Rafael Thein

The results of corrective osteotomy for valgus arthritic knees

PurposeTo evaluate the results of corrective varus osteotomy in the treatment of arthritic knees with valgus deformity.MethodsThe data were retrieved from a literature review. Each relevant study was screened for demographic details, surgical techniques, follow-up periods, clinical outcomes, and complications.ResultsA total of 27 publications describing the results of varus osteotomies for valgus arthritic knees were reviewed. All were small case series studies, variable in their patient population, surgical techniques, rehabilitation protocols, follow-up periods, clinical assessments and were categorized as level IV of scientific evidence.ConclusionThe role of varus osteotomy remains poorly defined. The literature generally supports this procedure in active and cooperative patients to reduce pain and delay the need for knee replacement. New techniques hold promising results regarding shortening of rehabilitation time and low reoperation and complication rates.Level of evidenceIV.

Mid-term Outcome of Opening-wedge High Tibial Osteotomy for Varus Arthritic Knees

Gonarthrosis in the relatively young and active population causes major daily discomfort and disability. If the arthritic process is mainly limited to the medial compartment, the axis of a varus knee can be realigned laterally with high tibial osteotomy to unload the medial compartment and allow some cartilage regeneration and pain relief. This study describes the outcomes of patients who underwent opening-wedge high tibial osteotomies using Puddu plate (Arthrex, Naples, Florida) fixation. Eighteen patients (22 knees) with genu varum and medial compartment osteoarthritis were followed-up for an average of 6.3±2.3 years after high tibial osteotomy with Puddu plate fixation and iliac crest allograft. Clinical outcome was assessed by the Oxford Knee Score and subjective satisfaction rating. Pre- and postoperative radiographs were evaluated for tibiofemoral angle, Insall-Salvati index, and Kellgren-Lawrence Grading Scale for osteoarthritis. Mean patient age at surgery was 44±13.7 years, and mean body mass index was 29.1±4.7 kg/m(2). At last follow-up, mean Oxford Knee Score improved from 22.4±13.5 to 37.2±13.7 (P=.002). Average subjective satisfaction rate at last follow-up was 8±3. The measured tibiofemoral angle was corrected to an average genu valgum of 3.3°±4.8° (P=.001). No patient showed severe postoperative osteoarthritis (ie, Kellgren-Lawrence grade 4) at last follow-up. All radiographs showed full incorporation of the bone grafts. At the end of the study, 2 patients underwent total knee replacement. Opening-wedge high tibial valgus osteotomy with Puddu plate fixation can be a reliable procedure for the treatment of medial-compartment osteoarthritis of the knee associated with varus deformity.

Intra-articular injection of hyaluronic acid following arthroscopic partial meniscectomy of the knee.

The short-term recovery period post-arthroscopic meniscectomy is characterized by pain and impaired function most likely related to the irrigation of synovial fluid from the knee intraoperatively. Consequently, along with removal of harmful debris, the irrigation fluid dilutes the hyaluronic acid layer covering the joint tissues. Hyaluronic acid contributes to the homeostasis of the joint environment and is an important component of synovial fluid and cartilage matrix. Hence, the instillation of hyaluronic acid after the procedure may relieve symptoms. This prospective, single-blind, randomized, controlled study evaluated clinical outcome after hyaluronic acid injection to patients who underwent arthroscopic meniscectomy of the knee. Patients with ligamentous injuries or severe chondral damage were excluded. Fifty-six patients with a mean age of 34 years (range, 17-44 years) were injected with Viscoseal (TRB Chemedica International S.A., Geneva, Switzerland) or normal saline immediately post-arthroscopy and divided into the Viscoseal group or control group, respectively. Patients were evaluated for pain, swelling, and function at 1, 4, and 12 weeks postoperatively. Patients in the control group reported more pain at week 1, with a mean visual analog score (VAS) of 43, than did patients in the Viscoseal group, with a mean VAS of 28 (P=.006). At 4 weeks postoperatively, none of the Viscoseal patients had consumed analgesics, where 9 (of 28) in the control group reported acetaminophen intake (P=.039). No significant difference in knee function was found between groups. Intra-articular injection of Viscoseal after arthroscopic meniscectomy reduced pain in the short-term recovery period.

Chondrolysis of the Hip following Septic Arthritis: A Rare Complication of Magnetic Resonance Arthrography

Magnetic resonance arthrography (MRA) is commonly used to detect labral tears of the hip. Complications of MRA are unusual and include minor reactions such as chemical synovitis and urticaria. This paper presents a rapidly progressive chondrolysis of the hip in a young patient after arthrography. The patient had suffered from acute septic arthritis and was treated by emergent arthroscopic surgery followed by appropriate antibiotics. At 18 months of followup, there were no signs of active infection but evidence of joint chondrolysis. Magnetic resonance arthrography (MRA) of the hip is an invasive procedure and should therefore be recommended judiciously. Post-MRA pain is common but often mild and temporary, while post-MRA joint infection is rare; nevertheless, severe joint pain and limitation should raise suspicion for septic hip.

Does Timing of Arthroscopic Partial Meniscectomy in Stable Knees Matter

Abstract The timing of arthroscopic partial meniscectomy (APM) is not well defined. The purpose of this study was to evaluate the impact of early surgical intervention on the short‐term improvement in clinical outcome. Between June 2012 and July 2013, patients who had APM for symptomatic irreparable meniscal tears in stable knees with no preoperative radiographic osteoarthrosis were included (n = 187). The mean age was 45.6 ± 14.5 years. Early surgical intervention (duration of symptoms of less than 3 months) was evaluated together with various preoperative and operative variables in a multivariable stepwise regression analysis, while the improvement in Lysholm knee score was modeled as a function of these predictors. At the last follow‐up, the mean Lysholm knee score improved by 14.7 points and 79% of all patients declared they were satisfied to have had the operation; however, of the various predictors in the regression analysis, patients who had shorter duration of symptoms or better clinical function before surgical intervention had greater improvement in clinical score. In conclusion, early APM for symptomatic irreparable tears in stable knees without preoperative arthrosis had better improvement in clinical results than in delayed intervention.

Gender Effect on the Outcome of Partial Medial Meniscectomy

Complex posterior horn tears of the medial meniscus are common. Previous reports performed statistical stratifications to address the influence of gender on outcome following arthroscopic partial medial meniscectomy with variable conclusions. The aim of this study was to compare the clinical results of arthroscopic partial meniscectomy of the knee between men and women with complex medial meniscal tear type while controlling for other variables that may affect outcome. This study compared groups of 86 men and 49 women who were followed prospectively using the Lysholm Knee Scoring Scale, the visual analogue scale, and patients satisfaction. Mean age at operation was 51 years and mean follow-up was 26 months. Mean Lysholm score improved from 69 preoperatively to 82.1 postoperatively (P<.001) in the male group and from 64.2 preoperatively to 73.5 postoperatively (P=.04) in the female group. At last follow-up, 68 (79%) men and 35 (71%) women stated that they were satisfied with the operation. In both groups, the severity of chondral lesions was found to be negatively correlated to the preoperative score. Women had more severe chondral lesions at arthroscopy than men. This comparative study showed no significant difference between men and women in terms of clinical improvement following arthroscopic partial meniscectomies of complex tear types in stable knees with intact lateral meniscus. Women had lower functionality pre- and postoperatively, which correlated with more severe chondral degeneration at surgery compared with men.

Low prevalence of isolated medial meniscal tears in young females with stable knees.

The information regarding isolated tears of the meniscus in stable knees (ie, without cruciate ligament tears), specifically in a younger population, is scarce. Although surgical treatment is preferred for young patients with meniscal tears, the diagnosis at this age may be misled by other sources of knee pain. The purpose of this study was to report on the prevalence and sex variance of isolated meniscal tears in a younger population based on arthroscopic findings. From a database of 2425 arthroscopic knee surgeries performed over a period of 6 years, 591 patients (480 males and 111 females) younger than 40 years were included. Patients were divided into 5 age groups and subdivided according to their surgical findings. Measures included the prevalence of meniscal tears according to sex and age groups and also odds ratio calculations for the presence of meniscal tears. Of 591 arthroscopic surgeries in young patients with stable knees, only 6 females (vs 87 males) younger than 30 years had isolated medial meniscus tears. The number of stable knees without meniscal tear at arthroscopy in all age groups was relatively high. The odds ratio for having a medial meniscal tear was significantly higher in males. The results suggest a protective mechanism for isolated medial meniscal tears in younger females as opposed to other injuries of the knee. Isolated medial meniscus tears in stable knees are uncommon in females younger than 30 years; thus, young females with suspected tears should be reevaluated and treated conservatively before considering surgical solutions.

ACCURACY OF SPECT IMAGING FOR ARTHROSCOPICALLY CONFIRMED MENISCAL TEARS IN PATIENTS WITH ACUTE KNEE PAIN AND NO RADIOGRAPHIC ARTHRITIS

Purpose: To evaluate the accuracy of single photon emission computed tomography (SPECT) compared with arthroscopy in the diagnosis of acute knee pain due to meniscal tear. Methods: Patients with knee pain that persisted for less than six months with normal plain radiographs that had arthroscopic surgery following SPECT scan were included. The main scintigraphic criterion for diagnosing a tear of the meniscus was tibial plateau activity on the planar image with at least a half crescent of peripheral tibial plateau uptake. The accuracy of SPECT in detecting meniscal tears was calculated according to the arthroscopic findings as the gold standard. Results: There were 68 patients in the study (46 males and 22 females). The mean age was 45.3 (17–72) years and the mean time between SPECT scan and surgery was 3.5 (1–6) months. The overall sensitivity of SPECT was 90%, specificity 70%, NPV 54%, PPV 95% and accuracy 87%. Conclusion: SPECT was found to be an accurate imaging technique in the diagnosis of symptomatic meniscal tears in patients with acute knee pain and unremarkable plain radiographs. Thus, SPECT may be helpful in selecting candidates for arthroscopy.