Unicompartmental knee arthroplasty in patients over 75 years: a definitive solution?

INTRODUCTION

The purpose of this study was to perform a mid-long-term clinical and radiographic evaluation of the results obtained in patients older than 75 years treated with minimally invasive unicompartmental knee arthroplasty (UKA). The hypothesis was that UKA is a viable solution for the definitive treatment of localized disease in this age group, with good results and a low failure rate.

METHODS

An all-poly tibial component UKA was applied with a minimally invasive technique. Sixty-seven knees in patients with a minimum age of 75 years were evaluated at mean 9 years' follow-up. The Oxford knee score, Knee Society Score, WOMAC score, Visual Analogue Scale (VAS) for pain self-assessment and range of motion (ROM) were determined, as well as weight-bearing antero-posterior and laterolateral radiographs.

RESULTS

All clinical scores, as well as VAS and ROM, improved significantly at 9-year follow-up, and the outcome was considered good or excellent in 92.6% of the patients. Radiographic results showed that both tibial plateau angle and posterior tibial slope angles were maintained, whereas femoro-tibial angle was significantly changed at follow-up. Further analysis showed no significant correlation between clinical scores and body mass index, whereas the clinical outcome was correlated with the ROM obtained. Only two failures and one major post-operative complication were observed.

CONCLUSIONS

UKA is a viable option for treating unicompartmental knee osteoarthritis. With the proper indications and an accurate technique UKA may be indicated also in very elderly patients with reduced complications and morbidity, and excellent survivorship.

Technical variables of ACL surgical reconstruction: effect on post-operative static laxity and clinical implication

PURPOSE

The hypothesis was that an alteration of different surgical variables of ACL reconstruction would produce significant changes in post-operative static laxity of knee joint.

METHODS

Joint laxity was acquired by a surgical navigation system for 17 patients just after graft fixation during single-bundle reconstruction with extra-articular lateral tenodesis. The analysed laxity parameters were: internal/external rotation at 30° (IE30) and 90° (IE90) of flexion, varus/valgus rotation at 0° (VV0) and 30° (VV30) of flexion and anterior/posterior displacement at 30° (AP30) and 90° (AP90) of flexion. As surgical variables, the angles between the tibial tunnel and the three planes were defined as well as the lengths of the tunnel and the relationship between native footprints and tunnels. The same analysis was performed for the femoral side. All surgical variables were combined in a multivariate analysis to assess for predictive factors between them and post-operative laxities values. To quantify the performance of each multivariate model, the correlation ratio (η ²) and the corresponding P value (*P < 0.050) have been evaluated.

RESULTS

Multivariate analysis underlined statistically significant models for the estimation of: AP30 (η ² = 0.987; P = 0.014), IE30 (η ² = 0.995; P = 0.005), IE90 (η ² = 0.568; P = 0.010), VV0 (η ² = 0.932; P = 0.003). The parameters that greatly affected the identified models were the orientation of the tibial tunnel with respect to the three anatomical planes. The estimation of AP30, IE30 and IE90 got lower value as the orientation of the tibial tunnel with respect to transverse plane decreases. Considering the orientation to sagittal ([Formula: see text]) and coronal ([Formula: see text]) plane, we found that their reduction provoked a decrease in the estimation of AP30, IE30 and IE90 (except [Formula: see text] that did not appear in the estimation of AP30). The estimation of VV0 got an increase of [Formula: see text], and [Formula: see text] which led to a laxity reduction.

CONCLUSION

The main finding of the present in vivo study was the possibility to determine significant effects on post-operative static laxity level of different surgical variables of ACL reconstruction. In particular, the present study defined the conditions that minimize the different aspects of post-operative laxity at time-zero after surgery.

Is there a difference in clinical outcomes and repair integrity between arthroscopic single-row versus transosseous (anchorless) fixation? A retrospective comparative study

BACKGROUND

Few studies have investigated clinical and structural outcomes after transosseous (TO) repair. The purpose of this study was to compare structural and clinical outcomes of rotator cuff tear, repaired arthroscopically, with a single row (SR) or transossoeus (TO) anchorless technique.

METHODS

96 patients who underwent an arthroscopic repair for superior or posterosuperior rotator cuff tear using TO (n:54) or a SR (n:42) were retrospectively enrolled in this study after evaluation of clinical and surgical notes. Functional evaluation was performed with the adjusted Constant score, and American Shoulder and Elbow Surgeons (ASES) score. Postoperative cuff integrity was determined through MRI study.

RESULTS

Patients were recalled after a minimum follow-up of two years. All the patients were available for the study. In the SR group the Constant rating system showed a significant improvement from a preoperative average rating of 44.8 to an average of 85.7. In the group of TO repair the Constant rating system showed a significant improvement from a preoperative average of 46.1 to an average of 87.6 postoperatively. According to ASES index scores, the average total score improved from 42.8 to 92.0 in the anchor group and from 40.4 to 94.6 in the TO group. There was no statistical difference between the two groups about clinical outcomes. Postoperative MRI revealed no differences in term of complete re-tears between the two techniques. In the SR group at MRI we observe significant more cases of rotator cuff with a Sugaya type III healing.

CONCLUSIONS

Arthroscopic rotator cuff repair yielded successful clinical outcomes using SR and TO technique. However using the TO technique we saw less type 3 Sugaya readings on MRI suggesting a possible benefit with TO repair.

LEVEL OF EVIDENCE II

Retrospective study.

Endoscopic versus Open Bursectomy for Prepatellar and Olecranon Bursitis

Objectives Bursitis of the olecranon and the patella are not rare disorders, and conservative management is successful in most cases. However, when patients do not respond to conservative treatment, open excisional surgery or, recently, endoscopic bursectomy, can be used. The aim of this study was to evaluate the results of open and endoscopic treatments of olecranon and prepatellar bursitis. Patients and methods Forty-nine patients (37 male and 12 female), who were treated with endoscopic bursectomy (25 patients) or open bursectomy (24 patients) were included in this study. Thirty patients had olecranon bursitis, while 19 patients had prepatellar bursitis. The patients' average age was 61.1 ± 12.3 (range 33-81) years. All of the patients' hospitalization and surgery times were recorded. The satisfaction of the patients was evaluated with a satisfaction scoring system, as well as by evaluating residual pain, the range of joint movement, and the cosmetic results of the procedure. Results The average follow-up time was 16 ± 9 months (range 12-27). The median operation time was 23.2 ± 3.5 minutes for the endoscopic bursectomy group and 26.4 ± 6.8 minutes for the open bursectomy group. The median hospitalization time was 0.56 ± 0.5 days (range 0-1 day) for the endoscopic group and 1 ± 0 days for the open bursectomy group (P<0.01). According to the patient satisfaction questionnaire, the endoscopic bursectomy group's score was 8.5 ± 1.3 (range 5-10), and the open bursectomy group's score was 5.29 ± 1.8 (range 1-9) (P<0.01). Conclusion Endoscopic bursectomy is a time-saving and efficient surgical treatment option for patients with prepatellar and olecranon bursitis.

Arthroscopic chronic tennis elbow surgery preserves elbow proprioception

STUDY DESIGN

Retrospective cohort study.

INTRODUCTION

A new method of accurately assessing the compromised elbow's proprioception was developed for this postsurgical population using information from previous neurophysiologic proprioception studies of healthy elbows.

HYPOTHESIS

This retrospective cohort study investigated the patterns and the degree of proprioceptive impairment and recovery following arthroscopic surgery for chronic lateral epicondylitis.

MATERIAL AND METHODS

Participants had undergone arthroscopic elbow surgery two years prior to this study (n=15). Healthy, non-injured volunteers with similar demographics (n=15) served as controls. Both groups were evaluated using quantitative measures of joint position sense for proprioceptive functioning. In order to obtain the most accurate proprioceptive measurements, interindividual interaction and visual input biases were eliminated. Retrospective chart reviews were performed to compare qualitative self-reported measures of proprioceptive function in arthroscopic surgery patients before surgery and two years post-surgery.

RESULTS

Active and passive joint repositioning outcome measurements were similar between groups (p>0.05). No significant differences were found among any angles except one: passive joint position sense at 120° of flexion (p<0.05). At this angle, the arthroscopy group showed greater deviation from target angles than the control group. The novel proprioceptive testing method we developed was found to be accurate and reliable.

DISCUSSION

Outcomes of arthroscopic treatment of chronic lateral epicondylitis with no decortication yielded outcomes measure similar to those of healthy controls. The sole significant difference was at 120° flexion passive joint repositioning, with a higher negative angular deviation from the target point. We propose that our study results and specific proprioception method may have implications for improving accuracy of future elbow arthroscopy and proprioceptive recovery in this population.

LEVEL OF EVIDENCE

II, low-powered prospective randomized trial.

Anatomical axis validation of lower extremity for different deformities: A radiological study

Aim:

The aim of this study was to derive a pure, unbiased, reliable and accurate objective relationship between the local knee axis measurements through a short knee anteroposterior roentgenogram and the lower limb axis measurement through an orthoroentgenogram.

Patients and Methods:

Radiographs of 114 patients (114 knees) were evaluated by two independent raters for measurement of lower limb axis on an orthoroentgenogram and the local knee axis on short knee anteroposterior X-ray, which was derived by cropping the orthoroentgenogram by a blinded radiology assistant. The raters measured at two different time-points separated by an interval of 30-day period. Intra-rater and inter-rater reliabilities were calculated by intra-class correlation coefficients and three models were built to establish the relationships of X-ray anatomical axis with orthoroentgenogram anatomical axis, orthoroentgenogram anatomical axis with orthoroentgenogram mechanical axis and X-ray anatomical axis with orthoroentgenogram mechanical axis.

Results:

For three different measurements, intra-class correlation coefficients of Rater 2 were higher than 0.90 which shows perfect reliability, while that for Rater 1 was low. Furthermore, first measurements were more consistent than the second measurement. There was a strong positive correlation in all the three models except for varus cases in the last.

Conclusion:

The standardized correlation derived between the two different techniques for measuring knee alignment is fairly comparable with the studies in the past and would serve as a reliable template for future studies concerning relationships between the two, in addition to helping knee surgeons make more reliable and accurate interpretations through local knee axis measurements.

Early Complication Rates Following Total Shoulder Arthroplasty for Instability Arthropathy With a Prior Coracoid Transfer Procedure

The purpose of this study was to report early complications for anatomic total shoulder arthroplasty (aTSA) performed for instability arthropathy after a prior coracoid transfer procedure and compare them with those of a control group of patients following aTSA for primary osteoarthritis. A retrospective review was performed of 14 patients after aTSA with a prior coracoid transfer procedure. A control group of 42 patients with an aTSA for primary osteoarthritis were matched 3:1 according to age, sex, body mass index, comorbidities, and dominant shoulder. Chart reviews identified any complications within 1 year, in addition to blood loss and operative time in both groups. Preoperative computed tomography scans were used to determine Walch glenoid classification and Goutallier classification of the subscapularis. The mean operative time was not significantly different between the coracoid transfer cohort and the control group, and the mean estimated blood loss was only 6.9 mL greater in the coracoid transfer group. The coracoid transfer group had 2 (14.3%) patients with complications, with 1 early revision for an acute deep infection. The control group had 4 (9.5%) complications in 3 (7.1%) patients, with no early revisions. There was no statistical difference in complications between the groups (P=.618). Anatomic TSA for instability arthropathy after coracoid transfer had similar operative time, blood loss, and 1-year complication rates as those of the control group. These results provide some evidence to support the continued use of aTSA in select patients with instability arthropathy after prior coracoid transfer procedure. [Orthopedics. 2021;44(4):e482-e486.].

Shaver Suction Technique for Troubleshooting in Arthroscopic Double Foreign Body Removal From the Hip Joint

Most arthroscopic techniques provide easy invasive access and subsequent inspection of the lateral segments of the hip joint. However, it is a challenge to visualize medial segments of the hip joint using arthroscopic techniques. Hip arthroscopy offers minimally invasive access to the hip joint as compared to the standard open arthrotomy procedure. Yet, visualization of both the femoral head and acetabulum is difficult. The use of arthroscopic techniques in the diagnosis and treatment of hip-related disorders is still evolving, including great benefits for the postoperative healing and complications. The author describes a case of removing two loose bodies stuck in the superior basicervical rim of the femoral head of a 53-year-old man. The use of the inferomedial arthroscopic technique proved advantageous in preventing the shortcomings associated with standard arthrotomy and other arthroscopic mechanisms. Such shortcomings include the need for traction, alternate portals, and damage to the acetabular labrum and articular cartilage. Through this case report, the author establishes the effective use of hip arthroscopy in the removal of two loose bodies from the hip joint.

A new study of hindfoot endoscopy: Foreign body excision from the hindfoot

Residual foreign bodies are usually observed inside the body after foreign body penetration injuries. However, foreign bodies inside or near the joints are rarely encountered. In the case study included in this report, the case of a foreign body in the posterior ankle region of a 10-year-old child is presented, along with a new study highlighting the technique of its excision with hindfoot endoscopy. The visualization and capture of a foreign body within this region, and its relation to endoscopic excision, has been reported as being a support for hindfoot endoscopy. The aim of this article is to highlight the need for the provision of a low threshold arthroscopic hindfoot surgery in children who display the appropriate symptoms. The purpose of this surgery is to efficiently remove intra-articular hindfoot loose bodies and to gain functionally improved results, when compared with open techniques.

Thenar Compartment Syndrome: What If a Compartment Pressure Measuring Device is Absent?

Compartment syndrome (CS) is a threatening condition characterized by excessive tissue pressure accumulation associated with acute trauma. Compartment syndrome causes a significant reduction in blood flow with subsequent muscle and nerve ischemic necrosis. Recently, reports have described the importance of intramuscular pressure measurements as a basis for CS diagnosis. Unfortunately, the measuring devices that were utilized produced results with unsatisfactory reliability, making a diagnosis and subsequent treatment challenging. Here, we report the use of an anesthesia pressure monitoring device with greater precision for pressure measurements, as well as real-time monitoring of intraoperative compartment pressure decompression efficacy. This device enabled the accurate diagnosis and rapid treatment of a thenar compartment syndrome (TCS) in the left hand of a diabetic female in an emergency setting. She presented extreme pain in the thumb flexion-extension (FE). Her condition was complicated by diabetic cellulitis, primarily of Staphylococcus aureus. Consequently, successful microsurgery in the thenar space, together with debridement, resulted in remarkable pain relief during FE of the thumb metacarpophalangeal (MCP) and interphalangeal (IP) joints, as well as the disappearance of the infection by Day 10. Subsequent one- to two-year follow-up assessments revealed marked recovery.

Management of a Multi-Level Forearm Microsurgical Reconstruction and the Following Transfusion-Related Acute Lung Injury

Transfusion-related acute lung injury (TRALI) is a clinical syndrome characterized by acute respiratory distress following blood transfusion. This case-based technical report documents a case on the management of a multi-level forearm microsurgical reconstruction and the following TRALI syndrome that developed shortly after blood transfusion in a 29-year-old male. Multilevel microsurgical revascularization was performed via saphenous vein autograft arterial reconstruction from the proximal 1/3 ulnar artery to the ulnar side of the deep superficial palmar arterial arch. TRALI was resolved with intensive care unit monitoring and treatment. There are several reports of TRALI in literature, as well as proposed mechanisms of pathogenesis, however, no case on the management of a multilevel forearm arterial reconstruction via a long saphenous vein autograft and associated TRALI syndrome have been reported.