Geoffrey F. Dervin

Effect of arthroscopic débridement for osteoarthritis of the knee on health-related quality of life

Background: The available evidence supporting the use of arthroscopic debridement for the treatment of symptomatic osteoarthritis of the knee is largely retrospective and lacks validated health-related quality-of-life measures. The goal of the study was to prospectively assess a cohort of patients with osteoarthritis of the knee who were selected for arthroscopic debridement and determine which clinical criteria favor a sustained improvement in health-related quality of life after two years of follow-up. Methods: One hundred and twenty-six patients with symptomatic primary osteoarthritis of the knee underwent arthroscopic debridement of the knee after failure of medical management. Two groups of surgeons (postgraduate fellows and attending staff) independently evaluated the patients preoperatively with use of a standardized assessment of clinical symptoms and signs and plain radiography. The intervention was arthroscopic debridement, which included resection of unstable chondral flaps and meniscal tears. Abrasion was not performed. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a disease-specific scale, and the Short Form-36 (SF-36), a generic outcome measure. Results: Sixty-seven (53%) of the 126 patients were female, and the mean age (and standard deviation) was 61.7 ± 8.6 years (range, forty-three to seventy-five years). The medial compartment was more frequently and severely involved, with 57% showing Grade-III or IV involvement, according to the system of Dougados et al. Seventy-nine patients (63%) had an unstable meniscal tear. Fifty-six patients (44%) were rated as having had a clinically important reduction in pain, as determined with the WOMAC pain scale, at two years after the arthroscopic debridement. Physicians were poor at predicting which patients would have improvement. The rate of accuracy of the fellows and staff was 54% and 59%, respectively, and their agreement was only slightly better than chance, with a kappa of 0.27 (95% confidence interval, 0.09 to 0.45). Only three variables were significantly associated with improvement: the presence of medial joint-line tenderness (p = 0.04), a positive Steinman test (p = 0.01), and the presence of an unstable meniscal tear at arthroscopy (p = 0.01). Conclusions: The prospectively evaluated quality-of-life benefit from arthroscopic debridement of the osteoarthritic knee is less than that reported in previous retrospective surveys on satisfaction. These results may serve as a baseline for comparison against more sophisticated procedures for resurfacing of the articular cartilage. Clinical variables were only partially helpful for predicting a successful result after arthroscopic debridement, and a search for other biologic markers (such as synovial fluid) may be of benefit. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See p. 2 for complete description of levels of evidence.

Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution.

One thousand one hundred ninety patients underwent knee arthroplasty between January 2004 and July 1, 2007, and received an indwelling continuous infusion femoral catheter for postoperative ropivicaine pump infusion. Catheters were placed using electrical stimulation guidance. For the initial 469 patients (group 1), the continuous infusion ran for 2 to 3 days. In 721 patients, the infusion was discontinued 12 hours after surgery. There were 9 femoral nerve palsies (2 in group 1, 7 in group 2) and 8 major falls (0.7%). The overall complication rate was 1.5%, and the risk of permanent nerve injury was 0.2%. Patients should be made aware of these complications as part of the usual informed consent process before using this technique for postoperative pain control after knee arthroplasty. We did not observe fewer falls when the continuous infusion was stopped 12 hours after surgery.

Biodegradable Rods in Adult Osteochondritis Dissecans of the Knee

Symptomatic osteochondritis dissecans of the knee in skeletally mature patients does not follow a predictable natural history and there has been a trend toward internal fixation of the unstable fragment(s) where possible. Biodegradable implants are enticing for intraarticular use: implant removal is unnecessary and its degradation potentially allows a gradual shift of loading stress to the fracture site. Nine patients with a mean age of 18.6 years (range, 14-23 years) deemed skeletally mature by plain film radiography underwent internal fixation of fragments by 2-mm self reinforced polylactic rods. Six procedures were completed arthroscopically and three required arthrotomy. All fragments were of the medial femoral condyle. The procedure was tolerated well although three patients had early postoperative serosanguinous effusions develop that did not recur after one aspiration. At a mean followup of 33 months (range, 24-54 months), eight fragments radiographically were united whereas one remained ununited at 26 months, accounting for the one poor result in this series. Seven patients had good to excellent results according to Hughstons criteria and were satisfied with the procedure. One of these seven patients had a spontaneous effusion develop at 5 months that did not recur after aspiration and intraarticular steroid injection. Severe, unremitting synovitis did not occur in any patient. Internal fixation of osteochondritis dissecans of the knee with biodegradable polylactic rods provided satisfactory control of symptoms in the short term and resulted in radiographically stable lesions in eight of nine patients. These rods may be suited best for fragmented lesions with intact articular cartilage as an adjunct to drilling.

Initial experience with the oxford unicompartmental knee arthroplasty.

Our initial experience with mobile bearing medial compartment unicompartmental arthroplasty (UKA) is presented to highlight lessons that have been learned to avoid short-term failures. Consecutive cases of the Oxford medial UKA performed between February 2001 and April 2006 were reviewed to derive those cases that were revised to total knee arthroplasty (TKA). There were 545 patients available with mean age and body mass index of 65.0 and 30.1, respectively. At final follow-up, 32 patients were revised for lateral compartment arthritis, aseptic component loosening, persisting medial or anterior pain and dislocated meniscal bearing. Revisions were performed with primary unconstrained TKA implants with no stems or wedges required. Our results seem to reflect those seen in registries confirming an earlier higher revision rate and highlight the technical issues of overstuffing the compartment, inadequate cementation technique, and strict adherence to patient selection.

Self-reported disability following distal radius fractures: The influence of hand dominance

The purpose of this study was to record the spectrum of self-reported disability following distal radius fractures and to gauge for differences in hand dominance in the use of subjective outcome data. Items were generated through patient interviews, literature review, and peer consultation. Fifty-three items were evaluated by a group of 55 patients recovering from a fracture of the distal radius, which established the prevalence, mean severity score, and overall severity score (or impact) of each item as it related to physical function and social/emotional impact. Hand dominance, age, and gender were also recorded. The results confirm that many patients who sustain distal radius fractures experience substantial impairment across a spectrum of quality of life domains. Because patients who sustain a dominant wrist injury are likely to report greater functional impairment across a wider range of activities, they also possess a greater potential for improvement. The practical implication is that outcome studies for the treatment of distal radius fractures should take hand dominance into account.

A Randomized, Controlled Trial of Albumin versus Saline for the Treatment of Intradialytic Hypotension

Intradialytic hypotension (IDH) is the most common complication of hemodialysis. Symptomatic IDH requires the administration of fluid and often results in the early termination of dialysis, both of which may prevent adequate fluid removal. The optimal fluid for the treatment of IDH remains unknown. A randomized, double-blind, crossover trial was performed in 72 chronic hemodialysis patients to determine whether 5% albumin was more effective than normal saline for the treatment of IDH. The primary outcome measure was the percentage of target ultrafiltration achieved, which was defined as the actual ultrafiltration volume divided by target ultrafiltration volume. Secondary outcome measures included postdialysis BP, time to restore BP, recurrent IDH, and treatment failure (inability to restore BP with 750 ml of study fluid). The percentage of target ultrafiltration achieved was 0.84 +/- 0.17 for 5% albumin compared with 0.80 +/- 0.16 for saline (P = 0.14). The postdialysis systolic BP (121 +/- 19 mmHg versus 117 +/- 19 mmHg; P = 0.32), postdialysis diastolic BP (63 +/- 9 mmHg versus 61 +/- 9 mmHg; P = 0.33), volume of study fluid used to treat IDH (403 +/- 170 ml versus 428 +/- 191 ml; P = 0.34), time required to restore the BP (7.9 +/- 6.6 min versus 9.9 +/- 7.5 min; P = 0.09), total nursing time required to manage the hypotensive episode (15.1 +/- 7.2 min versus 15.9 +/- 7.3 min; P = 0.47), number of treatment failures (22% versus 24%; P = 1.0), and the frequency of recurrent IDH (36% versus 36%) were not significantly different when 5% albumin was used compared with saline. It is concluded that 5% albumin is no more effective than normal saline for the treatment of IDH in chronic hemodialysis patients. Normal saline should be used as the initial fluid for the treatment of IDH.

Unicompartmental Knee Arthroplasties Revised to Total Knee Arthroplasties Compared With Primary Total Knee Arthroplasties

We studied the technical operative features and the subjective outcomes of 63 patients requiring a revision to a total knee arthroplasty (TKA) for failed Oxford medial unicompartmental knee arthroplasty. We compared this revision study group to a contemporary control cohort of 126 patients who underwent primary TKAs. The 2 groups from the same institution had a minimum follow-up of 2 years and were retrospectively matched 1:2 for age, sex, body mass index, and follow-up time. Length of stay and hemoglobin level drop were similar. Technically, the revision group required larger polyethylene inserts (P < .001) and longer tourniquet times (P < .001) with 15 of these patients needing augments, grafts, and/or stems. Subjectively, the revision groups mean total Western Ontario and McMaster Universities Arthritis Index score was 25.8 ± 20.2, thus less satisfactory compared with the control group (19.8 ± 15.3) at a mean follow-up of 3.1 years (P = .03). A revision unicompartmental knee arthroplasty to TKA is technically more difficult and functionally less satisfactory at last follow-up when compared with a primary TKA.

Open Wedge High Tibial Osteotomy A Roentgenographic Comparison of a Horizontal and an Oblique Osteotomy on Patellar Height and Sagittal Tibial Slope

Background In patients with unicompartmental medial knee arthritis, medial opening wedge high tibial osteotomy is used to shift the mechanical weightbearing line laterally to reduce pain and improve function. There have been concerns that opening wedge high tibial osteotomy is associated with a reduction of patellar height and increase in the sagittal posterior tibial slope, both of which can adversely affect the final result. Hypothesis A more distal oblique osteotomy at the level of insertion of the patellar tendon should decrease these effects when compared with a horizontal osteotomy made proximal to the patellar tendon insertion. Study Design Cohort study; Level of evidence, 3. Methods Review of 22 horizontal and 19 oblique high tibial osteotomies with a mean follow-up of 4.2 ± 1.8 years (mean ± SD) was performed. Anatomic tibiofemoral angle, mechanical weightbearing line, medial coronal tibial plateau angle, patellar height (Blackburne and Peel ratio), and sagittal tibial slope were measured. Results In both groups, the weightbearing line was equally shifted toward the center of the plateau. In the horizontal group, the Blackburne and Peel ratio decreased from 0.85 ± 0.16 to 0.67 ± 0.12, and the sagittal tibial slope was increased from 7.7° ± 4.6° to 10.7° ± 3.8° (P < .001). In comparison, the oblique group did not show any significant postoperative changes for these 2 parameters. In the oblique group, 2 patients sustained loss of correction and early failure when the osteotomy remained below the metaphyseal flare on the lateral cortex. Conclusion The oblique osteotomy group showed more normalized postoperative sagittal tibial slope and patellar height. Caution should be exercised not to osteotomize too distally.

Skeletal fixation of grade IIIB tibial fractures. The potential of metaanalysis.

Contemporary management of Grade IIIB open tibial fractures has evolved to include intravenous antibiotics, thorough interval surgical debridement, rigid skeletal fixation, early local or free tissue myoplasty, and liberal use of autogenous bone graft beneath a clean, stable wound. External fixation has been the skeletal stabilization of choice with the lowest reported deep sepsis rates. Pin tract infection, malunion, and nonunion have complicated its use. Static unreamed locked nailing is an alternative treatment that has been successfully used in lower grade open tibial fractures. A metaanalysis of the literature was undertaken to determine whether there was evidence favoring 1 method of skeletal fixation. Inclusion criteria were restricted to studies that were randomized to either external fixation or unreamed intramedullary nail methods and that used a strict definition of Grade IIIB to include muscle transfer for soft tissue coverage. Two studies were identified and combined to show no difference in deep sepsis rate. Intramedullary nailing significantly shortened union time whereas external fixation showed a trend toward a higher incidence of malunion and superficial sepsis. More well designed randomized studies would add to this initial effort and yield more compelling evidence for either form of fixation.

3-Foot standing AP versus 45 degrees PA radiograph for osteoarthritis of the knee.

OBJECTIVE Flexion and erect standing radiographs were evaluated in the current study to compare their sensitivity in detecting articular cartilage wear. DESIGN Prospective cohort study. SETTING A tertiary care hospital outpatient orthopedic clinic. PATIENTS All patients with osteoarthritis of the knee ages 40 to 75 scheduled for arthroscopic debridement between March 1995 and November 1997 were considered for the current study. INTERVENTION Radiographs were obtained 1 week preoperatively in both the 3-foot standing anteroposterior (AP) and a 45 degrees posteroanterior (PA) flexion weight-bearing projection. Joint space height was measured with a ruler in millimeters at the narrowest point of each compartment. All radiographs were assessed by two independent observers who were blinded to the arthroscopic findings and clinical symptoms of the subjects. MAIN OUTCOME MEASURES Prediction accuracy of each radiograph for severe Grade IV articular cartilage wear in tibio-femoral compartments. RESULTS One hundred fifty-two patients with a mean (+/- SD) age of 60.5+/-8.5 years were enrolled in the study. Fifty-one percent were female. Twelve patients were categorized as having severe lateral compartment articular chondropathy (Grade IV) at the time of arthroscopy. The lateral joint space height averaged 1.0+/-1.7 mm SD on the 45 degrees PA radiograph compared with 2.7+/-1.1 mm SD on the 3-foot standing AP view. Using a cutoff of 2 mm or less, the 45 degrees PA view was much more sensitive (83% versus 42%) at correctly detecting the most severe chondropathy. Forty-one patients were classified with severe Grade IV medial compartment chondropathy at arthroscopy. There was little difference in the average joint space height measured by the 45 degrees PA view (1.4+/-1.4 mm SD) or the 3-foot standing AP view (1.9+/-1.6 mm SD). A number of cutoff measures were evaluated, but no significant advantage could be found for either view in evaluating the medial compartment severity. CONCLUSIONS The bilateral 45 degrees PA is superior for detecting lateral compartment wear but offers no advantage on the medial side. This view should be considered as the screening radiograph of choice in evaluating osteoarthritis of the knee.