Adil Ajuied

Anterior Cruciate Ligament Injury and Radiologic Progression of Knee Osteoarthritis A Systematic Review and Meta-analysis

Background: Knee osteoarthritis after anterior cruciate ligament (ACL) injury has previously been reported. However, there has been no meta-analysis reporting the development and progression of osteoarthritis. Purpose: We present the first meta-analysis reporting on the development and progression of osteoarthritis after ACL injury at a minimum mean follow-up of 10 years, using a single and widely accepted radiologic classification, the Kellgren & Lawrence classification. Study Design: Meta-analysis. Method: Articles were included for systematic review if they reported radiologic findings of ACL-injured knees and controls using the Kellgren & Lawrence classification at a minimum mean follow-up period of 10 years. Appropriate studies were then included for meta-analysis. Results: Nine studies were included for systematic review, of which 6 studies were further included for meta-analysis. One hundred twenty-one of 596 (20.3%) ACL-injured knees had moderate or severe radiologic changes (Kellgren & Lawrence grade III or IV) compared with 23 of 465 (4.9%) uninjured ACL-intact contralateral knees. After ACL injury, irrespective of whether the patients were treated operatively or nonoperatively, the relative risk (RR) of developing even minimal osteoarthritis was 3.89 (P < .00001), while the RR of developing moderate to severe osteoarthritis (grade III and IV) was 3.84 (P < .0004). Nonoperatively treated ACL-injured knees had significantly higher RR (RR, 4.98; P < .00001) of developing any grade of osteoarthritis compared with those treated with reconstructive surgery (RR, 3.62; P < .00001). Investigation of progression to moderate or severe osteoarthritis (grade III or IV only) after 10 years showed that ACL-reconstructed knees had a significantly higher RR (RR, 4.71; P < .00001) compared with nonoperative management (RR, 2.41; P = .54). It was not possible to stratify for return to sports among the patients undergoing ACL reconstruction. Conclusion: Results support the proposition that ACL injury predisposes knees to osteoarthritis, while ACL reconstruction surgery has a role in reducing the risk of developing degenerative changes at 10 years. However, returning to sports activities after ligament reconstruction may exacerbate the development of arthritis.

Systematic review of total hip arthroplasty in patients under 30 years old

We performed a systematic review to assess whether joint replacement in this very young patient group provides significant functional improvement and whether these procedures are associated with good implant survivorship. The studies included presented the results of 450 THA procedures. All patients showed an improvement in functional score and symptom relief. Unce-mented stems showed good integration with no signs of loosening. Cemented implants showed high rates of loosening. This study shows that THA in the very young patient can provide good functional improvement and relief of symptoms and that the more modern uncemented implant designs used with hard-on-hard bearings can be associated with improved implant survival. Long-term studies are necessary to confirm the superiority and improved survivorship of these newer implants.

The Use of the Ligament Augmentation and Reconstruction System (LARS) for Posterior Cruciate Reconstruction

PURPOSE To systematically review and assess the use of the Ligament Advanced Reinforcement System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France) for posterior cruciate ligament (PCL) reconstruction. METHODS A search of multiple databases was conducted using the following terms: (LARS[All Fields] AND posterior[All Fields]) OR (LARS[All Fields] AND PCL[All Fields]). The methodologic quality of each article was assessed by use of abridged Downs and Black criteria. RESULTS Fifty-four studies were found from the database search, of which 5 were included in the final review (4 case series and 1 case-control study). One hundred twenty-nine PCL reconstructions with LARS were performed. The mean patient age was 32.2 years, with 89 male and 40 female patients included. The mean follow-up time ranged from 10.5 to 44 months. Lysholm scores improved from a mean of 64.8 preoperatively to 89.8 postoperatively. No patients had International Knee Documentation Committee grade 1 or 2 preoperatively, with 93.0% achieving this postoperatively. Only 1 case of synovitis and 1 case of graft rupture were reported. CONCLUSIONS There is little evidence on the effectiveness of PCL reconstructions using LARS ligaments. What data there are show great promise, with short- and medium-term outcome data appearing favorable to autograft reconstruction. Complication rates are encouragingly low. CLINICAL RELEVANCE LARS has great potential for PCL reconstruction. Further studies are needed regarding the use of LARS ligaments during PCL reconstruction, including longer follow-up periods and investigation into the optimal timing for reconstruction. This may be best achieved by way of a multicenter study.

Diagnostic Efficacy of 3-T MRI for Knee Injuries Using Arthroscopy as a Reference Standard: A Meta-Analysis

OBJECTIVE The objectives of our study were to assess the evidence for the diagnostic efficacy of 3-T MRI for meniscal and anterior cruciate ligament (ACL) injuries in the knee using arthroscopy as the reference standard and to compare these results with the results of a previous meta-analysis assessing 1.5-T MRI. MATERIALS AND METHODS The online Cochrane Library, MEDLINE, and PubMed databases were searched using the following terms: MRI AND ((3 OR three) AND (Tesla OR T)) AND knee AND arthroscopy AND (menisc* OR ligament). Patient demographics, patient characteristics, MRI scanning details, and diagnostic results were investigated. The methodologic quality of the included studies was assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. A meta-analysis of studies using 3-T MRI was performed, and the results were compared with a previous meta-analysis of studies using 1.5-T MRI. RESULTS One hundred one studies were identified by the search strategy, and 13 studies were included in our review. Twelve studies were considered to have level 1b evidence, and one study was considered to have level 2b evidence. All 13 studies had high methodologic integrity and low risk of bias using the QUADAS-2 tool. The studies included 1197 patients with a mean age of 41.9 years. Ten of the 13 studies were eligible for meta-analysis. The mean sensitivity and mean specificity of 3-T MRI for knee injuries by location were as follows: medial meniscus, 0.94 (95% CI, 0.91-0.96) and 0.79 (95% CI, 0.75-0.83), respectively; lateral meniscus, 0.81 (95% CI, 0.75-0.85) and 0.87 (95% CI, 0.84-0.89); and ACL, 0.92 (95% CI, 0.83-0.96) and 0.99 (95% CI, 0.96-1.00). The specificity of 3-T MRI for injuries of the lateral meniscus was significantly lower than that of 1.5-T MRI (p = 0.0013). CONCLUSION This study does not provide evidence that 3-T scanners have superior diagnostic efficacy for meniscal damage and ACL integrity when compared with previous studies of 1.5-T machines.

Functional outcomes of total hip arthroplasty in patients aged 30 years or less: a systematic review and meta-analysis

Introduction Young adult hip surgery is a growing subspecialty. Increasingly total hip arthroplasty (THA) is offered to patients aged 30 or less suffering from end-stage hip arthropathy from a variety of congenital, developmental and acquired conditions. There is a paucity of evidence to advise such patients and surgeons alike on the functional outcomes of THA in this age group, as individual studies tend to include small cohorts. Methods A systematic review and meta-analysis was performed to assess whether THA in patients aged 30 years or less provides significant functional improvement. The primary outcome measure was change in Harris Hip Score. Secondary outcome measures were implant survivorship and the effect of fixation type and bearing surface. Results The results of 743 primary THA procedures were included. Weighted mean patient age was 22.7 years. Harris Hip Score improved by a weighted mean difference of 42.17 points out of 100 (95% confidence interval, 36.48-47.86 points, p<0.001) after THA at a weighted mean follow-up of 8.4 years. Pooled revision rate was 5.0% for the same time period. Conclusions This is the largest review to date of THA in patients aged 30 or less. The results show significant functional improvement measured by Harris Hip Score. The revision rate of 5% at 8.4 years is comparable to the general THA population. This contrasts high revision rates reported in older reviews of the literature, suggesting adoption of improved techniques and implants in the more recent literature.

Publication Trends in Knee Surgery: A Review of the Last 16 Years

The trends in the publication of articles regarding knee arthroplasty and soft tissue surgery were analysed with regard to geographical authorship, institutional funding and number of authors. Over 7500 articles from relevant journals with the highest impact factors according to the Thomson Reuters Journal Citation Report (2010) were evaluated from 1995 to 2010. The rate of publication increased by 16.9 per year for arthroplasty articles and by 13.9 per year for soft tissue surgery articles. The relative supremacy of the USA has declined over the 16 years, its share dropping from 72.2% to 39.2% for arthroplasty articles and from 61.7% to 36.6% for soft tissue surgery articles. The UK, Japan, South Korea and smaller countries in Asia and South America have become increasingly prolific.

A Survey of Rehabilitation Regimens Following Isolated ACL Reconstruction

Anterior Cruciate Ligament (ACL) reconstruction is a well established and widely practiced surgical procedure. Wide variation in surgical techniques and postoperative rehabilitation may predispose to early graft failure or sub-optimal functional outcomes. Surgical technique has been investigated extensively. There is little data as to the effect of rehabilitation regimens. This article assesses the current rehabilitation practices after ACL reconstruction within London, UK. Materials and Method: A survey of all NHS (National Health Service) physiotherapy departments that provide rehabilitation for patients undergoing isolated ACL reconstruction in the Greater London area. Results: 38 physiotherapy departments participated in our study. Of these, only 31 (81.6%) had written rehabilitation guidelines. A majority of departments, 31 (81.6%), adopted immediate postoperative full weight bearing. Day surgery ACL reconstruction was performed routinely at 27 (71.0%) units. Braces were used in only 12 (31.6%) departments. Rehabilitation milestones (e.g. return to sports) varied significantly across the study group. Discussion: This survey demonstrates a significant variation in rehabilitation regimens following ACL reconstruction. Current trends are towards day case surgery, immediate weight bearing, and reduced use of bracing. National ligament registries allow for multivariate analysis to identify variables associated with graft failure and sub optimal outcomes. Presently no registries collect data on rehabilitation regimens.

Diagnosis of glenoid labral tears using 3-tesla MRI vs. 3-tesla MRA: a systematic review and meta-analysis

BackgroundVarious protocols exist for magnetic resonance arthrogram (MRA) of the shoulder, including 3D isotropic scanning and positioning in neutral (2D neutral MRA), or abduction-external-rotation (ABER).HypothesisMRA does not improve diagnostic accuracy for labral tears when compared to magnetic resonance imaging (MRI) performed using 3-Tesla (3T) magnets.MethodSystematic review of the Cochrane, MEDLINE, and PubMed databases according to PRISMA guidelines. Included studies compared 3T MRI or 3T MRA (index tests) to arthroscopic findings (reference test). Methodological appraisal performed using QUADAS-2. Pooled sensitivity and specificity were calculated.ResultsTen studies including 929 patients were included. Index test bias and applicability were a concern in the majority of studies. The use of arthroscopy as the reference test raised concern of verification bias in all studies. For anterior labral lesions, 3T MRI was less sensitive (0.83 vs. 0.87 p = 0.083) than 3T 2D neutral MRA. Compared to 3T 2D neutral MRA, both 3T 3D Isotropic MRA and 3T ABER MRA significantly improved sensitivity (0.87 vs. 0.95 vs. 0.94). For SLAP lesions, 3T 2D neutral MRA was of similar sensitivity to 3T MRI (0.84 vs. 0.83, p = 0.575), but less specific (0.99 vs. 0.92 p < 0.0001). For posterior labral lesions, 3T 2D neutral MRA had greater sensitivity than 3T 3D Isotropic MRA and 3T MRI (0.90 vs. 0.83 vs. 0.83).ConclusionsAt 3-T, MRA improved sensitivity for diagnosis of anterior and posterior labral lesions, but reduced specificity in diagnosis of SLAP tears. 3T MRA with ABER positioning further improved sensitivity in diagnosis of anterior labral tears.Level of evidenceIV.

Non-resurfacing techniques in the management of the patella at total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND Recent meta-analyses support not resurfacing the patella at the time of TKA. Several different modes of intervention are reported for non-resurfacing management of the patella at TKA. METHODS We have conducted a systematic review and meta-analysis of non-resurfacing interventions in TKA. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study methodology and reporting system was adopted, utilising the PRISMA checklist and statement. Classes of patella interventions were defined as: 0. No intervention. 1. Osteophyte excision only. 2. Osteophyte excision, denervation, with soft tissue debridement. 3. Osteophyte excision, denervation, soft tissue debridement, and drilling or micro-fracture of eburnated bone. 4. Patellar resurfacing. A meta-analysis was conducted upon the pre- and post-operative KSS for each technique. RESULTS Four hundred and twenty-three studies were identified, 12 studies met the inclusion criteria for the systematic review and eight for the meta-analysis. Two studies compared different non-resurfacing patellar techniques, the other studies used the non-resurfacing cohort as controls for their prospective RCTs comparing patellar resurfacing with non-resurfacing. The meta-analysis revealed no significant difference between the techniques. CONCLUSIONS We conclude that there is no significant difference in KSS for differing non-resurfacing patellar techniques, but further trials using patellofemoral specific scores may better demonstrate superior efficacy of specific classes of patella intervention, by virtue of greater sensitivity for patellofemoral pain and dysfunction. LEVEL OF EVIDENCE I.

Saw Cut Accuracy in Knee ArthroplastyâAn Experimental Case-ControlStudy

Introduction: Navigated TKA (Total Knee Arthroplasty) has heightened awareness of mal-alignment in conventional TKA, as well as providing an accurate means of measuring alignment intra-operatively. Debate as to the importance and significance of alignment versus knee balance continues. Aim: To assess cutting error, and examine the hypothesises: • ‘Slotted osteotomies are more accurate than non-slotted’ • ‘Second pass of the saw blade improves the accuracy of osteotomies’ Method: Three pairs of fresh frozen human knees were prepared, exposed, and positioned as for primary TKA. Standard cutting guides were used in conjunction with a clinical navigation system, and the error (difference between the achieved resection, and the planned resection) in each osteotomy was measured. A second, tidying, pass of the saw blade was made and the error re-measured. Cutting guides were used with a slotted and un-slotted technique in left and right knees respectively. A single experienced surgeon performed all 96 osteotomies. Results: Slotted tibial osteotomies are significantly more accurate in the sagittal (p=0.01) and coronal (p=0.04) planes. Second pass osteotomies reduce variability in femoral (p=0.07) and tibial (p=0.17) osteotomies. Discussion: The bone cutting process is prone to high levels of random error that can result in implant malalignment, and thus predispose to aseptic loosening. Navigated TKA gives the operating surgeon the opportunity to check each osteotomy, and correct any error where necessary. In conventional TKA the use of dual pass, slotted osteotomies should provide improved accuracy.