High tibial osteotomy versus unicompartmental knee arthroplasty for Kellgren-Lawrence grade 3-4 knee osteoarthritis in younger patients: comparable improvements in patient-reported outcomes, adjusted for osteoarthritis grade and sex.

PURPOSE: Previous studies comparing high tibial osteotomy (HTO) with unicompartmental knee arthroplasty (UKA) have seldom accounted for differing patient characteristics between both groups. This study compared patient-reported outcomes (PROs) of HTO and UKA patients, adjusted for preoperative PROs, osteoarthritis grade and sex. METHODS: A retrospective study was performed analysing prospectively collected PROs, namely the Oxford Knee Score (OKS) and pain/satisfaction scores, collected preoperatively and at 6 months, 12 months and 24 months postoperatively. Consecutive medial opening-wedge HTOs and medial UKAs from 2016-2019, with a preoperative Kellgren-Lawrence grade ≥ 3, aged 50-60 years, were included. Linear mixed model analyses, with the OKS over time as the primary outcome, were used. RESULTS: We included 84 HTO patients (mean age 55.0 ± 3.0, 79% male, mean BMI 27.8 ± 3.4, 75% Kellgren-Lawrence grade 3) and 130 UKA patients (mean age 55.7 ± 2.8, 47% male, mean BMI 28.7 ± 4.0, 36% Kellgren-Lawrence grade 3). Response rates were ≥ 87% at all time points. Corrected for preoperative PROs, Kellgren-Lawrence grade and sex, the HTO group had a 2.5 (95% CI 1.0-4.0) points lower OKS over time than the UKA group (p = 0.001). The Numeric Rating Scale scores (NRS; 0-10) for pain at rest and during activity were higher (p < 0.01) in the HTO group. The EQ-5D-descriptive system (p < 0.01), NRS satisfaction (p < 0.01), anchor function and pain scores (p < 0.01) were lower over time in the HTO group. CONCLUSION: UKA patients had better OKS scores, pain and satisfaction scores over time than HTO patients. However, the observed differences were below their established minimal clinically important differences. Therefore, from the patients' perspective, HTO did not appear to be inferior to UKA under the indications outlined in this study. Level of evidence Level IV.

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis.

PURPOSE: The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis. METHODS: Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol. RESULTS: The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions. CONCLUSION: Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers. LEVEL OF EVIDENCE: Level II.

Does Consulting an Occupational Medicine Specialist Decrease Time to Return to Work Among Total Knee Arthroplasty Patients? A 12-Month Prospective Multicenter Cohort Study.

PURPOSE: The aim of this study is to investigate whether total knee arthroplasty (TKA) patients who consulted an occupational medicine specialist (OMS) within 3 months after surgery, return to work (RTW) earlier than patients who did not consult an OMS. METHODS: A multi-center prospective cohort study was performed among working TKA patients, aged 18 to 65 years and intending to RTW. Time to RTW was analyzed using Kaplan Meier and Mann Whitney U (MWU), and multiple linear regression analysis was used to adjust for effect modification and confounding. RESULTS: One hundred and eighty-two (182) patients were included with a median age of 59 years [IQR 54-62], including 95 women (52%). Patients who consulted an OMS were less often self-employed but did not differ on other patient and work-related characteristics. TKA patients who consulted an OMS returned to work later than those who did not (median 78 versus 62 days, MWU p < 0.01). The effect of consulting an OMS on time to RTW was modified by patients' expectations in linear regression analysis (p = 0.05). A median decrease in time of 24 days was found in TKA patients with preoperative high expectations not consulting an OMS (p = 0.03), not in patients with low expectations. CONCLUSIONS: Consulting an OMS within 3 months after surgery did not result in a decrease in time to RTW in TKA patients. TKA patients with high expectations did RTW earlier without consulting an OMS. Intervention studies on how OMSs can positively influence a timely RTW, incorporating patients' preoperative expectations, are needed.

The effect of restored medial knee anatomy in total knee arthroplasty with the flexion first balancer technique on mid-flexion laxity and functional outcome.

BACKGROUND: The Flexion First Balancer (FFB) technique for total knee arthroplasty (TKA) was developed to maintain the isometry of the medial collateral ligament (MCL) by restoring the medial anatomy of the knee. Inability to correct MCL isometry could hypothetically result in an increased mid-flexion laxity. The aim of the current study was to evaluate if the FFB technique results in improved functional outcome and less mid-flexion laxity compared to Measured Resection (MR). METHODS: A cross-sectional study was performed comparing 27 FFB patients with 28 MR patients. Groups were matched for age, gender, BMI and ASA classification. All patient received the cruciate retained type, Vanguard Complete Knee System (Biomet Orthopedics, Warsaw, IN, USA). Stress X-rays of the knee with 30 degrees of flexion were made to assess varus-valgus laxity. Furthermore, three tests were conducted to asses functional outcome: a 6 min walk test, a stair climb test and quadriceps peak force measurements. Mean follow-up was respectively 2.6 (SD 0.4) and 3.9 years (SD 0.2). RESULTS: The MR group showed a postoperative elevation in joint line in contrast to the FFB group, the mean difference between the two groups was 3 mm (p < 0.001). No differences in total laxity between the two groups was found. The FFB group showed a higher quadriceps peak force (1.67 (SD 0.55) N/BMI) in comparison with the MR group (1.38 (SD 0.48) N/BMI) (p < 0.05). All other outcome parameters were comparable between the two groups (p: n.s.). Correlation analysis showed a moderate negative correlation between joint line elevation and quadriceps peak force (r = - 0.29, p < 0.05). CONCLUSION: The FFB technique did not lead to less coronal laxity in the mid-flexion range compared to MR. Although peak quadriceps force was significantly higher for the FFB group no clinically relevant benefits could be identified for the patients with regards to functional outcome. Therefore, minor deviations in joint line seems to have no effect on functional outcome after TKA. TRIAL REGISTRATION: ISRCTN, ISRCTN85351296. Registered 23 april 2021 - Retrospectively registered, https://www.isrctn.com/ISRCTN85351296.

Synovial neutrophilic gelatinase-associated lipocalin in the diagnosis of periprosthetic joint infection after total knee arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). However, the diagnosis remains a challenge for clinicians. In 2011, the muscoskeletal infection society (MSIS) criteria provided a consensus which has been updated in 2013, but these criteria are complex and contain tests that are time-consuming. The same is applicable to the pro-Implant guidelines. Therefore, a simpler diagnostic test is desirable. OBJECTIVES: The value of neutrophil gelatinase-associated lipocalin (NGAL), leucocyte esterase (LE) levels, and the white blood cell (WBC) count in synovial fluid to diagnose PJI after TKA was evaluated. METHODS: In a retrospective cohort study, we analyzed 89 synovial fluid samples from 86 patients with suspected PJI after TKA. Thirteen and 23 of those samples were classified as PJI according to the MSIS and pro-Implant criteria, respectively. Subsequently, NGAL, LE levels, and the WBC count were determined, the former one using an immunoassay. Using either the MSIS or pro-Implant criteria as the golden standard for PJI, sensitivity and specificity of those markers were determined with ROC curves, and medians were compared with Mann-Whitney U and Pearson Chi-square tests. RESULTS: When applying the MSIS criteria, NGAL revealed 92% sensitivity and 83% specificity. WBC count showed similar sensitivity (92%) and specificity (84%), whereas sensitivity and specificity for LE were 39% and 88% respectively. When applying the pro-Implant criteria, sensitivity was 95% and specificity was 95% for NGAL. Sensitivity and specificity for WBC count were 100% and 97% and for LE 39% and 92% respectively. CONCLUSION: NGAL and WBC count in synovial fluid has high accuracy in the diagnosis of PJI after TKA and should seriously be considered as part of PJI diagnostics. Leucocyte esterase can serve as rule-in criterion peroperatively. These conclusions are independent of which criteria set was used as golden standard.

Flexion First Balancer: description of new technique in TKA to reproduce joint line and pre-disease mechanical alignment.

A considerable proportion of patients (19%) are dissatisfied after total knee arthroplasty (TKA). Possible factors contributing to this dissatisfaction are decreased posterior condylar offset (PCO) with subsequent joint line elevation, leading to mid-flexion instability. Secondly, the pre-disease mechanical alignment is changed into a neutral alignment. The Flexion First Balancer was developed to avoid these problems. This technique aims to maintain MCL isometry by restoring medial PCO and medial joint line to its pre-disease level. Also, to reconstruct the pre-disease mechanical alignment by adjusting the distal femoral angle. In this study we provide a detailed technical overview of the Flexion First Balancer technique.

Adequate joint line restoration and good preliminary clinical outcomes after total knee arthroplasty using the Flexion First Balancer technique.

INTRODUCTION: Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA). Factors which could possibly contribute to this dissatisfaction are a decreased posterior condylar offset (PCO) and subsequent joint line elevation which leads to mid-flexion instability. The Flexion First Balancer (FFB) technique aims to adequately restore the medial PCO and thereby reconstruct the medial native joint line to its pre-disease height. METHODS: A retrospective cohort of 59 patients operated using the FFB technique was analyzed and matched with a historic measured resection (MR) cohort of 59 patients. Groups were matched for age, gender, BMI and ASA classification. Joint line and PCO changes as well as patient reported outcome measurement scores (PROMs) were evaluated at one year [1.0 - 1.6] postoperatively. RESULTS: Radiographic evaluation revealed no changes in joint line height in the FFB group, whereas an elevation in joint line was seen in the MR group (p = 0.002). The PCO increased after surgery in both group without any statistically significant differences. Evaluation of PROMs found no differences between the two groups for total OKS and KOOS scores, nor in re-operation or complication rates. CONCLUSION: The FFB technique seems to be a safe technique to use in TKA and reconstructs the pre-disease joint line in contrast to the MR technique. The clinical outcomes were comparable between both groups.

Outcome after corrective osteotomy for malunited fractures of the forearm sustained in childhood.

We analysed the operative technique, morbidity and functional outcome of osteotomy and plate fixation for malunited fractures of the forearm sustained in childhood. A total of 20 consecutive patients underwent corrective osteotomy of 21 malunited fractures at a mean age of 12 years (4 to 25). The mean time between the injury and the osteotomy was 30 months (2 to 140). After removal of the plate, one patient suffered transient dysaesthesia of the superficial radial nerve. The mean gain in the range of movement was 85 degrees (20 degrees to 140 degrees ). The interval between injury and osteotomy, and the age at osteotomy significantly influenced the functional outcome (p=0.011 and p=0.004, respectively). Malunited fractures of the forearm sustained in childhood can be adequately treated by osteotomy and plate fixation with excellent functional results and minimal complications. In the case of established malunion it is advisable to perform corrective osteotomy without delay.

Factors determining outcome of corrective osteotomy for malunited paediatric forearm fractures: a systematic review and meta-analysis.

The aim of this study was to identify predictors of a superior functional outcome after corrective osteotomy for paediatric malunited radius and both-bone forearm fractures. We performed a systematic review and meta-analysis of individual participant data, searching databases up to 1 October 2016. Our primary outcome was the gain in pronosupination seen after corrective osteotomy. Individual participant data of 11 cohort studies were included, concerning 71 participants with a median age of 11 years at trauma. Corrective osteotomy was performed after a median of 12 months after trauma, leading to a mean gain of 77° in pronosupination after a median follow-up of 29 months. Analysis of variance and multiple regression analysis revealed that predictors of superior functional outcome after corrective osteotomy are: an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20° and the use of three-dimensional computer-assisted techniques. LEVEL OF EVIDENCE: II.

Palliative treatment in "peri"-pancreatic carcinoma: stenting or surgical therapy?

Mostly, patients with peri-pancreatic cancer (including pancreatic, ampullary and distal bile duct tumors) are diagnosed in a stage in which curative resection is not possible. The median survival rate of patients with non resectable peri-pancreatic cancer varies between 6 and 12 months. During this period palliative treatment is necessary, which should focus on major symptoms as obstructive jaundice, duodenal obstruction and pain. Controversy exists about how to provide optimal palliative treatment. Both surgical and non surgical palliative procedures relief obstructive jaundice. From early retrospective and prospective randomized studies it is known that in the early phase after treatment, more complications are found after surgical palliation, whereas in the late phase more complications are seen after endoscopic palliation. Because more recent studies clearly showed improved results after surgical palliation, current recommendations probably should be that patients with a suspected poor short-term survival (< 6 months) should be offered non surgical palliative therapy and those with a longer life expectancy may best be treated with bypass surgery. Unfortunately, valid criteria for estimating the remaining survival time are not available, except for the presence of metastases. The use of a prognostic score chart might assist in estimating the prognosis. Literature does not give sufficient information to make a well deliberated (evidence based) selection between the different types of surgical bypasses, but a choledochojejunostomy is generally preferred. After stenting, a correlation is found between survival and the development of duodenal obstruction, and between 9% and 21% of the patients who underwent a surgical biliary bypass without a prophylactic gastric bypass, will develop gastric outlet obstruction. Therefore, in patients with a relatively good prognosis it is recommended to perform routinely a double--biliary and gastric--bypass. Pain is a frequent symptom and is related with poor survival. Pain management aside from pain medication can be performed by means of a celiac plexus blockade or a thorascopic splanchnicectomy, and also radiotherapy seems to have a positive result on pain.