Joan Leal-Blanquet

Influence of Depression on Total Knee Arthroplasty Outcomes

It is not clear whether indicating TKA-surgery is advisable in depressed patients. A prospective cohort of 716 patients undergoing TKA was designed. SF36, KSS, WOMAC and VAS plus 2 satisfaction questions were evaluated. There were 2 groups: 200 patients were depressed and 516 were not. Preoperative/postoperative results show better scores for non-depressed patients on almost every sub-scale. Nevertheless, net change results (improvement) were quite similar: 65.74 improvement in depressed-KSS and 74.58 in non-depressed (P=0.049); 8.93 net change in depressed-Physical Composite Score and 11.84 in non-depressed (P=0.003); 2.38 in depressed-Mental Composite Score and -0.61 in non-depressed (P=0.024). Depressed patients obtained great improvement from preoperative at one-year follow-up and even greater than non-depressed patients in some domains. Moreover, satisfaction was similar. Therefore, TKA can be recommended to depressed patients.

Anterior cruciate ligament reconstruction: a multicenter prospective cohort study evaluating 3 different grafts using same bone drilling method.

Objective:To compare the clinical outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft (BPTBAu), BPTB allograft (BPTBAll), or hamstring (semitendinosus-gracilis) tendon autograft (HTAu), performing bone drilling with same methods in terms of transtibial drilling, orientation, positioning, and width of femoral and tibial tunnels. Design:Multicenter prospective cohort study (level of evidence II). Setting:Departments of Orthopedic Surgery of Centro Médico Teknon (Barcelona, Spain) Clínica Universitaria de Navarra (Navarra, Spain), and Clínica FREMAP (Gijón, Spain). Patients:All patients with ACL tears attending 3 different institutions between January 2004 and June 2006 were approached for eligibility and those meeting inclusion criteria finally participated in this study. Intervention:Each institution was assigned to perform a specific surgical technique. Patients were prospectively followed after undergoing ACL reconstruction with BPTBAu, BPTBAll, or HTAu, with a minimum follow-up of 24 months. Main Outcome Measures:Included knee laxity and International Knee Documentation Committee (IKDC) score. Knee laxity was assessed with the KT-1000 arthrometer (evaluated with neutral and external rotation positions) and both Lachman and pivot shift tests. Additional outcomes included main symptoms (anterior knee pain, swelling, crepitation, and instability), disturbance in knee sensation, visual analogue scale (VAS) for satisfaction with surgery, range of motion (ROM), and isokinetic knee strength. Results:There were no significant differences among the 3 groups for any of the clinical outcomes, except for a slightly greater KT-1000-measured knee laxity in external rotation in the BPTBAu compared with the other groups. All patients demonstrated grade A or B of the IKDC. The mean VAS for satisfaction with surgery in all patients was 8.5. Conclusions:The selection of the surgical technique for ACL reconstruction may be based on the surgeons preferences.

Use of antibiotic-loaded cement in total knee arthroplasty

Bone cement has the capacity to release antibiotic molecules if any antibiotic is included in it, and these elution properties are improved as cement porosity is increased. In vitro studies have shown high local antibiotic concentration for many hours or few days after its use. Antibiotic loaded bone cement (ALBC) is helpful when treating an infection in total knee arthroplasty (TKA) revision surgery. The purpose of this paper was to review the evidence for the routine use of ALBC in TKA in the literature, its pros and cons. Many authors have recommended the use of ALBC also in primary TKA for infection prophylaxis, but the evidence based on data from National Registries, randomized clinical trials and meta-analysis suggest a protective effect of ALBC against infection when used in hips, but not (or only mild) in knees. A possible explanation to this finding is that the duration and quantity of locally elevated antibiotic levels after surgery are smaller in TKA, due to the smaller amount of cement used for fixation in TKA-only a layer in the bone surface. There are some concerns about the routine use of ALBC in primary TKA as prophylaxis against infection: Firstly, there is a risk of hypersensivity or toxicity even when the chance is highly improbable. Secondly, there is a reduction in the mechanical properties of the cement, but this can be probably neglected if the antibiotic is used in low doses, not more than 1 g per 40 g cement package. Another significant concern is the increased economic cost, which could be overlooked if there were enough savings in treating fewer prosthetic infections. Finally, there is also a risk of selection of antibiotic-resistant strains of bacteria and this could be the main concern. If used, the choice of the antibiotic mixed in ALBC should consider microbiological aspects (broad antimicrobial spectrum and low rate of resistant bacteria), physical and chemical aspects (thermal stability, high water solubility), pharmacological characteristics (low risk to allergic reactions or toxicity) and economic aspects (not too expensive). The most commonly used antibiotics in ALBC are gentamicin, tobramycin and vancomycin. In conclusion, there is a paucity of randomized clinical trials in the use of ALBC in primary TKAs and the actual evidence of the effect of ALBC in reducing the risk of infection is insufficient. This, in addition to concerns about patient safety, risks of increase in the antibiotic resistance of microorganisms and the increase in costs in the procedure, lead us to recommend a cautious use of ALBC, perhaps only in high-risk patients (immunocompromised, morbidly obese, diabetic and patients with previous history of fracture or infection around the knee) unless the benefits of ALBC use were fully proven. Meanwhile, the rigorous use of peri-operative prophylactic systemic antibiotics and adoption of efficient antiseptic procedures and improved surgical techniques must be considered the gold standard in infection prevention in TKA surgery.

Long Term Follow-Up of Successfully Treated Superficial Wound Infections Following TKA

The relevance of wound complications in association with acute prosthetic joint infection (PJI) is well known. However, whether a successfully treated superficial infection can result in a chronic deep infection remains unclear. The aim of this study was to determine the prevalence, treatment and late complications of superficial wound infections following TKA. In a 3000 TKA prospective cohort, 45 superficial infections were diagnosed and treated successfully with antibiotic therapy along with or without surgical debridement. None of the cases developed deep chronic PJI at 70 months of follow-up. Three cases were in need of a TKA exchange due to aseptic loosening. A successfully treated superficial wound infection does not result in a chronic deep TKA infection.

Comparison of quality of life between elderly patients undergoing TKA.

The purpose of this study was to compare the short-term changes in quality of life for patients younger than 80 years with those 80 years and older undergoing total knee arthroplasty (TKA). It was hypothesized that patients 80 years and older had a similar quality of life after TKA compared with those younger than 80 years.All consecutive patients undergoing primary TKA were enrolled in this prospective, comparative, prognostic (level I evidence) study and were stratified into 2 groups based on their age (younger than 80 years and 80 years and older). Data on quality of life assessed using the Short Form 36 health survey were obtained preoperatively and 1 year postoperatively (short-term follow-up) and were compared between groups. A total of 328 (83.89%) patients younger than 80 years (mean age, 70.7 years) and 63 (16.11%) patients 80 years and older (mean age, 82.1 years) were included. No significant differences in preoperative quality of life were observed between groups. Postoperative physical function, vitality, social function, and physical component summary were lower in patients 80 years and older. Older patients had a lower difference between pre- and postoperative values in Short Form 36 physical function and role-emotional scores.Patients 80 years and older had a similar improvement in quality of life 1 year after TKA compared with patients younger than 80 years. Therefore, changes in quality of life justify TKA as a treatment option for elderly patients with end-stage knee osteoarthritis.

Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies

Patellar instability is a common clinical problem encountered by orthopedic surgeons specializing in the knee. For patients with chronic lateral patellar instability, the standard surgical approach is to stabilize the patella through a medial patellofemoral ligament (MPFL) reconstruction. Foreseeably, an increasing number of revision surgeries of the reconstructed MPFL will be seen in upcoming years. In this paper, the causes of failed MPFL reconstruction are analyzed: (1) incorrect surgical indication or inappropriate surgical technique/patient selection; (2) a technical error; and (3) an incorrect assessment of the concomitant risk factors for instability. An understanding of the anatomy and biomechanics of the MPFL and cautiousness with the imaging techniques while favoring clinical over radiological findings and the use of common sense to determine the adequate surgical technique for each particular case, are critical to minimizing MPFL surgery failure. Additionally, our approach to dealing with failure after primary MPFL reconstruction is also presented.

Managing septic arthritis after knee ligament reconstruction.

PurposeJoint infection after anterior cruciate ligament (ACL) reconstruction is uncommon but has potentially serious consequences for the graft and articular cartilage. Most recently published series are in agreement that an urgent arthroscopic washout and antibiotic treatment are mandatory to preserve both graft and cartilage. However, several questions have not as yet been touched upon.MethodsWe performed a literature review to assess the most interesting series published about this issue.ResultsIn this review, a management protocol is first presented that discusses the different diagnostic parameters to consider and surgical and antibiotic treatment suggested according to the literature. Outcomes published in different series are also discussed.

Pressure algometry is a useful tool to quantify pain in the medial part of the knee: An intra- and inter-reliability study in healthy subjects

PURPOSE Pain quantification is essential for diagnostic and pain monitoring purposes in disorders around the knee. Pressure algometry is a method described to determine pressure pain threshold (PPT) by applying controlled pressure to a given body point. The purpose of this study was to determine the reliability of this method when it was applied to the medial part of the proximal tibia metaphysis and to evaluate the PPT levels between genders. METHODS Fifty healthy (mean age; 46.9) volunteers were recruited, 25 men and 25 women. Pressure algometry was applied to a 1 cm(2)-probe area on the medial part of the knee by 2 raters. Intra- and interclass correlation (ICC) was obtained and differences between genders were evaluated. Bland-Altman plots were performed to evaluate the variability of the measures. RESULTS The mean values of PPT obtained by rater 1 and 2 were 497.5 Kpa and 489 Kpa respectively. The intrarater reliability values (95% IC) for rater 1 and 2 were 0.97 (0.95-0.98) and 0.84 (0.73-0.90) respectively. With regard to interrater reliability, the ICC (95% IC) for the first measurement was 0.92 (0.87-0.95) and 0.86 (0.78-0.92) for the second one. Women showed significant lower values of PPT than men. The Bland-Altmand plots showed excellent agreement. CONCLUSIONS Pressure algometry has excellent reliability when it is applied to the medial part of the proximal metaphysis of the tibia. Women have lower values of PTT than men. The high reliability of the PA in an individual volunteer makes it a more valuable tool for longitudinal assessment of a given patient than for comparison between them. LEVEL OF EVIDENCE Level III. Prospective study.

Meniscal Allograft Transplantation: Where are we Standing?

Meniscal allograft transplantation (MAT) is becoming a common procedure in Orthopedic departments worldwide. This procedure has demonstrated good and excellent results in terms of pain relief, improvement in clinical and functional outcomes, return to sports, and patient’s satisfaction. However, MAT is not a universally accepted procedure due to its questionable chondroprotective effects and the relatively high rate of complications and/or reoperations. The present short review summarizes the principal indications, contraindications, outcomes, and complications. Also, it covers several controversial topics like graft preservation, graft sizing, graft fixation, results in MAT associated with concomitant procedures, and the role of MAT in the prevention of knee osteoarthritis.

Influence of Common Associated Forefoot Disorders on Preoperative Quality of Life in Patients With Hallux Valgus

Background: Hallux valgus (HV) is frequently associated with other forefoot disorders, but its influence on preoperative quality of life (QOL) has not been well characterized. The main purpose of this study was to assess the influence of common associated forefoot disorders (metatarsalgia and lesser toe deformities) on preoperative QOL in patients with HV. Methods: Preoperative QOL assessed through the Short Form–36 (SF-36, version 2) was obtained from 94 patients with HV from a database. Patients were classified according to their condition: HV alone, HV and metatarsalgia, HV and lesser toe deformities, and HV and both metatarsalgia and lesser toe deformities. Values of each domain were compared among groups. In addition, a correlational study between SF-36 and radiographic severity of HV was performed. The mean age of the 94 patients was 62.6 ± 12.3 years. There were 42.6% patients with HV alone, 30.8% with HV and metatarsalgia, 16% with HV and lesser toe deformities, and 10.6% with HV and both metatarsalgia and lesser toe deformities. Results: Patients with HV and associated metatarsalgia and lesser toe deformities had significantly worse physical function (P = .029), role-physical (P = .017), bodily pain (P = .045), role-emotional (P = .016), mental health (P = .001), and mental component summary (P = .003) compared to patients with HV alone. There were no significant correlations between radiographic HV and intermetatarsal angles and any of the domains or summaries of the SF-36. Conclusion: Patients with HV and both metatarsalgia and lesser toe deformities have significantly worse QOL compared to patients with HV alone. The presence of associated forefoot deformities may be a discriminating factor for the prioritization of surgical treatment of HV. Level of Evidence: Level III, cross-sectional study.