partial/total knee replacement surgery, death, disenrollment, or end of study. Demographic and clinical characteristics were compared and used to derive propensity scores. A Cox proportional hazards model was used to estimate the risk of knee replacement surgery and greater healthcare utilization associated with KA vs. PT-only. RESULTS Among 7,026 patients (KA, 69%; PT-only, 31%), 27% had partial or total knee replacement surgery during follow-up. PT-only patients were older and more likely to be women and had more comorbidities. After accounting for differences between groups, the cumulative incidence of knee replacement was modestly but significantly higher for those who received KA than those who underwent PT-only (hazard ratio, 1.30; 95% confidence interval, 1.17-1.44; p < 0.001), although there was no significant difference in health service utilization, narcotic medication dispenses, or knee injections after initiating treatment. CONCLUSIONS For patients with meniscal damage complicated by OA, those who underwent KA were 30% more likely to have partial or total knee replacement surgery at any given time than those who had PT alone.
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Affiliation(s)
- Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente South Bay Medical Center, Harbor City, CA, USA
| | - Annette L. Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Charles C. Lin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - John Fleming
- Torrance Orthopaedic and Sports Medicine Group, Torrance, CA, USA
| | - Ivan A. Garcia
- Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, CA, USA
| | - Janet Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Mary Helen Black
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Kalske J, Nurmi H, Kumm J, Sillanpää N, Kiekara T, Turkiewicz A, Toivonen P, Englund M, Taimela S, Järvinen TLN. Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial. Br J Sports Med 2020; 54:1332-1339. [PMID: 32855201 PMCID: PMC7606577 DOI: 10.1136/bjsports-2020-102813] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 01/14/2023]
Abstract
Objectives To assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up. Design Multicentre, randomised, participant- and outcome assessor-blinded, placebo-surgery controlled trial. Setting Orthopaedic departments in five public hospitals in Finland. Participants 146 adults, mean age 52 years (range 35–65 years), with knee symptoms consistent with degenerative medial meniscus tear verified by MRI scan and arthroscopically, and no clinical signs of knee osteoarthritis were randomised. Interventions APM or placebo surgery (diagnostic knee arthroscopy). Main outcome measures We used two indices of radiographic knee osteoarthritis (increase in Kellgren and Lawrence grade ≥1, and increase in Osteoarthritis Research Society International (OARSI) atlas radiographic joint space narrowing and osteophyte sum score, respectively), and three validated patient-relevant measures of knee symptoms and function (Western Ontario Meniscal Evaluation Tool (WOMET), Lysholm, and knee pain after exercise using a numerical rating scale). Results There was a consistent, slightly greater risk for progression of radiographic knee osteoarthritis in the APM group as compared with the placebo surgery group (adjusted absolute risk difference in increase in Kellgren-Lawrence grade ≥1 of 13%, 95% CI −2% to 28%; adjusted absolute mean difference in OARSI sum score 0.7, 95% CI 0.1 to 1.3). There were no relevant between-group differences in the three patient-reported outcomes: adjusted absolute mean differences (APM vs placebo surgery), −1.7 (95% CI −7.7 to 4.3) in WOMET, −2.1 (95% CI −6.8 to 2.6) in Lysholm knee score, and −0.04 (95% CI −0.81 to 0.72) in knee pain after exercise, respectively. The corresponding adjusted absolute risk difference in the presence of mechanical symptoms was 18% (95% CI 5% to 31%); there were more symptoms reported in the APM group. All other secondary outcomes comparisons were similar. Conclusions APM was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at 5 years after surgery. Trial registration ClinicalTrials.gov (NCT01052233 and NCT00549172).
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Affiliation(s)
- Raine Sihvonen
- Department of Orthopaedics and Traumatology, Pihlajalinna Oyj, Tampere, Pirkanmaa, Finland.,Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland
| | - Mika Paavola
- Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Uusimaa, Finland.,Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
| | - Antti Malmivaara
- Centre for Health and Social Economics - CHESS, National Institute for Health and Welfare, Helsinki, Finland
| | | | - Antti Joukainen
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Juha Kalske
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Heikki Nurmi
- Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Jaanika Kumm
- Department of Medicine, Tartu Ulikool, Tartu, Tartumaa, Estonia
| | - Niko Sillanpää
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - Tommi Kiekara
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | | | - Pirjo Toivonen
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland.,Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Uusimaa, Finland.,Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Lund University, Lund, Sweden
| | - Simo Taimela
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland.,Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Uusimaa, Finland.,Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
| | - Teppo L N Järvinen
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland .,Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Uusimaa, Finland.,Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
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Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique. Arthroscopy 2020; 36:501-512. [PMID: 31901384 DOI: 10.1016/j.arthro.2019.08.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/22/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to perform an evidence-based, expert consensus survey using the Delphi panel methodology to develop recommendations for the treatment of degenerative meniscus tears. METHODS Twenty panel members were asked to respond to 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds served to develop a Likert-style questionnaire for round 3. In round 4, the panel members outside consensus were contacted and asked to either change their score in view of the group's response or argue their case. The level of agreement for round 4 was defined as 80%. RESULTS There was 100% agreement on the following items: insidious onset, physiological part of aging, tears often multiplanar, not all tears cause symptoms, outcomes depend on degree of osteoarthritis, obesity is a predictor of poor outcome, and younger patients (<50 years) have better outcomes. There was between 90% and 100% agreement on the following items: tears are nontraumatic, radiographs should be weightbearing, initial treatment should be conservative, platelet-rich plasma is not a good option, repairable and peripheral tears should be repaired, microfracture is not a good option for chondral defects, the majority of patients obtain significant improvement and decrease in pain with surgery but results are variable, short-term symptoms have better outcomes, and malalignment and root tears have poor outcomes. CONCLUSIONS This consensus statement agreed that degenerative meniscus tears are a normal part of aging. Not all tears cause symptoms and, when symptomatic, they should initially be treated nonoperatively. Repairable tears should be repaired. The outcome of arthroscopic partial meniscectomy depends on the degree of osteoarthritis, the character of the meniscus lesion, the degree of loss of joint space, the amount of malalignment, and obesity. The majority of patients had significant improvement, but younger patients and patients with short-term symptoms have better outcomes. LEVEL OF EVIDENCE Level V - expert opinion.
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Byrne C, Alkhayat A, Bowden D, Murray A, Kavanagh E, Eustace S. Degenerative tears of the posterior horn of the medial meniscus: correlation between MRI findings and outcome following intra-articular steroid/bupivacaine injection of the knee. Clin Radiol 2019; 74:488.e1-488.e8. [DOI: 10.1016/j.crad.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
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Editorial Commentary: Anterolateral Ligament Augmentation for the Anterior Cruciate Ligament-Deficient Knee Debate-The Proof Is in the Pudding. Arthroscopy 2019; 35:893-895. [PMID: 30827441 DOI: 10.1016/j.arthro.2018.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 02/02/2023]
Abstract
The highly debatable and contentious anterolateral ligament (ALL) and its use as an augmentation for the anterior cruciate ligament (ACL)-deficient knee during ACL reconstruction continue to flourish in the literature, but the proof will be in the clinical outcome. Despite the ALL controversy, what clearly stands out from authors on either side of the debate is that there is much more going on than just the ACL in the ACL-deficient knee. Techniques of ALL augmentation or lateral extra-articular tenodesis continue to show promise that the lateral soft-tissue structures may provide the answer for the residual pivot and for better outcomes, higher return-to-sport rates, and lower rupture rates. Many authors and researchers believe that this may be a critical adjunct in high-risk situations during ACL reconstruction. But the proof of the pudding will be in the eating.
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Crall TS. Editorial Commentary: Morton Forks a Knee: Magnetic Resonance Imaging Versus Needles Arthroscopy for Knee Meniscus Tears. Arthroscopy 2019; 35:563-565. [PMID: 30712632 DOI: 10.1016/j.arthro.2018.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/17/2018] [Indexed: 02/02/2023]
Abstract
Recent literature tells us that knee arthroscopy in the setting of osteoarthritis is no better than placebo, but arthroscopy for isolated, nondegenerative meniscus tears is both helpful to patients and cost-effective. Since most patients with osteoarthritis have meniscus pathology, we need an accurate way to rule out degenerative disease in patients who are otherwise good candidates for arthroscopic partial meniscectomy. Magnetic resonance imaging can be misleading. Needle arthroscopy is a new tool that can potentially help dig us out of this diagnostic dilemma.
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Law GW, Lee JK, Soong J, Lim JWS, Zhang KT, Tan AHC. Arthroscopic debridement of the degenerative knee - Is there still a role? ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2018; 15:23-28. [PMID: 30581756 PMCID: PMC6289903 DOI: 10.1016/j.asmart.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 11/16/2018] [Accepted: 11/20/2018] [Indexed: 01/03/2023]
Abstract
Objectives The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee. Methods We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire. Results Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2-8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results. Conclusion Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.
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Liebs TR, Ziebarth K, Berger S. Randomized Controlled Trials for Arthroscopy in Degenerative Knee Disease: Was Conservative Therapy Appropriately Tried Prior to Arthroscopy? Arthroscopy 2018; 34:1680-1687.e6. [PMID: 29397289 DOI: 10.1016/j.arthro.2017.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/07/2017] [Accepted: 12/09/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE We aimed to determine if the randomized controlled trials (RCTs) evaluated in the most recent meta-analysis on arthroscopic surgery for degenerative knee arthritis included documented trials of appropriate conservative treatment prior to randomization. METHODS We selected all RCTs of the most recent meta-analysis by Brignardello-Petersen and recorded for each RCT, if physiotherapy prior to randomization was mandatory. We compared the treatment effect of arthroscopy in studies in which physiotherapy prior to randomization was mandatory versus studies in which it was not. This review was registered in the PROSPERO database (CRD42017070091). RESULTS Of the 13 RCTs in the meta-analysis, there were 2 in which physiotherapy prior to randomization was mandatory. In 1 additional multicenter RCT, prior conservative treatment was mentioned as mandatory in the publication, but not in the protocol. The treatment effects attributed to arthroscopy in terms of short-term pain (P = .0037), short-term function (P = .0309), and long-term function (P = .0012) were larger in studies in which prior physiotherapy was mandatory. CONCLUSIONS Although the most recent meta-analysis claims that it is based "on patients who do not respond to conservative treatment," physiotherapy was mandatory prior to randomization only in 2 of the 13 studies. As several orthopaedic guidelines recommend that the first line of treatment in patients with degenerative arthritis of the knee should be conservative, for instance with physiotherapy, and the question of performing arthroscopy arises once conservative treatment fails, 11 of the 13 RCTs failed to adhere to these accepted guidelines. Therefore, patient selection in these 11 studies may not represent the typical indications for arthroscopy, where patients have tried conservative management prior to being offered surgery. When comparing studies where prior physiotherapy was mandatory to studies in which it was not mandatory, there were statistically significant effects favoring arthroscopy in terms of pain in the short term, and for function both in the short and the long term. These findings suggest that the treatment effects attributed to arthroscopy were higher when prior physiotherapy was mandatory. Given these findings, the external validity of most of these RCTs, and the resulting "strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease," is called into question. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
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Affiliation(s)
- Thoralf R Liebs
- Department of Paediatric Orthopaedics and Paediatric Traumatology, Clinic for Paediatric Surgery, Inselspital, University of Bern, Switzerland.
| | - Kai Ziebarth
- Department of Paediatric Orthopaedics and Paediatric Traumatology, Clinic for Paediatric Surgery, Inselspital, University of Bern, Switzerland
| | - Steffen Berger
- Clinic for Paediatric Surgery, Inselspital, University of Bern, Switzerland
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15
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Su X, Li C, Liao W, Liu J, Zhang H, Li J, Li Z. Comparison of Arthroscopic and Conservative Treatments for Knee Osteoarthritis: A 5-Year Retrospective Comparative Study. Arthroscopy 2018; 34:652-659. [PMID: 29229416 DOI: 10.1016/j.arthro.2017.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the effectiveness of arthroscopic and conservative treatments in patients with knee osteoarthritis (KOA) with 5 years of follow-up. METHODS Patients diagnosed with Kellgren-Lawrence grade 2 to 4 KOA who underwent arthroscopic or conservative treatment from May 2005 to May 2012 were included. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score was collected 1, 2, 3, 4, and 5 years after the initial treatment, and the number of patients who underwent total knee arthroplasty (TKA) at every time point was recorded. RESULTS Three hundred eighty-two patients (168 in the conservative group and 214 in the arthroscopy group) were included. Five years after the initial treatment, 32 of the 214 patients who underwent arthroscopy (15.0%) compared with 30 of the 168 patients in the conservative treatment group (17.9%) ultimately underwent TKA, with no statistically significant difference between groups (P = .20). The WOMAC score was significantly lower in the arthroscopy group than in the conservative group at year 1 (24.33 ± 21.56 vs 36.43 ± 16.22, respectively) and year 2 (26.31 ± 17.84 vs 35.41 ± 19.21, respectively). There were no significant between-group differences at years 3, 4, and 5. CONCLUSIONS Compared with conservative treatment, arthroscopy provided no benefit in decreasing or delaying arthroplasty surgery. However, arthroscopy had a greater ability to relieve symptoms at 1 and 2 years. Our results suggest that arthroscopy can relieve symptoms up to 2 years without elevating the risk of arthroplasty. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Xiangzheng Su
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China.
| | - Chunbao Li
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China
| | - Weixiong Liao
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China
| | - Jianheng Liu
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China
| | - Hao Zhang
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China
| | - Ji Li
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China
| | - Zhongli Li
- Department of Sport Medicine, The General Hospital of PLA, Beijing, People's Republic of China
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16
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McIntyre LF. Editorial Commentary: Are We Running Out of Treatments for Osteoarthritis of the Knee? Arthroscopy 2018; 34:660-662. [PMID: 29502687 DOI: 10.1016/j.arthro.2017.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 02/02/2023]
Abstract
A considerable body of literature with high-level evidence has been published in the past 15 years calling into question the value of arthroscopic surgery in treating osteoarthritis of the knee (OAK). This, plus recent guidelines advising against the use of conservative treatments such as hyaluronic viscosupplementation, threatens to limit patient access to treatment for a chronic disease state with no known cure. The disease burden of OAK is considerable and represents one of the largest health care dollar expenditures in the United States and the world. Orthopaedic surgeons are the primary specialty dealing with OAK and manage this disease from inception to the final endpoint of total joint arthroplasty. As the population ages and the incidence of OAK increases, we must find ways to improve our ability to show efficacy in our treatments and also promote innovative modalities and applications to ameliorate the disability and dysfunction associated with OAK. Arthroscopy is recognized as a global leader in the presentation of evidence and debate surrounding all treatments for OAK and plays an important role in improving knowledge and treatment efficacy.
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Affiliation(s)
- Louis F McIntyre
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
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17
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Delanois RE, Gwam CU, Piuzzi NS, Chughtai M, Malkani AL, Bonutti PM, Mont MA. Hip and Knee Arthroplasty Orthopedic Literature in Medical Journals-Is It Negatively Biased? J Arthroplasty 2018; 33:615-619. [PMID: 28993088 DOI: 10.1016/j.arth.2017.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Healthcare policy is often determined by well-designed studies most often published in high-impact medical journals. However, concern about the presence of publication bias against lower-extremity arthroplasty-related studies has called into question some of the validity of certain reports. There are only a few studies investigating the presence of the bias in high-impact medical journals against lower-extremity arthroplasty intervention, particularly in the Journal of American Medical Association (JAMA), New England Journal of Medicine (NEJM), and the Lancet. Thus, the purpose of this study was to assess (1) the distribution of positive, neutral, and negative results; (2) the number of reports focused on lower-extremity arthroplasty complications among these 3 journals; and (3) difference in bias between 2 time periods (1975 to 1990 and 2000 to 2016). METHODS A review of the literature from 3 major medical journals (NEJM, Lancet, and JAMA) was performed using PubMed electronic databases, which retrieved articles between January 1976 and December 2016. Studies were categorized as being positive, neutral, and negatively biased by 2 reviewers. Studies were categorized as reporting on lower-extremity arthroplasty-related complications if they were based on complications including deep vein thrombosis, infection, metal-related complication, fat embolism, readmission, or mortality. In addition, we have compared the journal bias between 2 different time points (1975 to 1990 and 2000 to 2016). Descriptive analyses were performed to assess frequencies. Chi-squared analysis was conducted for categorical variables, whereas a z-test was performed for dichotomous data. RESULTS When assessing all 3 journals, there were 46 positive (30.3%), 46 negative (30.3%), and 60 neutral reports (39.5%). There was no statistically significant difference in classification proportions between the 3 groups (P = .905). There was a higher percentage of medical literature reporting on the complications of arthroplasty (55.9%); however, this was not statistically significant (z-score = 1.38; 95% confidence interval, 0.48-0.64; P = .17). There was no difference in overall journal reporting between 1975 to 1990 and 2000 to 2016 (P = .548). CONCLUSION There was no evidence of publication bias of lower-extremity arthroplasty reports in the major medical journals (JAMA, NEJM, and Lancet). However, there were more published studies reporting on complications of lower-extremity arthroplasty. This may be due to systematic bias among journal editors in these journals, or due to low journal submission reporting noncomplications after arthroplasty intervention. We did not find the time period to be a factor in bias reporting of orthopedic literature in major medical journals. More work is needed to verify the results of this study.
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Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Morad Chughtai
- Department of Orthopaedic Surgery and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Arthur L Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | | | - Michael A Mont
- Department of Orthopaedic Surgery and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio
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18
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Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Ikonen A, Järvelä T, Järvinen TAH, Kanto K, Karhunen J, Knifsund J, Kröger H, Kääriäinen T, Lehtinen J, Nyrhinen J, Paloneva J, Päiväniemi O, Raivio M, Sahlman J, Sarvilinna R, Tukiainen S, Välimäki VV, Äärimaa V, Toivonen P, Järvinen TLN. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis 2018; 77:188-195. [PMID: 28522452 PMCID: PMC5867417 DOI: 10.1136/annrheumdis-2017-211172] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/03/2017] [Accepted: 04/13/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus. METHODS In this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35-65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out. RESULTS In the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, -4.3; 95% CI, -11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (-3.2; -8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (-0.4; -1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups. CONCLUSIONS In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.
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Affiliation(s)
- Raine Sihvonen
- Department of Orthopedics and Traumatology, Hatanpää Hospital, Tampere, Finland
| | - Mika Paavola
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Antti Malmivaara
- Center for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
| | - Ari Itälä
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Antti Joukainen
- Department of Orthopedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Heikki Nurmi
- Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Juha Kalske
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Anna Ikonen
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Timo Järvelä
- Arthroscopic and Sports Medicine Center Pohjola Sairaala, Helsinki, Finland
| | - Tero A H Järvinen
- Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Kari Kanto
- Department of Orthopedics and Traumatology, Hatanpää Hospital, Tampere, Finland
| | - Janne Karhunen
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Jani Knifsund
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Heikki Kröger
- Department of Orthopedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Tommi Kääriäinen
- Department of Orthopedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Janne Lehtinen
- Department of Orthopedics and Traumatology, Hatanpää Hospital, Tampere, Finland
| | - Jukka Nyrhinen
- Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Juha Paloneva
- Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Outi Päiväniemi
- Department of Orthopedics and Traumatology, Hatanpää Hospital, Tampere, Finland
| | - Marko Raivio
- Department of Orthopedics and Traumatology, Hatanpää Hospital, Tampere, Finland
| | - Janne Sahlman
- Department of Orthopedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Roope Sarvilinna
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Sikri Tukiainen
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | | | - Ville Äärimaa
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Pirjo Toivonen
- Department of Orthopaedics and Traumatology, Helsinki University, Töölö Hospital, Helsinki, Finland
| | - Teppo L N Järvinen
- Department of Orthopaedics and Traumatology, Helsinki University, Töölö Hospital, Helsinki, Finland
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19
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Affiliation(s)
| | | | | | - Amar Rangan
- James Cook University Hospital, Middlesbrough, Tees Valley, United Kingdom
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20
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Wetzler MJ, Brand JC, Rossi MJ, Lubowitz JH. Related Research and Arthroscopy: Increasing the Breadth of Arthroscopy and Arthroscopy Techniques. Arthroscopy 2017; 33:1916-1917. [PMID: 29102005 DOI: 10.1016/j.arthro.2017.08.280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 08/31/2017] [Indexed: 02/02/2023]
Abstract
An editorial goal is to increase the breadth of Arthroscopy and Arthroscopy Techniques. Our readers are more than arthroscopic surgeons and scientists. Rather, the health care providers and scientists who read our journals are, first and foremost, physicians, allied health practitioners, and academic intellectuals whose interests include improving individual and public health and welfare across a wide spectrum of scholarly topics. By reaching a broader audience, we hope to expand our contribution to arthroscopic and related surgery and continue to develop the potential of our subspecialty.
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21
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Stone JA, Salzler MJ, Parker DA, Becker R, Harner CD. Degenerative meniscus tears - assimilation of evidence and consensus statements across three continents: state of the art. J ISAKOS 2017. [DOI: 10.1136/jisakos-2015-000003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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22
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Seil R, Karlsson J, Beaufils P, Becker R, Kopf S, Ollivier M, Denti M. The difficult balance between scientific evidence and clinical practice: the 2016 ESSKA meniscus consensus on the surgical management of degenerative meniscus lesions. Knee Surg Sports Traumatol Arthrosc 2017; 25:333-334. [PMID: 28247038 DOI: 10.1007/s00167-017-4458-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- R Seil
- Département de l'Appareil Locomoteur, Centre Hospitalier de Luxembourg-Clinique d' Eich, 78, Rue d'Eich, 1460, Luxembourg, Germany.
- Sports Medicine Research Laboratory, Luxembourg Institute of Health, 78, Rue d'Eich, 1460, Luxembourg, Germany.
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Molndal, Sweden
| | - P Beaufils
- Orthopaedics Department, Centre Hospitalier de Versailles, 78150, Le Chesnay, France
| | - R Becker
- Department of Orthopaedics and Traumatology, Hospital Brandenburg, Medical School Theodor, Fontane, Hochstrasse 26, 14770, Havel, Brandenburg, Germany
| | - S Kopf
- Center for Musculosketal Surgery, Charité-University Medicine Berlin, AugustenburgerPlatz, 1, 13353, Berlin, Germany
| | - M Ollivier
- Orthopaedics Department, Centre Hospitalier de Versailles, 78150, Le Chesnay, France
| | - M Denti
- Galeazzi Orthopaedic Institute, Milan, Italy
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23
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Rongen JJ, Rovers MM, van Tienen TG, Buma P, Hannink G. Increased risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears: a multi-center longitudinal observational study using data from the osteoarthritis initiative. Osteoarthritis Cartilage 2017; 25:23-29. [PMID: 27712957 DOI: 10.1016/j.joca.2016.09.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/23/2016] [Accepted: 09/22/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The primary objective was to assess whether patients with knee osteoarthritis and whom undergo arthroscopic meniscectomy have an increased risk for future knee replacement surgery. DESIGN Data used were obtained from the Osteoarthritis Initiative (OAI) study. SETTING Participants were enrolled, in four clinical centers, between February 2004 and May 2006 and were followed up on an annual basis up to and including 108-months from enrollment. PARTICIPANTS 4674 participants (58.4% female), aged 45-79, of all ethnic groups, who had, and those who were at high risk for developing, symptomatic knee osteoarthritis were included, of which 3337 (71.4%) were included in the final follow up visit. MAIN OUTCOME MEASURES Hazard ratio of knee replacement surgery for participants who underwent arthroscopic meniscectomy during follow up compared to propensity score matched participants who did not undergo arthroscopic meniscectomy during follow up. RESULTS 335 participants underwent arthroscopic meniscectomy during follow up, of which 63 (18.8%) underwent knee replacement surgery in the same knee. Of the 335 propensity score matched participants 38 (11.1%) underwent knee replacement surgery during follow up. Results from the Cox-proportional hazards model demonstrated that the hazard ratio of knee replacement surgery was 3.03 (95% CI (1.67-5.26)) for participants who underwent arthroscopic meniscectomy relative to the propensity score matched participants who did not undergo arthroscopic meniscectomy. CONCLUSIONS In patients with knee osteoarthritis arthroscopic knee surgery with meniscectomy is associated with a three fold increase in the risk for future knee replacement surgery.
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Affiliation(s)
- J J Rongen
- Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Orthopaedic Research Lab, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - M M Rovers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - T G van Tienen
- Kliniek Viasana, PO Box 4, 5450 AA Mill, The Netherlands.
| | - P Buma
- Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Orthopaedic Research Lab, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - G Hannink
- Radboud University Medical Center, Radboud Institute for Health Sciences, Orthopaedic Research Lab, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Rossi MJ. Editorial Commentary: Addressing the Anterolateral Side of an Anterior Cruciate Ligament-Deficient Knee: The Controversy Is Getting Even More Interesting. Arthroscopy 2016; 32:2048-2049. [PMID: 27697184 DOI: 10.1016/j.arthro.2016.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 06/13/2016] [Indexed: 02/02/2023]
Abstract
Evidence is building to support consideration of anterolateral knee reconstruction in the anterior cruciate ligament-deficient knee with a high-grade pivot shift or participation in a high-risk sport. As the pendulum swings back to the future with the extra-articular augmentation, our anticipation should be tempered by cautious interpretation of the results as the controversy unfolds.
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25
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Wehling P, Moser C, Maixner W. How does surgery compare with advanced intra-articular therapies in knee osteoarthritis: current thoughts. Ther Adv Musculoskelet Dis 2016; 8:72-85. [PMID: 27247634 DOI: 10.1177/1759720x16642405] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The objectives of osteoarthritis (OA) management are to reduce pain and inflammation, slow cartilage degradation, improve function and reduce disability. Current strategies for managing knee OA include nonpharmacological interventions, oral pharmacological treatments, localized intra-articular injections, and surgery. It has become evident that the inflammatory response is a key contributor to the development and progression of knee OA. Signaling pathways involving growth factors and cytokines are being investigated for the development of new therapies that target the underlying biological processes causing the disease. This concept of 'molecular orthopedics' enables more patient-centered diagnostic and treatment strategies. In contrast to other conservative therapies, which ultimately only address OA symptoms, intra-articular injections, in particular autologous conditioned serum (ACS), provide benefits that have the potential to outweigh those of established pharmacological treatments and surgery. Surgery has historically been considered the final solution for treatment of knee OA, both by treating physicians and by patients; however, there are increasing concerns regarding the lack of randomized clinical trials providing evidence to support this opinion. Intra-articular injection of ACS has demonstrated efficacy as a treatment for knee OA in a number of studies, with a very low rate of adverse events and side effects, compared with surgery. Treatment with ACS utilizes the release of anti-inflammatory cytokines and regenerative growth factors to support the natural healing processes in the knee, and has the potential to provide a valuable alternative to surgical intervention.
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Affiliation(s)
- Peter Wehling
- Center of Molecular Orthopaedics and Regenerative Medicine, Stadttor 1, 40219 Düsseldorf, Germany
| | - Carsten Moser
- Grönemeyer Institute for Microtherapy, University Witten/Herdecke, Bochum, Germany
| | - William Maixner
- Center for Translational Pain Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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26
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Demange MK, Gobbi RG, Camanho GL. "Fatigue meniscal tears": a description of the lesion and the results of arthroscopic partial meniscectomy. INTERNATIONAL ORTHOPAEDICS 2015; 40:399-405. [PMID: 26438183 DOI: 10.1007/s00264-015-3010-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/21/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of this study was to describe the clinical outcomes of partial meniscectomy in patients with "fatigue meniscal tear", which presents as a non-traumatic tear with abrupt onset of symptoms of a radial tear in the transition between the middle and posterior thirds of the meniscus. METHODS We prospectively followed 71 patients with "fatigue meniscal tear" (41 women and 30 men, mean age of 63 years, SD 6.9 years) recruited among 497 patients with isolated medial meniscal lesions treated between January 2006 and June 2011. Inclusion criteria were spontaneous abrupt onset knee pain, minor or no trauma, no radiographic or MRI osteoarthritis, no bone oedema, pre-operative magnetic resonance image of medial meniscus tear, and arthroscopic evaluation demonstrating radial or vertical flap tear in the body to posterior horn junction of the medial meniscus. We followed all patients for a minimum of two years and reviewed their clinical symptoms, physical exam, functional outcome, and patient satisfaction at last follow-up. RESULTS The average follow-up was 4.2 years, with a minimum follow-up of two years. Among the 71 patients, there were 59 (83.1 %) good or excellent results and 12 (16.9 %) poor results. These 12 patients demanded further treatment because of persistent pain, with three of the patients developing subchondral bone fracture. All patient complaints and poor outcomes could be identified in the initial six months after surgery. There was no gender difference in the subgroup analysis. CONCLUSION Our findings indicate that patients with "fatigue meniscal tear" benefit from arthroscopic partial meniscectomy, with only 16.9 % reporting unfavourable results. LEVEL OF EVIDENCE IV, Cohort study or case series.
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Affiliation(s)
- Marco Kawamura Demange
- Institute of Orthopaedic Surgery - Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Rua Ouvidio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, Brazil.
| | - Riccardo Gomes Gobbi
- Institute of Orthopaedic Surgery - Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Rua Ouvidio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, Brazil
| | - Gilberto Luis Camanho
- Institute of Orthopaedic Surgery - Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Rua Ouvidio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, Brazil
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27
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Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Br J Sports Med 2015; 49:1229-35. [PMID: 26383759 PMCID: PMC4602246 DOI: 10.1136/bjsports-2015-h2747rep] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASURES Pain and physical function. DATA SOURCES Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed. RESULTS The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death. CONCLUSIONS The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014009145.
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Affiliation(s)
- J B Thorlund
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - C B Juhl
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
- Department of Orthopedics, Copenhagen University Hospital, Gentofte, Denmark
| | - E M Roos
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - LS Lohmander
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
- Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Orthopedics, Clinical Sciences Lund, University of Lund, Sweden
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Lubowitz JH. Editorial Commentary: Osteochondral Allograft of the Humeral Head. Arthroscopy 2015; 31:1835. [PMID: 26354201 DOI: 10.1016/j.arthro.2015.06.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 02/02/2023]
Abstract
Despite reports of significant improvement in some patients, osteochondral allograft of the humeral head could be considered a procedure of last resort.
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Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015; 350:h2747. [PMID: 26080045 PMCID: PMC4469973 DOI: 10.1136/bmj.h2747] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASURES Pain and physical function. DATA SOURCES Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed. RESULTS The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death. CONCLUSIONS The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014009145.
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Affiliation(s)
- J B Thorlund
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - C B Juhl
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark Department of Orthopedics, Copenhagen University Hospital, Gentofte, Denmark
| | - E M Roos
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - L S Lohmander
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark Department of Orthopedics, Clinical Sciences Lund, University of Lund, Sweden
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Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. Arthroscopic arthritis options are on the horizon. Arthroscopy 2015; 31:389-92. [PMID: 25744317 DOI: 10.1016/j.arthro.2015.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 01/09/2015] [Indexed: 02/02/2023]
Abstract
Arthroscopic treatment options are on the horizon for cartilage defects and arthritis. While arthroscopy is not a "cure" for osteoarthritis, arthroscopic and related surgery is of significant benefit to many patients with intra-articular pathology including osteoarthritis and articular cartilage disease. However, arthroscopy alone is insufficient, and arthroscopic treatment of patients with arthritis is a salvage procedure requiring an approach where arthroscopy must be combined with additional procedures. There are degrees of osteoarthritis severity, and arthroscopy is more effective in combination with additional procedures in younger patients, in more active patients, and in patients with less severe disease, or smaller lesions. On another note, we continue to be fascinated by the knee anterolateral ligament, although to date its clinical relevance is entirely speculative.
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Beaufils P, Becker R, Verdonk R, Aagaard H, Karlsson J. Focusing on results after meniscus surgery. Knee Surg Sports Traumatol Arthrosc 2015; 23:3-7. [PMID: 25527437 DOI: 10.1007/s00167-014-3471-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Philippe Beaufils
- Department of Orthopaedics and Traumatology, Centre Hospitalier de Versailles, 78150, Le Chesnay, France,
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Rossi MJ, Brand JC, Provencher MT, Lubowitz JH. A cavalcade of shoulder controversies: deadman angle revisited… divergent anchor angles and depths, and rotator cuff vectors confuse comparison… and more. Arthroscopy 2014; 30:1529-32. [PMID: 25464868 DOI: 10.1016/j.arthro.2014.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 10/07/2014] [Indexed: 02/02/2023]
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Krogsgaard MR, Lind M, Jørgensen U. A positive viewpoint regarding arthroscopy for degenerative knee conditions. Acta Orthop 2014; 85:681-2. [PMID: 25280131 PMCID: PMC4259041 DOI: 10.3109/17453674.2014.970071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - Martin Lind
- Division of Sportstraumatology Department of Orthopedics Aarhus University Hospital Århus C, Denmark
| | - Uffe Jørgensen
- The Orthopedic Research Unit Department of Orthopedics Odense University Hospital Odense C, Denmark
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Affiliation(s)
- Teppo L N Järvinen
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital and University of Helsinki, Helsinki
| | - Raine Sihvonen
- Department of Orthopedics and Traumatology, Hatanpää City Hospital, Tampere, Finland
| | - Martin Englund
- Orthopedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden,Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA
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Lubowitz JH, Provencher MT, Rossi MJ. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Part 2. Arthroscopy 2014; 30:654-5. [PMID: 24862693 DOI: 10.1016/j.arthro.2014.04.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 04/08/2014] [Indexed: 02/02/2023]
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