Sharon Griffin

A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

BACKGROUND The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown. METHODS We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life). RESULTS Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (+/-SD) WOMAC score for the surgery group was 874+/-624, as compared with 897+/-583 for the control group (absolute difference [surgery-group score minus control-group score], -23+/-605; 95% confidence interval [CI], -208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0+/-11.4 and 37.2+/-10.6, respectively (absolute difference, -0.2+/-11.1; 95% CI, -3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery. CONCLUSIONS Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy. (ClinicalTrials.gov number, NCT00158431.)

A Prospective, Double-Blind, Randomized Clinical Trial Comparing Subacromial Injection of Betamethasone and Xylocaine to Xylocaine Alone in Chronic Rotator Cuff Tendinosis

Background Rotator cuff tendinosis is a common problem with significant health and economic effects. Nonoperative management includes the widespread use of subacromial steroid injections despite the lack of evidence of its efficacy. Hypothesis A subacromial injection of betamethasone will be more effective than xylocaine alone in improving the quality of life, impingement sign, and range of motion in patients who have chronic rotator cuff tendinosis or partial rotator cuff tears. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Patients with rotator cuff tendinosis or partial cuff tear with symptoms longer than 6 months, with failure of 6 weeks of physical therapy and 2 weeks of nonsteroidal anti-inflammatory drugs, who were older than 30 years of age, and who showed > 50% improvement with the Neer impingement test were stratified for Workplace Safety and Insurance Board status and previous injection. Outcome measures—the Western Ontario Rotator Cuff Index; American Shoulder and Elbow Surgeons standardized form; Disabilities of the Arm, Shoulder and Hand; active forward elevation; active internal rotation; active external rotation; and the Neer impingement sign—were assessed at 2, 6, 12, and 24 weeks after injection. The injection into the subacromial space contained either 5 mL of 2% xylocaine alone or 4 mL of 2% xylocaine and 1 mL (6 mg) of betamethasone in an opaque syringe. Results In 58 patients (betamethasone group, n = 30; xylocaine group, n = 28), the authors found no statistically significant difference between the 2 treatment groups for all outcomes and time intervals. The scores for the Western Ontario Rotator Cuff Index at 3 months were xylocaine = 45.4% ± 13% and betamethasone = 56.3% ± 17% (P=. 13). At 6 months, the scores were xylocaine = 51% ± 32% and betamethasone = 59% ± 26% (P=. 38). All other outcomes showed similar values. As well, similar results were found for 2 and 6 weeks after injection. Both groups showed improvement from baseline in all outcomes. Conclusions With the numbers available for this study, the authors found betamethasone to be no more effective in improving the quality of life, range of motion, or impingement sign than xylocaine alone in patients with chronic rotator cuff tendinosis for all follow-up time intervals evaluated.

Outcome of Posterior Ankle Arthroscopy for Hindfoot Impingement

PURPOSE To provide short-term clinical results of posterior ankle arthroscopy in the treatment of posterior ankle impingement. METHODS This was a retrospective evaluation of the clinical outcomes of posterior ankle arthroscopy in a series of patients with posterior ankle pain. RESULTS Of 23 patients who underwent 24 posterior ankle arthroscopies between July 1998 and February 2004, 15 patients (mean age, 25 years) with 16 posterior ankle arthroscopies were evaluated at a mean follow-up time of 32 months (range, 6 to 74). Procedures carried out were: excision of os trigonum (11); decompression of prominent posterior talar process (5); tenolysis of flexor hallucis longus (5); removal of loose body (1); osteochondritis dissecans lesion debridement (1); and arthrotomy (1). The average time to return to work was 1 month (range, 0 to 3) and to sports, 5.8 months (range, 1 to 24). Fourteen patients returned to their preinjury level of athletics. Mean Health Survey Short Form (SF-12) scores were 51.80 for the mental component (range, 30.77 to 60.53) and 55.80 for the physical component (range, 44.26 to 63.33). Mean score on the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale was 91 (range, 77 to 100) and on the Lower Extremity Functional Scale was 75 (range, 65 to 80). Documented complications included temporary numbness in the region of the scar in 5 patients and temporary ankle stiffness in 1 patient. There were no permanent neurovascular injuries. All subjects reported significant improvement and indicated that they would undergo the surgery again if needed. CONCLUSIONS Functional and clinical evaluations following posterior ankle arthroscopy revealed that all patients were very satisfied. They reported good to excellent health-related quality of life scores, satisfactory functional outcomes, and a high rate of return to sporting activities. Most importantly, no significant complications were encountered. This review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Validity and reliability of the Western Ontario Rotator Cuff Index (WORC) for use in Brazil.

Objective:To evaluate the validity and reliability of the Brazilian Portuguese version of the Western Ontario Rotator Cuff Index (WORC). Design and Setting:A cross-sectional survey at the Physiotherapy Unit and Outpatient Orthopedic and Traumatology Clinic, Universidade Federal de São Paulo. Methods:To test validity, 100 patients with rotator cuff disorders were evaluated using the WORC, clinically relevant outcomes for patients with shoulder disorders (pain, range of motion, and strength), and the Disabilities of Arm, Shoulder, and Hand (DASH), University of California Los Angeles Shoulder Rating Scale (UCLA), and Short Form-36 (SF-36) self-report measures. The WORC was repeated on 50 patients on the same day (more than 1 hour later) and after a mean interval of 7 days to evaluate the test-retest reliability. Concurrent validity was tested by correlating the WORC to the other outcome measures using Pearsons correlation coefficient. Test-retest reliability and internal consistency were determined by the intraclass correlation coefficient and Cronbachs alpha coefficient, respectively. The scores were used to assess the standard error measurement (SEM) and minimal detectable change (MDC). Results:Analysis between the WORC and clinically relevant outcomes for patients with shoulder disorders revealed weak to strong correlations; the weakest for active internal rotation (r = -0.22) and the strongest for pain during movement (r = -0.75). Strong correlations were found among the WORC and the DASH and UCLA (r = -0.86 and r = 0.80, respectively). There were moderate correlations between the WORC and SF-36 domains (0.37 to 0.69); the best correlations related to the physical domains. Reliability analysis revealed excellent results, with the intraclass correlation coefficient ranging from 0.95 to 0.99 and Cronbachs alpha ranging from 0.88 to 0.97. The SEM was 5.2 and 3.0 for time 0 and after a mean interval of 7 days, respectively. The MDC was 7.1 over this mean time interval (90% confidence interval). Conclusions:The Brazilian version of the WORC proved to be a valid and reliable measurement tool for assessing health-related quality of life in patients with rotator cuff diseases.

Tourniquet Versus No Tourniquet Use in Routine Knee Arthroscopy: A Prospective, Double-Blind, Randomized Clinical Trial

PURPOSE The purpose of this study was to determine the effects of tourniquet use for routine knee arthroscopy based on both subjective and objective functional outcome measures. TYPE OF STUDY The study was a prospective, double-blind, randomized clinical trial. MATERIALS AND METHODS There were 120 patients randomized to tourniquet inflation (300 mm Hg) or no tourniquet inflation during routine knee arthroscopy. Patients recorded their average pain on a visual analog scale and their narcotic use for the previous 24 hours, for the first 5 postoperative days. Patients also completed a preoperative and postoperative (2 week, 6 week, 3 month) Western Ontario and McMaster University Osteoarthritis Index (WOMAC), 6-minute walk, 30-second stair climb, 1-leg standing vertical leap, range of motion, and isokinetic strength testing. Time to return to work and sport was documented. RESULTS No statistically significant difference was found between tourniquet-up and tourniquet-down groups for the WOMAC quality of life measure, functional tests, isokinetic muscle strengthening, or time to return to work or sport (t test/repeated measures analysis of variance). However, there was a trend for less early postoperative pain and slightly better isokinetic strength testing at 2 weeks in the tourniquet-down group. Visualization was rated by surgeons to be 3 times better in the tourniquet-up group, although mean operative time did not differ between the groups. CONCLUSION The use of a pneumatic tourniquet at 300 mm Hg does not significantly effect overall patient quality of life or functional outcome following routine knee arthroscopy.

The Development and Validation of a Quality of Life-measurement Tool for Patients With Meniscal Pathology: The Western Ontario Meniscal Evaluation Tool (womet)

Objective:To develop and validate a disease-specific, health-related quality of life (HRQOL) index for patients with meniscal pathology. Our hypothesis was that the Western Ontario Meniscal Evaluation Tool (WOMET) would provide adequate reliability, validity, and responsiveness in measuring HRQOL in patients with meniscal tears or who have undergone meniscal repair or resection. Study Design:Validation of a measurement tool. Setting:A tertiary, university-affiliated, sport medicine clinic. Participants:A methodological protocol based on that of Guyatt et al was used to develop the Western Ontario Meniscal Evaluation Tool (WOMET). Patients with meniscal symptomology and in whom magnetic resonance imaging had suggested meniscal pathology were selected from referrals to a sport medicine clinic. Using this cohort, the development of the WOMET proceeded through item generation, reduction, and instrument pretesting. A second cohort of postarthroscopy patients with confirmed meniscal pathology was used to assess the reliability of the WOMET and validate the instrument. Results:The final instrument has 16 items representing the domains of physical symptoms (nine items), sports/recreation/work/lifestyle (four items), and emotions (three items). It demonstrated adequate content and construct validity when compared with other measures. Test-retest reliability was assessed and was found to be high, with an intraclass correlation coefficient of 0.833. The new instrument was also found to be more responsive than other knee measurement tools when assessed in the same cohort. Conclusions and Clinical Relevance:The WOMET is a disease-specific tool designed to evaluate HRQOL in patients with meniscal pathology. It is therefore put forth as a validated measurement tool to be used in clinical trials evaluating treatments for meniscal pathology. It could also be used as a prospective outcome measure in research or in clinical practice.

Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthritis of the shoulder: a prospective, randomized, double-blind clinical trial—A JOINTs Canada Project

BACKGROUND Although cemented humeral fixation is recognized as the standard of care in total shoulder arthroplasty (TSA), uncemented fixation has the potential to provide stable fixation, decrease operative time, and simplify potential revision procedures. This prospective, randomized, double-blind clinical trial compared cemented and uncemented humeral fixation in TSA for primary shoulder osteoarthritis. METHODS Patients with primary shoulder osteoarthritis requiring replacement were screened for eligibility. After providing informed consent, subjects received baseline clinical and radiologic assessments, computed tomography scans, and standardized TSA. After glenoid component insertion, patients were randomized to either a cemented or uncemented humeral component. The primary outcome was the WOOS (Western Ontario Arthritis of the Shoulder Index) score at 2 years. Other outcomes included the Short Form 12 score, American Shoulder and Elbow Surgeons score, McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, operative time, complications, and revisions. Patients were assessed by a blinded evaluator at 2 and 6 weeks and 3, 6, 12, 18, and 24 months postoperatively. RESULTS In total, 161 patients consented to be included and were randomized: 80 in the cemented group and 81 in the uncemented group. There were no significant differences in demographics or baseline evaluations between groups, except for gender. The 12-, 18-, and 24-month WOOS scores showed a significant difference in favor of the cemented group. The cemented group also had better strength and forward flexion. As expected, the operative time was significantly less for the uncemented group. CONCLUSIONS These findings provide level I evidence that cemented fixation of the humeral component provides better quality of life, strength, and range of motion than uncemented fixation.

Cross-cultural Adaptation and Measurement Properties of an Italian Version of the Western Ontario Shoulder Instability Index (WOSI)

STUDY DESIGN Clinical measurement study. OBJECTIVES To translate and cross-culturally adapt the Western Ontario Shoulder Instability Index (WOSI) into Italian, and to evaluate its measurement properties in patients with shoulder instability secondary to a first-time traumatic anterior dislocation. BACKGROUND The WOSI was developed for English-speaking patients. To date, no Italian version of the WOSI exists. METHODS The WOSI was cross-culturally adapted to Italian according to established guidelines. Sixty-four (16 women, 48 men) patients with unilateral shoulder anterior instability were prospectively recruited for the purposes of this study. Internal consistency, test-retest reliability, construct validity, and responsiveness of the WOSI were evaluated. RESULTS The Italian version of the WOSI showed a high degree of internal consistency, with a Cronbach alpha of .93 (95% confidence interval [CI]: 0.91, 0.96). The test-retest reliability was high for both short-term (3 days, 64 patients) and medium-term (14 weeks, 20 patients) test-retest, with intraclass correlation coefficients of 0.95 (95% CI: 0.90, 0.97) and 0.92 (95% CI: 0.89, 0.95), respectively. The WOSI was more closely correlated to the Disabilities of the Arm, Shoulder and Hand questionnaire than to the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.794 and 0.113, respectively). The receiver-operating-characteristic curve analysis revealed that the WOSI was more responsive than the Disabilities of the Arm, Shoulder and Hand questionnaire (P = .03), with an area under the curve of 0.90 (95% CI: 0.78, 0.97) for the WOSI and 0.76 (95% CI: 0.61, 0.88) for the Disabilities of the Arm, Shoulder and Hand questionnaire. CONCLUSION The Italian version of the WOSI is a valid, reliable, and responsive tool that can be used to measure function in Italian-speaking patients with shoulder instability due to a first-time traumatic anterior dislocation.

The conceptually equivalent Dutch version of the Western Ontario Rotator Cuff Index (WORC)

BackgroundThe WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff, originally developed in English. The purpose of this study was to cross-culturally adapt the WORC for use in the Dutch population and to evaluate reliability, agreement and floor and ceiling effects of this Dutch version in a population of patients with rotator cuff disease.MethodsReliability was tested by measuring the Cronbach’s alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Agreement was measured using the Standard Error of Measurement (SEMagreement); and the smallest detectable change (SDC) was calculated based on the SEM. Pearson Correlations Coefficients were used to comparing the WORC with the RAND-36, the Constant Score and 11-point shoulder hindrance scale.ResultsFifty-seven patients entered into this study of whom 50 were available for test-retest validation. The internal consistency of the Dutch WORC tested by Cronbach’s alpha was 0.95 for the total questionnaire. The ICC for the WORC is 0.91 with a 95% confidence interval of 0.85-0.95. Standard Error of Measurement was 6.0 points with a Smallest Detectable Change of 16.7 points on a 0-100 scale. Pearson Correlations Coefficients showed a significant positive correlation between the Dutch WORC and Constant Score (r = 0.60) and a strong reversed correlation with the shoulder hindrance scale (r = -0.75).ConclusionThe Dutch WORC seems to be a reliable health-related quality of life questionnaire for patients with rotator cuff disorders.Trial registrationNCT01532492.

The cost-effectiveness of routine pathology consultation in knee arthroscopy

Regulations in Ontario, Canada, as in most provinces and states in North America, require human tissues (with few exceptions) removed at surgery to be sent to a pathology laboratory for examination and report. We hypothesized that this practice is inconsistently followed and that routine pathological consultation is costly and rarely results in a change in treatment for patients undergoing knee arthroscopy. Chiefs of pathology, orthopaedic surgeons, and orthopaedic operating room nurse managers in Ontario hospitals that perform arthroscopic knee surgery were surveyed for compliance. We determined cost using pathology department procedure codes and evaluated effectiveness as the correlation between the postoperative diagnoses of orthopaedic surgeons and pathologists for 1,036 consecutive knee arthroscopy cases. In only one case (0.1%) was it felt that pathology consultation had the potential to significantly alter patient care. The total cost of pathology consultation for the 1,036 cases reviewed was