Arthur J. Kievit

A Cross-Sectional Study Comparing the Rates of Osteoarthritis, Laxity, and Quality of Life in Primary and Revision Anterior Cruciate Ligament Reconstructions

PURPOSE The purpose of this study was to assess the degree of osteoarthritis, degree of laxity, and quality-of-life (QOL) scores in primary and revision anterior cruciate ligament (ACL) reconstruction. METHODS This was a cross-sectional study; 25 patients who had undergone revision ACL reconstruction with allografts were identified and compared with 27 randomly selected primary ACL reconstruction patients operated on in the same hospital in the same period with the same technique. The main outcome measure was the International Knee Documentation Committee (IKDC) radiographic osteoarthritis sum score, and secondary outcome measures were Knee injury and Osteoarthritis Outcome Score, IKDC functional outcome measures, anterior laxity, and QOL at follow-up. RESULTS The median follow-up was 5.3 years for revision reconstruction patients and 5.1 years for primary reconstruction patients. Radiographic IKDC sum scores for osteoarthritis were found to be significantly worse in revision patients, with a median of 4, compared with primary patients, with a median of 1 (P = .016). Differences were found in meniscal injury (P = .02) and cartilage status (P < .001) before or at the index operation. Significantly worse outcomes were found in the following subscores of the Knee injury and Osteoarthritis Outcome Score: pain (median, 92 v 97; P = .032), symptom (median, 86 v 96; P = .015), activities of daily living (median, 94 v 100; P = .020), sport (median, 50 v 85; P = .006), and QOL (median, 56 v 81; P = .001). IKDC functional outcome measures were the same in both groups except for the pivot-shift test (P = .007). No differences were found in anterior drawer, Lachman, or KT-1000 arthrometer (MEDmetric, San Diego, CA) testing. Present-day health scores on the EQ-5D were worse for revision reconstruction patients (median, 70 v 80; P = .009). CONCLUSIONS Revision reconstruction patients have more signs of osteoarthritis and worse QOL than primary reconstruction patients, even though they have comparable IKDC success rates and KT-1000 arthrometer laxity test results. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Early Experience With the Vanguard Complete Total Knee System: 2–7 Years of Follow-Up and Risk Factors for Revision

A cross-sectional study in two hospitals was performed on 807 patients with a primary Vanguard (Biomet) total knee Arthroplasty (TKA). The research questions addressed were (1) what are the two- and six year survival rates of the Vanguard, (2) what are the clinical outcome scores, (3) what are the findings at revision and (4) what are predictors for revision? The mean age at time of surgery was 67.0 (SD 10.0). The mean follow-up was 3.6 years (95% CI 3.56-3.73). At two years the survival was 97.2% for all-reasons (767 patients remaining) and 99%, for prosthesis-related-reasons (777 remaining). At six years this was 96.5% (40 remaining) and 98.6% (41 remaining). The mean clinical results (84% response on KOOS, Oxford and NRS) were good. A previous osteotomy was a risk factor for revision (hazard ratio 5.1, P=0.001). This early experience with the Vanguard shows a good survival with no adverse outcomes related to the implant and therefore further use of the implant is justified.

Occupational Exposure to Knee Loading and the Risk of Osteoarthritis of the Knee: A Systematic Review and a Dose-Response Meta-Analysis

Background Osteoarthritis of the knee is considered to be related to knee straining activities at work. The objective of this review is to assess the exposure dose-response relation between kneeling or squatting, lifting, and climbing stairs at work, and knee osteoarthritis. Methods We included cohort and case–control studies. For each study that reported enough data, we calculated the odds ratio (OR) per 5,000 hours of cumulative kneeling and per 100,000 kg of cumulative lifting. We pooled these incremental ORs in a random effects meta-analysis. Results We included 15 studies (2 cohort and 13 case–control studies) of which nine assessed risks in more than two exposure categories. We considered all but one study at high risk of bias. The incremental OR per 5,000 hours of kneeling was 1.26 (95% confidence interval 1.17–1.35, 5 studies, moderate quality evidence) for a log-linear exposure dose-response model. For lifting, there was no exposure dose-response per 100,000 kg of lifetime lifting (OR 1.00, 95% confidence interval 1.00–1.01). For climbing, an exposure dose-response could not be calculated. Conclusion There is moderate quality evidence that longer cumulative exposure to kneeling or squatting at work leads to a higher risk of osteoarthritis of the knee. For other exposure, there was no exposure dose-response or there were insufficient data to establish this. More reliable exposure measurements would increase the quality of the evidence.

Evaluation of a CT-based technique to measure the transfer accuracy of a virtually planned osteotomy

Accurate transfer of a preoperatively planned osteotomy plane to the bone is of significance for corrective surgery, tumor resection, implant positioning and evaluation of new osteotomy techniques. Methods for comparing a preoperatively planned osteotomy plane with a surgical cut exist but the accuracy of these techniques are either limited or unknown. This paper proposes and evaluates a CT-based technique that enables comparing virtual with actual osteotomy planes. The methodological accuracy and reproducibility of the technique is evaluated using CT-derived volume data of a cadaver limb, which serves to plan TKA osteotomies in 3-D space and to simulate perfect osteotomies not hampered by surgical errors. The methodological variability of the technique is further investigated with repeated CT scans after actual osteotomy surgery of the same cadaver specimen. Plane displacement (derr) and angulation errors in the sagittal and coronal plane (βerr, γerr) are measured with high accuracy and reproducibility (derr=-0.11±0.06mm; βerr=0.08±0.04°, γerr=-0.03±0.03°). The proposed method for evaluating an osteotomy plane position and orientation has a high intrinsic accuracy and reproducibility. The method can be of great value for measuring the transfer accuracy of new techniques for positioning and orienting a surgical cut in 3-D space.

Weer aan het werk na een totale knieprothese

SamenvattingDe knieprothese is een succesvolle operatie voor vermindering van pijn bij artrose van de knie. Voor weer kunnen werken, lijken de resultaten minder gunstig.

Knee joint replacement and individual susceptibility for progression of knee osteoarthritis and tibial cartilage volume loss: not only genes run in the family

The studyof interactions between genetic and non-genetic factors can be quite complex. Also the identification of risk factors for the worsening of knee osteoarthritis (OA) is difficult but knowing these risk factors is essential for the selection of effective individual, community level and workplace interventions for this rapidly growing disabling disease1. Khan et al. used in their longitudinal study with an impressive follow-up period of 10 years an innovative proxy for the genetic factor namely adults (offspring) of parents of whom at least one was operated for knee replacement due to severe primary knee OA2. All participating adults were of working age at baseline: mean 45 years, standard deviation 7. The radiographic changes and cartilage loss in the knee in the offspring group (n 1⁄4 115) were comparedwith105 sex and agematchedhealthypopulation controls. In the analysis, Body Mass Index (BMI), knee pain, cartilage defects, tibial bone area and leg strength were taken into account. Khan et al. concluded that this is the first study to confirm that offspring of thosewith a knee replacement for OA have a higher risk of worsening knee OA. This suggests that the genes responsible may express themselves later in life, possibly through interaction with factors such as BMI and muscle strength, as pointed out by reduction in estimates after adjustment for baseline differences2. We think that an important non-genetic factor should have been discussed in their interesting study, namely knee-demanding work. First of all, it has been established that persons with lower socio-economic position (SEP) have a substantial increased risk for knee joint replacement: in 2010 an estimated rate per 1,000 male person years of 8.32 (95% CI 7.97e8.68) vs 6.28 (95% CI 6.00e6.58)3. Moreover, the percentage patients in working age operated for knee replacement surgery perform more often physically demanding work compared to the distribution of physically demanding work among the general working population: an estimated ratio of about 5:3 in the Netherlands4. There is ample evidence that SEP is partly determined by intergenerational transmission and, thus, this also implies that their offspring has a lower SEP and are more exposed to established occupational risk factors for knee OA like lifting5,6. Adjusting for BMI as is done by Khan et al. seems not sufficient given for instance the finding of an multiplicative interaction between BMI and lifting6,7. Therefore, discussing possible confounding due to knee-demanding work and SEP might have shed more light on the complex interaction between genetic and non-genetic factors in their paper2.

Preoperative Planning for Osteochondral Defects

For operative treatment of talar osteochondral defects (OCD), several surgical treatment options are available [ 14 ]. Each surgical technique has its specifi c indication [ 11 ]. Debridement and bone marrow stimulation is the first treatment of choice in primary defects <15 mm in diameter. Large cystic lesions can be treated by retrograde drilling. Fixation is for large lesions, most often posttraumatic. Secondary treatment options are osteochondral autograft transfer (OATS), HemiCAP, and autologous chondrocyte implantation (ACI). In case of malalignment, a sliding calcaneal osteotomy can be indicated. For each treatment, a careful preoperative planning is needed.