Antti Joukainen

Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

BACKGROUND Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking. METHODS We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure. RESULTS In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, -1.6 points; 95% confidence interval [CI], -7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, -2.5 points; 95% CI, -9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, -0.1; 95% CI, -0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively). CONCLUSIONS In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.).

Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.

BACKGROUND The minimal clinically important difference (MCID) is increasingly used to evaluate treatment effectiveness. The MCID for the Constant score has not been previously reported. MATERIALS AND METHODS A prospectively collected cohort of 802 consecutive shoulders with arthroscopically treated partial- or full-thickness rotator cuff tears was analyzed. The Constant score was measured preoperatively and at 3 months and 1 year postoperatively. At follow-up visits, the patients were asked a simple 2-stage question: Is the shoulder better or worse after the operation compared with the preoperative state? This single 2-level question was used as an indicator of patient satisfaction and as an anchor to calculate the MCID for the Constant score. RESULTS At 1 year, 781 (97.4%) patients (474 men, 307 women) were available for follow-up. The preoperative Constant score was 53.1 (SD 17.2) in all patients, 56.2 (SD 17.4) in male patients, and 48.2 (SD 15.6) in female patients. Postoperatively at 3 months, the scores were 61.7 (SD 16.4) in all patients, 65.1 (SD 16.1) in male patients, and 56.8 (SD 15.5) in female patients. At 1 year, the scores were 75.9 (SD 15.2) in all patients, 79.0 (SD 14.9) in male patients, and 71.0 (SD 14.3) in female patients. At 3 months postoperatively, 92.2% of male patients and 87.2% of female patients were satisfied with the outcome (P = .027); at 1 year, the satisfaction was 93.2% and 89.5%, respectively (P = .067). Five different statistical approaches yielded 5 different MCID estimates (range, 2-16). The 3-month mean change estimate of MCID was 10.4 points. CONCLUSION Our study demonstrates an MCID estimate of 10.4 points as the threshold for the Constant score in patients with rotator cuff tear. LEVEL OF EVIDENCE Basic science study, validation of outcomes instruments/classification systems.

Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up.

BACKGROUND The optimal treatment for symptomatic, nontraumatic rotator cuff tear is unknown. The purpose of this trial was to compare the effectiveness of physiotherapy, acromioplasty, and rotator cuff repair for this condition. We hypothesized that rotator cuff repair yields superior results compared with other treatment modalities. METHODS One hundred and eighty shoulders with symptomatic, nontraumatic, supraspinatus tears were randomized into one of three cumulatively designed intervention groups: the physiotherapy-only group (denoted as Group 1), the acromioplasty and physiotherapy group (denoted as Group 2), and the rotator cuff repair, acromioplasty, and physiotherapy group (denoted as Group 3). The Constant score was the primary outcome measure. Secondary outcome measures were visual analog scale for pain, patient satisfaction, rotator cuff integrity in a control imaging investigation, and cost of treatment. RESULTS One hundred and sixty-seven shoulders (160 patients) were available for analysis at two years. There were no significant differences (p = 0.38) in the mean change of Constant score: 18.4 points (95% confidence interval, 14.2 to 22.6 points) in Group 1, 20.5 points (95% confidence interval, 16.4 to 24.6 points) in Group 2, and 22.6 points (95% confidence interval, 18.4 to 26.8 points) in Group 3. There were no significant differences in visual analog scale for pain scores (p = 0.45) and patient satisfaction (p = 0.28) between the groups. At two years, the mean sagittal size of the tendon tear was significantly smaller (p < 0.01) in Group 3 (4.2 mm) compared with Groups 1 and 2 (11.0 mm). Rotator cuff repair and acromioplasty were significantly more expensive than physiotherapy only (p < 0.01). CONCLUSIONS There was no significant difference in clinical outcome between the three interventions at the two-year follow-up. The potential progression of the rotator cuff tear, especially in the non-repaired treatment groups, warrants further follow-up. On the basis of our findings, conservative treatment is a reasonable option for the primary initial treatment for isolated, symptomatic, nontraumatic, supraspinatus tears in older patients. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

In vivo diagnostics of human knee cartilage lesions using delayed CBCT arthrography

The aim of this study was to investigate the feasibility of delayed cone beam (CBCT) arthrography for clinical diagnostics of knee cartilage lesions. Knee joints with cartilage lesions were imaged using native radiography, MRI, and delayed CBCT arthrography techniques in vivo. The joints were imaged three times with CBCT, just before, immediately after (arthrography) and 45 min after the intra‐articular injection of contrast agent. The arthrographic images enabled sensitive detection of the cartilage lesions. Use of arthrographic and delayed images together with their subtraction image enabled also detection of cartilage with inferior integrity. The contrast agent partition in intact cartilage (ICRS grade 0) was lower (p < 0.05) than that of cartilage surrounding the ICRS grade I–IV lesions. Delayed CBCT arthrography provides a novel method for diagnostics of cartilage lesions. Potentially, it can also be used in diagnostics of cartilage degeneration. Due to shorter imaging times, higher resolution, and lower costs of CT over MRI, this technique could provide an alternative for diagnostics of knee pathologies. However, for comprehensive evaluation of the clinical potential of the technique a further clinical study with a large pool of patients having a wide range of cartilage pathologies needs to be conducted.

Strength retention of self-reinforced drawn poly-L/DL-lactide 70/30 (SR-PLA70) rods and fixation properties of distal femoral osteotomies with these rods. An experimental study on rats

Self-reinforced polylevo-dextro-lactic acid(SR-PLA)70 composite rods,(2 mm×26 mm) were implanted in the dorsal subcutaneus tissue of sixteen rats. Osteotomies of the distal femur were fixed with SR-PLA70 composite rods (2 mm × 15 mm) in 39 rats. The follow-up times varied from 1 week to 1 year. After sacrifice three-point bending and shear tests were performed for subcutaneously placed rods, and radiological, histological, histomorphometrical, microradiographic, and oxytetracycline-fluorescence studies of osteotomized and intact control femora were performed. At 52 weeks the shear strength and flexural modulus of the rods were 41% of the initial value, and the flexural strength was 43% of the initial value. In the osteotomies seven specimens had to be excluded due to postoperative infection or dislocation of the fragment. Six of the thirty-two evaluated osteotomies showed signs of postoperative infection. Twenty-six osteotomies healed uneventfully. No signs of inflammatory or foreign-body reaction were observed. The present investigation demonstrated that the mechanical strength and fixation properties of the SR-PLA70 rods are suitable for fixation of cancellous bone osteotomies in rats. The present article is the first report on successful application of SR-PLA70 rods for fixation of cancellous bone osteotomies studied.

Arthroscopic Ultrasound Technique for Simultaneous Quantitative Assessment of Articular Cartilage and Subchondral Bone: An In Vitro and In Vivo Feasibility Study

Traditional arthroscopic examination is subjective and poorly reproducible. Recently, we introduced an arthroscopic ultrasound method for quantitative diagnostics of cartilage lesions. Here we describe our investigation of the feasibility of ultrasound arthroscopy for simultaneous measurements of articular cartilage and subchondral bone. Human osteochondral samples (n = 13) were imaged using a clinical 9-MHz ultrasound system. Ultrasound reflection coefficients (R, IRC), the ultrasound roughness index (URI) and the apparent integrated backscattering coefficient (AIB) were determined for both tissues. Mechanical testing, histologic analyses and micro-scale computed tomography imaging were the reference methods. Ultrasound arthroscopies were conducted on two patients. The ultrasound reflection coefficient correlated with the Mankin score and Youngs modulus of cartilage (|r| > 0.56, p < 0.05). Ultrasound parameters (R, IRC, AIB) for subchondral bone correlated with the bone surface/volume ratio (|r| > 0.70, p < 0.05) and trabecular thickness (|r| > 0.59, p < 0.05). Furthermore, R and subchondral bone mineral density were significantly correlated (|r| > 0.65, p < 0.05). Arthroscopic ultrasound examination provided diagnostically valuable information on cartilage and subchondral bone in vivo.

Results of Operative and Nonoperative Treatment of Rockwood Types III and V Acromioclavicular Joint Dislocation A Prospective, Randomized Trial With an 18- to 20-Year Follow-up

Background: The optimal treatment of acute, complete dislocation of the acromioclavicular joint (ACJ) is still unresolved. Purpose: To determine the difference between operative and nonoperative treatment in acute Rockwood types III and V ACJ dislocation. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: In the operative treatment group, the ACJ was reduced and fixed with 2 transarticular Kirschner wires and ACJ ligament suturing. The Kirschner wires were extracted after 6 weeks. Nonoperatively treated patients received a reduction splint for 4 weeks. At the 18- to 20-year follow-up, the Constant, University of California at Los Angeles Shoulder Rating Scale (UCLA), Larsen, and Simple Shoulder Test (SST) scores were obtained, and clinical and radiographic examinations of both shoulders were performed. Results: Twenty-five of 35 potential patients were examined at the 18- to 20-year follow-up. There were 11 patients with Rockwood type III and 14 with type V dislocations. Delayed surgical treatment for ACJ was used in 2 patients during follow-up: 1 in the operatively treated group and 1 in the nonoperatively treated group. Clinically, ACJs were statistically significantly less prominent or unstable in the operative group than in the nonoperative group (normal/prominent/unstable: 9/4/3 and 0/6/3, respectively; P = .02) and in the operative type III (P = .03) but not type V dislocation groups. In operatively and nonoperatively treated patients, the mean Constant scores were 83 and 85, UCLA scores 25 and 27, Larsen scores 11 and 11, and SST scores 11 and 12 at follow-up, respectively. There were no statistically significant differences in type III and type V dislocations. In the radiographic analysis, the ACJ was wider in the nonoperative than the operative group (8.3 vs 3.4 mm; P = .004), and in the type V dislocations (nonoperative vs operative: 8.5 vs 2.4 mm; P = .007). There was no statistically significant difference between study groups in the elevation of the lateral end of the clavicle. Both groups showed equal levels of radiologic signs of ACJ osteoarthritis and calcification of the coracoclavicular ligaments. Conclusion: Nonoperative treatment was shown to produce more prominent or unstable and radiographically wider ACJs than was operative treatment, but clinical results were equally good in the study groups at 18- to 20-year follow-up. Both treatment methods showed statistically significant radiographic elevations of the lateral clavicle when compared with a noninjured ACJ.

Ultrasound arthroscopy of human knee cartilage and subchondral bone in vivo.

Arthroscopic ultrasound imaging enables quantitative evaluation of articular cartilage. However, the potential of this technique for evaluation of subchondral bone has not been investigated in vivo. In this study, we address this issue in clinical arthroscopy of the human knee (n = 11) by determining quantitative ultrasound (9 MHz) reflection and backscattering parameters for cartilage and subchondral bone. Furthermore, in each knee, seven anatomical sites were graded using the International Cartilage Repair Society (ICRS) system based on (i) conventional arthroscopy and (ii) ultrasound images acquired in arthroscopy with a miniature transducer. Ultrasound enabled visualization of articular cartilage and subchondral bone. ICRS grades based on ultrasound images were higher (p < 0.05) than those based on conventional arthroscopy. The higher ultrasound-based ICRS grades were expected as ultrasound reveals additional information on, for example, the relative depth of the lesion. In line with previous literature, ultrasound reflection and scattering in cartilage varied significantly (p < 0.05) along the ICRS scale. However, no significant correlation between ultrasound parameters and structure or density of subchondral bone could be demonstrated. To conclude, arthroscopic ultrasound imaging had a significant effect on clinical grading of cartilage, and it was found to provide quantitative information on cartilage. The lack of correlation between the ultrasound parameters and bone properties may be related to lesser bone change or excessive attenuation in overlying cartilage and insufficient power of the applied miniature transducer.

Preliminary Experience of a Single Session of Low-energy Extracorporeal Shock Wave Treatment for Chronic Plantar Fasciitis

Background: The purpose of the present study was to evaluate the effect of a single session of ultrasound- and biofeedback-assisted extracorporeal shock wave treatment (ESWT) in patients with chronic plantar fasciitis. Materials and Methods: 20 patients (22 heels) with symptomatic plantar fasciitis that did not respond to conservative treatment for at least 6 months were studied. Patients received a single session of low-energy, ultrasound- and patient feedback-guided ESWT. Visual analog scale (VAS) was used to compare pain intensity before treatment and at followup (72 ± 15 days after treatment). Results: There was a significant decrease in overall pain (VAS 5.5 ± 1.8 vs. 3.3 ± 2.7, p = 0.001), maximum pain (7.7 ± 2.1 vs. 4.0 ± 3.9, p = 0.008) and pain at activities of daily living (5.3 ± 2.1 vs. 2.5 ± 2.6, p = 0.018). Night pain decreased to a lesser extent (2.4 ± 2.5 vs. 1.3 ± 2.1, p = 0.317). ESWT improved symptoms in 16 heels, of which six were completely symptom-free at followup 2.4 months after treatment. Six patients experienced no change. Fourteen patients with pain localized to the heel and all male patients benefited from ESWT. No difference was noted for age, body mass index, duration, and severity of symptoms or previous treatment. Conclusion: Low-energy ESWT proved to be an effective treatment option for the majority of patients with chronic plantar fasciitis that failed to respond to conservative treatment. Predictive parameters for successful outcome are male gender and an easily detectable pain center at the heel.

Optimal graft stiffness and pre-strain restore normal joint motion and cartilage responses in ACL reconstructed knee

Anterior cruciate ligament (ACL) rupture leads to abnormal loading of the knee joint and increases the risk of osteoarthritis. It is unclear how different ACL reconstruction techniques affect knee joint motion and mechanics. As the in vivo measurement of knee joint loading is not possible, we used finite element analysis to assess the outcome of ACL reconstruction techniques. Effects of different ACL reconstruction techniques on knee joint mechanics were studied using six models during gait; with 1) healthy ACL, 2) ACL rupture, 3) single bundle ACL reconstruction, 4) double bundle ACL reconstruction, 5) weakened (softer) single bundle reconstruction and 6) single bundle reconstruction with less pre-strain. Early in the gait, the ACL rupture caused substantially increased tibial translation in the anterior direction as well as a smaller but increased lateral translation and internal tibial rotation. ACL rupture substantially reduced average stresses and strains, while local peak stresses and strains could be either increased or decreased. Single bundle and double bundle reconstructions restored joint motion close to normal levels. However, cartilage strains and stresses were elevated during the entire gait cycle. Models with modulated graft stiffness and pre-strain restored the joint motion and cartilage stresses and strains close to the normal, healthy levels. Results suggest that rather than the choice of reconstruction technique, stiffness and pre-strain of the ACL reconstruction affect the motion and mechanics of the operated knee. We suggest that an optimal choice of graft properties might help restore normal knee joint function and cartilage responses, thus, minimizing the risk of osteoarthritis.