Shlomo Bronak

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.

Correlation between body mass index and chondral lesions in isolated medial meniscus tears

Background: Chondral lesions of the knee are commonly found during arthroscopic partial meniscectomy. The literature advises against arthroscopic medial meniscectomy in the presence of advanced chondral derangement because of unfavorable outcome. Recent studies have shown an association between obesity and chondropathy in patients with meniscal tears. The aim of this study was to assess whether body mass index (BMI) correlates with the severity of chondral lesions in patients with isolated medial meniscus tears (i.e. without ligamentous or lateral meniscal injury). Materials and Methods: 837 knee arthroscopies were performed in a regional referral center of arthroscopic surgery between January 2011 and December 2012. Of these 168 (109 males, 59 females) patients with no axial knee deformity and no radiological signs of osteoarthritis who have had arthroscopic debridement for isolated torn medial meniscus were included in the study. The correlation between different demographic factors and the level of chondral damage reported at surgery was evaluated. The mean age of patient was 50 years (range 13-82 years) and an average BMI was 28.2 kg/m2 (range17.5-42.5 kg/m2). Results: Overall, regression analysis showed both age and BMI to be linearly correlated to chondral score (r = 0.53, P < 0.04); however, there were no advanced chondral lesions found in patients younger than 40 years of age and all severe lesions were at age 50 years or more. Therefore, further analysis was performed for age subgroups: patients were grouped as younger than 40, between the age of 40 and 50 (middle age) and older than 50 years. The BMI was linearly correlated to the severity of chondral score exclusively in the middle aged group (i.e. 40-50 years old). There was no correlation between activity level and chondral damage. Women had worse chondral lesions than men in all age groups. Conclusion: Higher BMI in middle aged patients with isolated medial meniscus tears and unremarkable radiographs may predict more advanced chondral lesions at arthroscopy.

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.

Prevalence and clinical implications of nerve injury during bone patellar tendon bone harvesting for anterior cruciate ligament reconstruction.

Purpose: Tendon harvesting for anterior cruciate ligament (ACL) reconstruction often injure sensory branches of the saphenous nerve (SN). Our purpose was to estimate the prevalence and postoperative course of sensory nerve injuries in bone patellar tendon bone (BPTB) autograft harvesting for ACL reconstruction. Methods: Between 2012 and 2014, patients who had primary ACL with BPTB autograft were included (n = 60) and interviewed specifically for sensory loss and its recovery. The surface area of sensory loss was documented. Evaluation also included demographic details, level of activity, and description of postoperative sensation disturbances. Results: The mean postoperative follow-up time was 24 ± 14 months. At the last follow-up, 46 (77%) patients reported on postoperative reduced sensation; however, only 35 (58%) remained with sensation loss. The most involved region of reduced sensation was of the infrapatellar branch of the SN. Three patients claimed they regret to have had the surgery specifically because of sensation loss and kneeling difficulties, while all others did not. Conclusion: Primary ACL reconstruction using the midline incision for harvesting the middle third of the patellar tendon autograft has a high prevalence of sensory nerve injury with a minor possibility for complete recovery within the first year. However, sensory loss secondary to this injury does not impair normal daily activities in these patients.

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.

Nerve injury during anterior cruciate ligament reconstruction: A comparison between patellar and hamstring tendon grafts harvest

BACKGROUND Tendon harvesting for anterior cruciate ligament reconstruction often injures sensory branches of the saphenous nerve. The reports on the prevalence of these injuries are scarce, while the implications on patient satisfaction are not known. Our objective was to compare the prevalence of sensory nerve injuries in patellar to hamstring autograft harvesting for anterior cruciate ligament reconstructions and follow up their postoperative course. METHODS Between 2012 and 2014, patients who had a primary anterior cruciate ligament reconstruction with bone patellar tendon bone or hamstring autografts were included (n=94). We evaluated and compared demographic details, level of activity and postoperative sensation disturbances between both groups. Data was analyzed retrospectively. RESULTS The mean postoperative follow-up time was 23months. At the last follow-up 46 (77%) patients of the patellar tendon group and 22 (58%) of the hamstring tendons group reported on reduced sensation; however, in both groups a quarter of these patients experienced full recovery within an average of seven to eight months. There were more patients in the hamstring tendons group that reported on partial recovery. In most cases midline incisions for patellar tendons harvesting injured the infrapatellar branch and medial incisions for hamstring tendons harvesting injured the sartorial branch of the saphenous nerve. CONCLUSIONS Harvesting tendon autografts for anterior cruciate ligament reconstructions by vertical incisions had high prevalence of saphenous nerve branches injury with a minor possibility for complete recovery within the first year. The loss of sensation was perceived by patients as a minor complication. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Anamnestic prediction of bucket handle compared to other tear patterns of the medial meniscus in stable knees

Objective The aim of this study was to analyze and compare the preoperative anamnestic details between patients with an arthroscopic diagnosis of bucket handle and other tear patterns of the medial meniscus in stable knees. Methods A total of 204 patients (mean age 49.3 ± 13 years) were included in the study. The mean age was 49.3 ± 13 years. The study group included 65 patients (63 males, 2 females) with an arthroscopic diagnosis of bucket handle tear and the control group included 139 patients (90 males, 49 females) with non-bucket handle tear patterns. The preoperative clinical assessments of the two groups were analyzed retrospectively. Anamnestic prediction for the diagnosis of a bucket handle tear was based upon various medical history parameters. Multivariate logistic regression was carried out to identify independent anamnestic factors for predicting isolated bucket handle tears of the medial meniscus compared to non-bucket handle tears. Results Analysis of the multivariate logistic regression yielded 3 statistically significant independent anamnestic risk factors for predicting isolated bucket handle tears of the medial meniscus: male gender (OR, 9.7; 95% CI, 1.1–37.6), locking events (OR, 4.6; 95% CI, 1.8–11.3) and pain in extension (OR, 6.9; 95% CI, 2.5–23.7). Other preoperative variables such as age, BMI, activity level, comorbidities, duration of symptoms, pain location, preceding injury and its mechanism had no significant effect on tear pattern. Conclusions Preoperative strong clues for bucket handle tears of the medial meniscus in stable knees are male gender, locking events and limitation in extension. Level of evidence: Level III, Diagnostic study.