Matrix-Augmented Bone Marrow Stimulation With a Polyglycolic Acid Membrane With Hyaluronan vs Microfracture in Local Cartilage Defects of the Femoral Condyles: A Multicenter Randomized Controlled Trial

Background

Microfracture (MF) is an established operative treatment for small, localized chondral defects of the knee joint. There is evidence from animal studies that matrix augmentation of bone marrow stimulation (m-BMS) can improve the quality of the repair tissue formation.

Purpose

To evaluate the therapeutic outcome of a matrix made of polyglycolic acid and hyaluronan as compared with a conventional MF technique.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Patients between the ages of 18 and 68 years who had an articular femoral cartilage defect of 0.5 to 3 cm² in the weightbearing area of the femoral condyles with indication for MF were included in this study. Patients were randomized and treated with either MF or m-BMS with Chondrotissue. Defect filling, as assessed on magnetic resonance imaging (MRI), at postoperative 12 weeks was defined as the primary outcome measure, with follow-up MRI at weeks 54 and 108. Follow-up data were also collected at 12, 54, and 108 weeks after surgery and included patient-reported clinical scores: visual analog scale for pain, Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score, and 36-Item Short Form Health Survey.

Results

MRI scans confirmed cartilage repair tissue formation in both groups 12 weeks after treatment. There was no significant difference between the m-BMS and MF groups in the percentage of defect filling at 12, 54, and 108 weeks postoperatively. No significant difference was found in terms of patient-reported clinical scores. Both groups showed significant improvement in 4 KOOS subscales-Pain, Activities of Daily Living, Sport and Recreation, and Quality of Life-at 54 and 108 weeks after treatment.

Conclusion

This is the first randomized controlled trial comparing m-BMS with a polyglycolic acid matrix with hyaluronan with MF. The use of the Chondrotissue implant in m-BMS has been proven to be a safe procedure. No difference was found between m-BMS and MF in terms of patient-reported outcome scores and MRI assessment until postoperative 2 years. Long-term follow-up studies including histological assessment are desirable for further investigation.

Registration

EUCTR2011-003594-28-DE (EU Clinical Trials Register).

How gait and clinical outcomes contribute to patients' satisfaction three months following a total knee arthroplasty

The objective of this study was to investigate how gait and clinical outcomes contribute to patients' satisfaction three months following a total knee arthroplasty (TKA). Seventy-eight patients with knee osteoarthritis (OA) and a control group of twenty-nine subjects were evaluated. The gait parameters, Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain and functional levels, quality of life and patients' satisfaction following TKA were assessed. A multiple linear regression model shows that the WOMAC functional score explained 39% of the global satisfaction and 37% of the satisfaction related to pain relief following TKA. Finally, the model shows that 65% of the satisfaction related to the functional improvement was explained by a combination of clinical and gait parameters. This study demonstrated the contribution of both gait and clinical outcomes to patients' satisfaction following TKA.

Do synovial leptin levels correlate with pain in end stage arthritis?

PURPOSE

We evaluated whether synovial fluid (SF) leptin concentrations correlate with pain severity in patients with hip or knee endstage osteoarthritis (OA) and whether they mediate the association between increased joint pain and (1) female gender and (2) obesity.

METHODS

We conducted a cross-sectional study including patients with primary hip and knee OA undergoing joint replacement between January and December 2010. SF leptin concentrations obtained on the day of surgery were assessed. Main outcome was pain severity measured pre-operatively using WOMAC and VAS pain scales.

RESULTS

A total of 219 patients were included, 123 hip and 96 knee arthroplasties. Mean age was 72 years, 59% were women. Mean SF leptin levels were 22.9 (±25.6) ng/ml in women and 5.4 (±5.9) ng/ml in men. Levels >19.6 ng/ml (highest quartile) were significantly associated with increased pain on both WOMAC (mean difference -9.6, 95% CI -15.1 to -4.0) and VAS scale (mean difference 0.8, 95% CI 0.2-1.3). Associations remained unchanged after adjusting for age, co-morbidities, contra-lateral arthritic joint, OA site, and disability. The associations observed between increased pain and female gender or obesity were substantially reduced after adjusting for SF leptin.

CONCLUSION

Joint pain is associated with SF leptin concentrations. Increased pre-operative pain observed in women and obese may be related to high intra-articular leptin levels.

Associations between gait and clinical parameters in patients with severe knee osteoarthritis: a multiple correspondence analysis

BACKGROUND

Given the complexity of the gait of patients with knee osteoarthritis, a multiple correspondence analysis may be helpful to optimise the extraction of relevant gait and clinical information. Therefore, the aims of this study are to identify the main associations with clinical and gait biomechanical parameters and to evaluate whether there are more specific knee osteoarthritis groups with different gait profiles.

METHODS

Ninety patients with severe knee osteoarthritis and twenty-six healthy individuals participated in this study. Pain and function were assessed with the WOMAC Index; knee joint deformity was assessed by the hip-knee-ankle angle on full-limb radiography; and full body gait analysis was performed with a motion analysis system and force plates.

FINDINGS

Using multiple correspondence analysis, two categories of gait parameters that best explain the gait variance of patients with knee osteoarthritis were highlighted. The forward displacement category is composed of the parameters speed, stride length, hip flexion and knee flexion. The frontal category is composed of the parameters thorax obliquity and knee adductor moments. Moreover, based on these parameters, four distinct gait profiles were identified: two gait profiles were associated with knee varus deformities, increased thorax obliquity and different forward displacements, while two gait profiles were associated with valgus deformities and different forward displacements.

INTERPRETATION

These gait parameters can be used to simplify the characterisation of the gait of the knee osteoarthritis population. Patients in varus profiles increase thorax obliquity on the stance limb and may reduce forward displacement. Patients in valgus profiles, however, only reduce forward displacement.

Influence of CYP2D6 activity on pre-emptive analgesia by the N-methyl-D-aspartate antagonist dextromethorphan in a randomized controlled trial of acute pain

BACKGROUND

There is some evidence that dextromethorphan (DM) is effective as a pre-emptive analgesic agent.  DM is mainly metabolized to dextrorphan (DOR) by CYP2D6 whose activity can be inhibited by pharmacologic intervention.

OBJECTIVES

To investigate the efficacy of DM as a pre-emptive analgesic agent and describe the population pharmacokinetics in the presence of normal and poor CYP2D6 metabolism in acute post-operative pain.

STUDY DESIGN

Double blind, randomized, placebo-controlled trial

SETTING

Post-surgical analgesic consumption after knee ligament surgery, a setting of acute pain.

METHODS

Forty patients were randomized to a single oral dose of 50 mg quinidine or placebo, administered 12 hours before 50 mg DM. Patients were genotyped for the major CYP2D6 and ABCB1 variants and phenotyped for CYP2D6 using urine DM/DOR metabolic ratios and blood samples for population pharmacokinetic modeling.

RESULTS

Quinidine was effective in inhibiting CYP2D6 activity, with 2-fold reduction of DM to DOR biotransformation clearance, prolonged DM half-life, and increased DM systemic availability. Patients in the quinidine group required significantly less often NSAIDs than patients in the placebo group (35.3% vs. 75.0%, P = 0.022). The odds ratio for NSAID consumption in the placebo vs. quinidine group was 5.5 (95% confidence interval (CI) 1.3 - 22.7) at 48 hours after surgery.

LIMITATIONS

While this study shows an impact of DM on pre-emptive analgesia and is mechanistically interesting, the findings need to be confirmed in larger trials.

CONCLUSION

CYP2D6 inhibition by quinidine influenced the pre-emptive analgesic effectiveness of DM confirming that CYP2D6 phenotypic switch increases the neuromodulatory effect of oral dextromethorphan.

Does knee alignment influence gait in patients with severe knee osteoarthritis?

BACKGROUND

Patients with knee osteoarthritis present an altered gait pattern. Amongst many factors, the lower limb alignment (varus, valgus) has been identified as an important risk factor for the progression of knee osteoarthritis. Among the large number of studies on knee osteoarthritis gait, only a few have included patients with a valgus deformity. The aims of this study were to determine how knee alignment influences full-body gait in patients with knee osteoarthritis and if knee malalignment is associated with pain and functional capacity.

METHODS

Sixty patients with severe knee osteoarthritis scheduled for a total knee arthroplasty were included in this study. Twenty-six subjects were recruited as the control group. The spatio-temporal parameters, three-dimensional full-body kinematics, and lower body kinetics were evaluated during a comfortable gait and compared between the groups. Pain and function were assessed with the WOMAC questionnaire.

FINDINGS

The full-body gait analysis demonstrated substantially different gait patterns and compensation mechanisms between the three groups. Patients with varus knee alignment significantly augmented their trunk movements in sagittal and frontal planes compared to patients with a valgus knee. In addition, patients with a valgus knee reported lower pain and lower functional deficits compared to patients with a varus knee.

INTERPRETATION

We found that gait compensations were significantly influenced by lower limb alignment. These new insights related to different knee osteoarthritis gait patterns might help in the understanding of gait compensation behaviours prior to total knee arthroplasty and better manage the strategies of rehabilitation following surgery.

[Saving the meniscus]

Meniscal tears are described in a great variety of knee accidents. According to the affected region, the healing prognosis will be different: a tear in the peripheral vascularized red zone has an important healing capacity and must be repaired as far as possible. In the intermediate zone, a suture may still heal when inner tears, in the white zone, must be resected. After 65 years of age, 2/3 of knees demonstrate meniscal lesions. Surgical indications must be careful discussed in these non-traumatic lesions. Enthusiastic surgery, guided by imaging, is often deleterious.

[Knee extensor mechanism ruptures]

Knee extensor mechanism is composed of the quadriceps and its tendon, patella and patellar tendon. Rupture of either the quadriceps or patellar tendon, or of the patella itself, lead to a disruption of the knee extensor mechanism. Clinical examination reveals an inability to actively extend the knee. Standard radiographs of the knee show a suprapatellar swelling of the soft tissues in case of quadriceps tendon rupture, or a displaced patellar fracture, or a patella alta in case of patellar tendon rupture. Echography and MRI confirm the diagnosis and may reveal associated injuries. In case of knee extensor mechanism rupture, early surgical reconstruction of quadriceps or patellar tendon, or patella osteosynthesis, are mandatory to achieve early functional recovery.

α-Smooth muscle actin and TGF-β receptor I expression in the healing rabbit medial collateral and anterior cruciate ligaments

The aim of our study was to advance the knowledge about the biological differences in the healing of the anterior cruciate ligament (ACL) versus the medial collateral ligament (MCL). We quantified α-smooth muscle actin (α-SMA) expression and TGF-β receptor I (TGF-βRI) expression in experimentally injured rabbit ligaments (from day 3 to 12 weeks post-injury). Myofibroblasts (α-SMA positive cells) were identified as early as the third day post-injury in MCL and their density increased steadily up to day 21. Myofibroblasts were also detected in injured ACL but their density remained very low at all time points. The percentage of positive TGF-βRI area significantly increased in both injured ligaments compared to controls, with a peak expression at day 21; however, it remained constantly lower in ACL compared to MCL. A significant correlation was found between the percentage of TGF-βRI positive cells and the percentage of α-SMA expression only in injured MCL. These results provide evidence that myofibroblasts are important players in MCL remodelling after injury. The combined presence of myofibroblasts and TGF-βRI in the first 3 weeks post-MCL injury may partially explain the difference in the MCL and ACL healing process.

[What's new after an ACL tear?]

Following a severe knee sprain during which the anterior cruciate ligament has been torn, the patient and his doctor are facing the choice between a conservative treatment or a surgical approach. Reviewing the international literature allows us to build a pertinent opinion. If the conservative treatment is selected, one must be aware that the proportion of good results does not exceed 50%. This is why, this treatment is only recommended for little demanding and non-sports active persons. In various surgical options, the autologous anterior cruciate ligament reconstruction, using a graft of patellar or hamstrings tendons gives good, reliable and reproducible results.

[Severe knee sprain: which surgery and for whom?]

After a knee sprain, some anamnestic and clinical elements may suspect and eventually establish the diagnosis. The association of a crack, an hemarthrosis and a knee joint laxity correspond to a severe sprain. The initial management of a traumatic knee is essential because it leads to the good treatment option. Misdiagnosed lesions often do not heal optimally and induce new traumas synonymous of functional impairment and handicap.

EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee

Objectives:

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of variation in diagnostic and therapeutic performance across disciplines, have found consensus in starting task forces aiming at achieving diagnostic and therapeutic uniformity, and have identified medical conditions with which representatives of both organisations will frequently be confronted in common clinical practice. The aim of the present work was to establish recommendations for the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

Methods:

The EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations were followed.

Results:

In all, 11 rheumatologists from 11 countries and 12 orthopaedic surgeons from 7 countries met twice under the leadership of 2 conveners, a clinical epidemiologist and a research fellow. After carefully defining the content and procedures of the task force, research questions were developed, a comprehensive literature search was performed and the results were presented to the entire committee. Subsequently, a set of 10 recommendations was formulated based on evidence from the literature if available, and after discussion and consensus building.

Conclusions:

This is the first combined interdisciplinary project of rheumatologists and orthopaedic surgeons, successfully aiming at achieving consensus in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

Fixed-bearing versus mobile-bearing total knee arthroplasty: a prospective randomised, clinical and radiological study with mid-term results at 7 years

Mobile-bearing (MB) total knee arthroplasty (TKA) was developed as an alternative to the established fixed-bearing (FB) design because of theoretical advantages. Short-term studies comparing these designs have not shown any differences in clinical and radiographic results. We compared the results at 7 years of a randomised study of patients undergoing TKA using either a FB or a MB variant of the same prosthesis. Fifty-two patients (52 knees) with an average age of 70 years received a FB posterior-stabilized prosthesis, and 50 patients (52 knees) with an average age of 72 years, a MB prosthesis. All implants were cemented and the patella was routinely resurfaced. Preoperatively, there were no differences between the two groups, and surgical procedure and postoperative protocol were the same for both. At an average follow-up of 7.1 years, no significant differences of FB over MB design could be demonstrated with respect to the American Knee Society score (AKSS), pain score, a questionnaire of general health (SF-12 score), range of motion (ROM), or complication rates. Radiographs showed no significant difference in prosthetic alignment or evidence of loosening. Two knees with a MB design required reoperation, one for persistent joint stiffness and another to treat septic loosening. One patient with a MB prosthesis with signs of tibial component loosening was asymptomatic. We conclude that at mid-term follow-up there is no evidence to prove the superiority of MB over FB TKA with regard to the clinical and radiographic results.

"Biological failure" of the anterior cruciate ligament graft

Anterior cruciate ligament (ACL) reconstruction has the best chance for success when the graft undergoes extensive biologic remodeling and incorporation after implantation. There are many factors that can lead to graft failure and possible revision surgery. These include patient selection; surgical technique such as graft placement and tensioning; the use of allograft versus autograft; mechanical factors such as secondary restraint laxity; lack of a correct, carefully controlled post-operative rehabilitation program; and biological factors. When a patient presents with knee instability following ligament reconstruction and there is no history of a new trauma or identifiable technical error, biological failure should be considered. However, the biologic response of the grafted tissue is closely linked to the mechanical and biochemical environment into which the graft is placed. Thus, the "biological failure" of the ACL graft is a complex pathological entity whose cause is not fully understood. Failure may be initiated by early extensive graft necrosis, disturbances in revascularization, problems in cell repopulation and proliferation, and as well difficulties in the ligamentization process. However, further study of the biological characterization of a failed graft placed in a correct mechanical environment is warranted.

Outcome of boxer's fractures treated by a soft wrap and buddy taping: a prospective study

INTRODUCTION

The ideal treatment for a boxer's fracture remains controversial, particularly the degree of volar dislocation considered acceptable for nonoperative treatment.

PATIENTS AND METHODS

From December 2003 to December 2004, 25 patients who sustained a subcapital metacarpal fracture of the little finger with volar angulation between 30 to 75 degrees were prospectively enrolled in the study. All patients were treated with a circular self-adherent wrap covering metacarpal bones II-V and buddy taping of the ring and little fingers for a period of 3 weeks while allowing immediate free range of motion.

RESULTS

Final evaluation at a mean of 5 months revealed all patients to be satisfied without subjective functional impairment. All fractures healed, and the angulation of the fracture remained unchanged, but moderate shortening was observed. Active flexion of the metacarpophalangeal (MCP) joint was significantly lower on the fracture side, but as the median degree of MCP flexion was the same, this statistical difference was without clinical relevance. There was no loss in grip strength. A subjective long-term evaluation was performed by phone; at a median of 3 years, a QuickDash score gave a median of 0 point.

CONCLUSION

Treating a boxer's fracture with angulation of up to 75 degrees by soft wrap and buddy taping resulted in satisfied patients and good clinical results.

Accuracy of stress radiography techniques in grading isolated and combined posterior knee injuries: a cadaveric study

BACKGROUND

Stress radiography techniques have been shown to be superior to the arthrometer and clinical examination in evaluating the posterior cruciate ligament-deficient knee, but no precise relationship has been established between the extent of the lesion and the laxity measured by stress radiography.

HYPOTHESIS

It is possible to establish a precise relation between posterior laxity and the anatomical lesions of the posterior cruciate ligament and posterior structures using stress radiography.

STUDY DESIGN

Controlled laboratory study.

METHODS

Measurements were performed on 15 fresh-frozen cadaveric knee specimens. A partial posterior cruciate ligament lesion was created by sectioning the anterolateral bundle, followed by a complete section. Then the lateral collateral ligament and the posterolateral corner were transected, and finally the medial collateral ligament and the posteromedial corner were sectioned. Stress radiography was performed first on the intact knee and again after each lesion was created using 4 techniques: Gravity Sag View, PCL-Press, Telos at 80 degrees , and Telos at 30 degrees of flexion.

RESULTS

Telos 30 and Telos 80 revealed the best overall performance as a diagnostic test in terms of accuracy in discriminating between the different types of lesions. Using the Telos device, we determined the following cut-off points: for a partial lesion, less than 3 mm at 30 degrees and less than 6 mm at 80 degrees ; for a complete lesion, between 4 mm and 9 mm at 30 degrees and between 7 mm and 12 mm at 80 degrees ; for associated peripheral lesions, more than 9 mm at 30 degrees and more than 12 mm at 80 degrees .

CONCLUSION

The Telos 30 degrees and 80 degrees allow us to accurately distinguish between the different types of lesion and permit grading of posterior knee laxity.

CLINICAL RELEVANCE

Stress radiography allows characterization of posterior knee injuries and helps to determine treatment strategy.

[Symptomatic treatment of non-displaced avulsion and Jones fractures of the fifth metatarsal: a prospective study]

The objective was to compare the results of a conservative treatment of non-displaced Jones fractures and of avulsion fractures of the fifth metatarsal. In 2004/2005 29 fractures of the fifth metatarsal were distinguished into avulsion fractures (n = 21) and Jones fractures (n =8). Six patients with avulsion fractures were lost. We proposed the same treatment for the two groups: Elastic banding, pain killers, crutches if needed and thromboembolic prophylaxis with low molecular heparin. After twelve weeks none of the patients complained about pain. Radiographic consolidation of the fracture was noticed after 7.3 weeks for the Jone's fractures and after 7.1 weeks for the avulsion fractures. We propose symptomatic treatment for the non-displaced avulsion and Jones fractures.

[Autologous chondrocyte implantation for focal cartilage lesions: state of the art in 2007]

Autologous chondrocyte implantation (ACI) is a frequently used procedure for full-thickness cartilage lesions in the knee joint. However, to date, there are just a few prospective, randomized clinical studies and most publications are case series on small and heterogenic cohorts with short-term follow-up. To date, ACI is a surgical treatment option for single traumatic lesions on the distal femur in young active subjects with a recent lesion. Lesion size should be between 3 and 8 cm2, < 6 mm in depth, tidemark preserved without penetration of the subchondral bone. Absolute contraindications for ACI include osteoarthrosis, kissing lesions, lesions size greater than 10 cm2 or deeper than 8 mm, ligament instability, partial or total meniscectomy, axis malalignment > 5. Further studies are mandatory to determine the precise indications to the technique and to show its superiority on the established treatment of chondral lesions.

The popliteal cyst

A popliteal cyst, originally called Baker's cyst, is a synovial fluid-filled mass located in the popliteal fossa. The most common synovial popliteal cyst is considered to be a distension of the bursa located beneath the medial head of the gastrocnemius muscle. Usually, in an adult patient, an underlying intra-articular disorder is present. In children, the cyst can be isolated and the knee joint normal. The anatomy, etiopathogenesis, clinical presentation, differential diagnosis, imaging and treatment modalities of the popliteal cyst are presented. The authors try to answer some questions dealing with this condition. Is the cyst isolated, can it be treated as such, is its origin always well-defined and does surgical excision provide a permanent cure?

Anatomy of the anterior cruciate ligament

The anterior cruciate ligament (ACL) is a band of dense connective tissue which courses from the femur to the tibia. The ACL is a key structure in the knee joint, as it resists anterior tibial translation and rotational loads. When the knee is extended, the ACL has a mean length of 32 mm and a width of 7-12 mm. There are two components of the ACL, the anteromedial bundle (AMB) and the posterolateral bundle (PLB). They are not isometric with the main change being lengthening of the AMB and shortening of the PLB during flexion. The ACL has a microstructure of collagen bundles of multiple types (mostly type I) and a matrix made of a network of proteins, glycoproteins, elastic systems, and glycosaminoglycans with multiple functional interactions. The complex ultrastructural organization and abundant elastic system of the ACL allow it to withstand multiaxial stresses and varying tensile strains. The ACL is innervated by posterior articular branches of the tibial nerve and is vascularized by branches of the middle genicular artery.

[Knee replacement]

Total knee replacement is nowadays a surgical technique that has reached maturity and is used as frequently as total hip replacement. It is mainly aimed at patients suffering from knee osteoarthrosis when it becomes invalidating and painful and does not respond anymore to medical conservative treatment and physiotherapy. Long term results are excellent in patients aged over 70 years old. They are still amenable to improvement in young patients who are more active and who put under stress their implants in a longer and more intense way. Infection, loosening and malpositioning of the implants are the most common complications.

Development of a Force Amplitude- and Location-Sensing Device Designed to Improve the Ligament Balancing Procedure in TKA

To improve the ligament balancing procedure during total knee arthroplasty a force-sensing device to intraoperatively measure knee joint forces and moments has been developed. It consists of two sensitive plates, one for each condyle, a tibial base plate and a set of spaces to adapt the device thickness to the patient-specific tibiofemoral gap. Each sensitive plate is equipped with three deformable bridges instrumented with thick-film piezoresistive sensors, which allow accurate measurements of the amplitude and location of the tibiofemoral contact forces. The net varus-valgus moment is then computed to characterize the ligamentous imbalance. The developed device has a measurement range of 0-500 N and an intrinsic accuracy of 0.5% full scale. Experimental trials on a plastic knee joint model and on a cadaver specimen demonstrated the proper function of the device in situ. The results obtained indicated that the novel force-sensing device has an appropriate range of measurement and a strong potential to offer useful quantitative information and effective assistance during the ligament balancing procedure in total knee arthroplasty.

[Patella dislocation]

Patella dislocation is a classical injury affecting teenagers. In 2/3 of cases, it occurs in sports activities. It is often a benign trauma which happens in a patello-femoral dysplasia context, leading to dislocation and reccurence if nothing is done to correct the defaults. Radiographic and scanner examinations allow to measure the dysplasia parameters and think about its correction. With MRI documentation, capsulo-ligamentous and cartilaginous lesions can be identified and their surgical repair can be discussed. When the dislocation occurs in a normal anatomical context, conservative therapy is still indicated.

Expert panel on anterior cruciate ligament case studies

Anterior cruciate ligament (ACL) reconstructions cannot, and should not, be considered "recipe-driven" or "cookie-cutter" operations. There are multiple variables that must be considered both pre- and intraoperatively in order to execute a successful procedure. The following case studies present a number of challenging situations, many of which do not have a straightforward, or only one, solution. The goal is to provide some ral-life clinical situations in which the reader can "observe" an expert panel of ACL surgeons working through the problems--offering solutions based on science, experience, and intuition.

Medial meniscectomy in patients over the age of fifty: a six year follow-up study

PURPOSE

Meniscectomy in the older patient remains a controversial topic. The aim of our study is to assess the mid-term outcome of arthroscopic partial medial meniscectomy in patients over fifty years of age and attempt to retrospectively identify symptoms and/or findings on examination which can differentiate between non-degenerative medial meniscal tears versus degenerative meniscal changes.

MATERIALS AND METHODS

Thirty-two patients over the age of fifty who had undergone arthroscopic medial partial meniscectomy, were reviewed. The average age was 60 (51-74 yrs) and the average follow-up was six years (3-7 yrs). Based upon the intra-operative findings, patients were divided into two groups: (1) non-degenerative meniscal tears (NDM; n = 12) and (2) degenerative meniscal changes (DM; n = 20). Our outcome measurements were with the HSS knee score, a satisfaction score, and weight-bearing X-rays.

RESULTS

In the NDM group, eleven patients were rated excellent or good, and one was rated poor. In the DM group, three patients were rated as excellent or good, eight as fair, and nine as poor. The HSS score was 97 +/- 4.6 for the NDM group and 85 +/- 9.5 for the DM group. The average satisfaction score was 9.2 +/- 0.7 (very satisfied) for the NDM group and 5.8 +/- 2.6 (fairly satisfied) for the DM group. There was no significant difference between the NDM and the DM groups with regards to pre-operative symptoms and signs, except for the McMurray sign, which was found to be positive in 83% of NDM cases versus 25% of DM cases (sensitivity = 83%). Using only these data, the McMurray sign was 67% specific for NDM.

CONCLUSIONS

Arthroscopic medial meniscectomy in older patients provides 90% good results six years after a non-degenerative meniscal tear, but only 20% of good results after a degenerative meniscal tear. However, based on this study, neither symptoms nor physical examination are able to differentiate between traumatic meniscal tears and degenerative meniscal changes in older patients. A positive McMurray's sign favors the diagnosis of a traumatic tear. However, a specificity of this test of only 67% as shown in our data questions its utility in clinical decision-making.

The axial view to measure posterior laxity of the knee. A mathematical analysis

Posterior laxity of the knee can be assessed clinically, but interpretation of the amount of displacement is highly subjective. Mechanical methods are more efficacious for measuring anterior laxity. Radiologic techniques are available for measurement in a lateral projection, but some variables may interfere with their accuracy. We undertook a trigonometric analysis of the axial view to confirm that it can be used to reliably measure posterior displacement. The ideal radiologic conditions consist of 80 degrees of knee flexion in both knees maintained with a knee support and a 26 degrees x-ray beam incidence with respect to the tibia. Although such accuracy is rarely obtained in routine clinical practice, even with a variability of +/- 10 degrees in the x-ray beam incidence the error factor will be less than 10%. Such a degree of error is in the same range (+/- 2 mm) as noted by investigators using the lateral radiograph to measure anteroposterior displacement. We believe that our study validates the use of a single axial radiograph of both knees to assess the state of the posterior cruciate ligament of an injured knee as compared with a normal knee.

[AT-TG (anterior tuberosity-trochlear groove): interobserver variability in CT measurements in subjects with patellar instability]

PURPOSE OF THE STUDY

Measurements between the anterior tuberosity of the tibia and the trochlear groove of the patellar surface of the femur AT-AG) are recognized parameters for exploring patellar instability. Interobserver variability should be less than 4 mm and reproducibility should be greater than 85 per cent for valid measurements. We assessed interobserver variability with CT measurements.

MATERIAL AND METHOD

The radiography files (left and right knee) of thirteen patients with patellar instability were examined by six radiologists working in private practice after training in our university center.

RESULTS

The results demonstrated major variability with acceptable reproducibility in only 15% of the measurements. Differences greater than 5 mm were observed for 14 groups of values (54 per cent) and greaterd than 8 mm in 5 groups (19 per cent). The spread was mainly related to determinations of the TG point in case of major dysplasia and in defining the precise contour of the tibial tuberosity. Surgical decisions made on the basis of these millimetric values should be made prudently.

Subtalar subluxation in ballet dancers

Ankle injuries frequently occur in dancers. Among these injuries, only a few cases of talar subluxation have been reported in the literature. In our series, we diagnosed and treated 25 subtalar subluxations over a 1-year period in the Ballet Béjart Lausanne company. The subluxations occurred after a grand plie on pointes or at the landing of a jump on demi-pointes, without any mechanism of ankle sprain. The dancer usually noted a sudden and sharp pain in the talonavicular joint and hindfoot with a feeling of "forward displacement" of the foot. At palpation, the talonavicular ligament, the anterior talofibular ligament, and the posteromedial part of the subtalar joint were painful. A limitation of the ankle extension and a clear hypomobility of the subtalar joint were noted. Under the effect of shearing forces on the midtarsal joint, a posteromedial subtalar subluxation occurred. Treatment consisted of a manipulation that reduced the subluxation. Continuous taping, which locks the talonavicular joint in the anterior direction, was recommended for 6 weeks. Dancing could be resumed in a swimming pool after 2 weeks, and on the ground after 3 to 4 weeks. We found that subluxation could recur, and that it could eventually become chronic.

Nine cases of osteonecrosis in elderly patients following arthroscopic meniscectomy

We report nine cases of osteonecrosis of the knee after arthroscopic meniscectomy between 1992 and 1996. In five women and four men aged between 58 and 82 years (mean 69 years), magnetic resonance imaging (MRI) demonstrated a meniscal tear for which arthroscopic meniscectomy was performed. MRI was done between 3 days and 72 weeks after the onset of symptoms. Signs of osteonecrosis were not present on the initial MRI scan. Postoperatively, all patients experienced persistent knee pain and joint effusion. A repeat MRI scan 6-48 weeks after meniscectomy confirmed the diagnosis of osteonecrosis. In eight patients osteonecrosis was located on the medial, in one patient on the lateral femoral condyle. Our report supports the results of recent studies which have related osteonecrosis to arthroscopic meniscectomy. Further studies need to be undertaken to determine the aetiology of the osteonecrosis related to this procedure in the elderly. Until the results of these studies are available, we recommend considering carefully before performing arthroscopic procedures in the elderly.

[Arthroscopic removal of intra-articular loose foreign bodies of the elbow]

PURPOSE OF THE STUDY

We have retrospectively studied the results of arthroscopic removal of loose bodies in the elbow. The aim of the study was to determine if the etiology of the loose bodies could be considered as a criteria for technical difficulty and clinical prognosis.

MATERIAL

16 patients (11 men and 5 female) had an elbow arthroscopy for loose bodies removal. Their average age was 29.5 years (range: 16-49). The post-operative results were recorded in their medical files with an average follow-up of six months.

METHODS

In each case we have determined the etiology of the intra-articular loose bodies. The results were analyzed according to technical difficulty and clinical outcome.

RESULTS

The etiology of the loose bodies was 8 chondromatosis, 4 osteochondritis dissecans and 4 post-traumatic osteoarthritis. The removal of the loose bodies was possible in 13 cases. Three arthroscopies were interrupted because of arthritic joint space narrowing. Twelve patients with primary chondromatosis and osteochondritis dissecans were improved. We did not find any significant clinical improvement in osteoarthritic elbows. A correlation between the results and the etiologies could therefore be shown.

DISCUSSION

In arthroscopic removal of elbow loose bodies, technical difficulties and clinical results are correlated to the etiology of the loose bodies and also to the statement of the osteochondral surfaces.

[Aseptic osteonecrosis of the femoral condyle after meniscectomy by the arthroscopic approach]

Retrospective review of 10 patients who presented with avascular necrosis of the ipsilateral femoral condyle following arthroscopic meniscectomy (9 medial, 1 lateral). The bone lesions were evaluated by radiography and MRI, which were repeated for few patients. MRI allows earlier diagnosis of avascular necrosis of the femoral condyle and offers an evaluation of extent of the lesions whose evolution is variable: 3 patients required a knee prothesis, the other 7 patients were treated medically.

Can we predict the outcome of a partial rupture of the anterior cruciate ligament? A prospective study of 43 cases

The concept of partial rupture of the anterior cruciate ligament (ACL) has been confirmed by arthroscopic examination and palpation. We present a prospective study of 43 patients who were diagnosed arthroscopically as suffering from a partial rupture of the ACL by the same surgeon. The patients followed a rehabilitation protocol and were examined by an independent observer after 5 years. Twenty-five patients had a stable knee, whereas 18 eventually suffered a complete ACL rupture. ACL partial rupture is easily recognizable with arthroscopy, but the quantity and state of the still intact fibres is difficult to assess.

An unusual arthroscopic discovery: an intraarticular schwannoma of the knee

This case report describes an unusual arthroscopic finding in a patient presenting with typical symptomatology of a medial meniscal tear of the right knee. Arthroscopy showed an multilobulated tumor that on histological examination was diagnosed as an intraarticular Schwannoma.

[Fracture of the femoral neck: therapeutic approach]

The therapeutic approach for treatment of femoral neck fractures is reviewed. The choice of implant is dependent primarily on patient age and amount of fracture displacement. Hemiarthroplasty remains the treatment of choice for displaced femoral neck fractures in older or debilitated patients. Internal fixation is always indicated in healthy and active subjects, whether the fracture is displaced or undisplaced. Internal fixation with three cancellous screws provides good mechanical stability without compromising head vitality when compared to other implants.