Location of Talar Osteochondral Defects in Chronic Lateral Ankle Instability in an Asian Population.

Osteochondral defect of the talus is traditionally described to involve the anterolateral and posteromedial portion of the talar dome in patients with chronic lateral ankle instability. Recent studies challenged this notion with advances in preoperative imaging and arthroscopy. Since Asian patients are more prone to ligamentous laxity, we postulate that the morphology and severity of osteochondral defects may be different in this population. Intraoperative records of 272 patients undergoing modified Broström-Gould procedure were reviewed for arthroscopic evidence of osteochondral defects. We characterized the morphology according to an anatomical 9-grid classification. Talar osteochondral defects were seen in 52 (19.1%) patients with a double lesion present in 1 patient. Medial-sided lesions account for nearly 3-quarters (n = 38, 73.1%) of all lesions and tend to be larger (79.4 ± 55.7 mm2 vs 51.0 ± 28.6 mm2, p =.08). There was no osteochondral defect seen in the central zones. There was no significant gender or age differences between patients with medial and lateral lesions. The most commonly performed procedure was microfracture. Osteochondral defects are commonly encountered in our Asian patients undergoing surgery for chronic lateral ankle instability. Contrary to published data, medial lesions are prevalent with no central lesions seen.

The Impact of Diabetes on Patient Outcomes After Total Knee Arthroplasty in an Asian Population.

BACKGROUND: Diabetes is implicated with poorer outcomes and more complications after total knee arthroplasty (TKA). We aim to determine whether diabetes affects infection risk, functional outcomes, patient-reported outcome measures, and patient satisfaction in Asian patients after TKA. METHODS: Prospectively collected data for 905 patients who underwent unilateral TKA by a single surgeon from February 2004 to July 2014 were reviewed, of which 123 (13.6%) patients suffered from diabetes. At 2-year follow-up, the change in range of motion of the operated knee, body mass index, Knee Society Score, Oxford Knee Score (OKS), and Short Form-36 from baseline was compared between diabetic and nondiabetic patients. We also analyzed the length of hospitalization stay, infection risk, and patient satisfaction between the 2 groups. RESULTS: Compared with nondiabetic patients, diabetic patients had significantly poorer preoperative OKS (37.6 on 8.3 to 35.8 .38.0, P = .02) and Short Form-36 Mental Component Score (48.3 Me11.2 to 51.7 1.10.7, P = .01). At 2-year follow-up, diabetes continued to be associated with poorer OKS of 21.2 018.4 and Knee Society Score Function score of 64.7 Fu20.9 compared to 19.1 0.6.2 (P = .02) and 71.8 0220.1 (P = .01) respectively in nondiabetic patients. Interestingly, the difference in mental well-being was no longer significant after TKA. A significantly larger proportion of diabetic patients (50%) had a reduction in body mass index after TKA compared to 36% in nondiabetic patients (P < .01). There was no difference in range of motion, length of hospitalization stay, infection risk, and patient satisfaction. CONCLUSION: Despite poorer physical scores throughout, diabetic patients are no less satisfied and had significantly greater improvement in mental well-being and weight reduction after surgery.

Cell-based therapy improves function in adolescents and young adults with patellar osteochondritis dissecans.

BACKGROUND: Recent advances have been made in using chondrocytes and other cell-based therapy to treat cartilage defects in adults. However, it is unclear whether these advances should be extended to the adolescent and young adult-aged patients. QUESTIONS/PURPOSES: We assessed cell-based surgical therapy for patellar osteochondritis dissecans (OCD) in adolescents and young adults by (1) determining function with the International Knee Documentation Committee (IKDC) subjective and Lysholm-Gillquist scores; and (2) evaluating activity level using the Tegner-Lysholm scale. METHODS: We retrospectively reviewed 23 patients between 12 and 21 years of age (mean 16.8 years) treated for OCD lesions involving the patella from 2001 to 2008. Twenty patients had autologous chondrocyte implantation and three patients had cultured bone marrow stem cell implantation. There were 19 males and four females. We obtained preoperative CT scans to assess patella subluxation, tilt, and congruence angle to determine choice of treatment. We obtained IKDC subjective knee evaluation scores, Tegner-Lysholm activity levels, and Lysholm-Gillquist knee scores preoperatively and at 6, 12, and 24 months postoperatively. RESULTS: Mean IKDC score, Tegner-Lysholm outcomes, and Lysholm-Gillquist scale improved from 45, 2.5, and 50, respectively, at surgery to 75, 4, and 70, respectively, at 24-month followup. Complications include periosteal hypertrophy observed in two patients. CONCLUSION: Cell-based therapy was associated with short-term improvement in function in adolescents and young adults with patellar OCD. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The double-lasso loop technique of Biceps tenodesis has lower displacement after cyclic loading, compared to interference screw fixation: Biomechanical analysis in an ovine model.

Background: Biceps tenodesis is an effective treatment for symptomatic long head of biceps tendon pathology. Recently the arthroscopic "double lasso-loop" suture anchor (DLSA) technique was described, advantaged by reduced cost, complexity, and operative time. We aimed to compare the in vitro strength of DLSA with conventional interference screws (IS). Methods: A biomechanical analysis was conducted on 14 sheep shoulders (8 DLSA, 6 IS), consisting of a 500-cycle cyclic loading experiment of 5-70 N and ultimate failure load (UFL) test where each specimen was pulled until failure. Displacement (mm) was recorded every 100 cycles, while stiffness and UFL were observed. Results: Cyclic displacement was significantly lower with DLSA at 100 cycles, but not above. During the UFL test, IS was stiffer (27.68 ± 6.56 N/mm versus 14.10 ± 5.80 N/mm, p = .005) and had higher UFL (453.67 ± 148.55 N versus 234.22 ± 44.57 N, p = .001) than DLSA. All DLSA failures occurred with suture/anchor pull-out, while all IS constructs failed at the muscle/tendon. Discussion: Comparison of the novel DLSA technique with a traditional IS method found lower initial displacement. While our IS constructs could withstand higher UFL, peak load characteristics of DLSA were similar to previous ovine studies. Hence, the DLSA technique is a viable alternative to IS for biceps tenodesis with its purported non-biomechanical advantages.

Preoperative Oswestry Disability Index Cannot Reliably Predict Patient Satisfaction After Single and Double Level Lumbar Transforaminal Interbody Fusion Surgery.

Introduction: The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery. Aims: To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving post-operative MCID and patient satisfaction. Methods: 1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score. Results: At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 (P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups. Conclusions: Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients' satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction.

Use of complementary and alternative medicine among dermatology outpatients in Singapore.

BACKGROUND/OBJECTIVES: Although the prevalence of complementary and alternative medicine (CAM) use has been studied among general and specific disease populations, little is known on the use of CAM among Asian dermatology patients. This study assesses prevalence, demographics, disease determinants, expectations and reasons for CAM use among patients visiting a major referral dermatology centre in Singapore. METHODS: A descriptive cross-sectional study of 855 dermatology outpatients was done. Consecutive sampling using interviewer-administered questionnaires collected information on patient demographics, dermatological condition, prevalence, reasons and expectations of CAM use. Patient-perceived disease severity was measured via the Dermatological Life Quality Index (DLQI). Dermatologists completed Patient Data Forms, detailing diagnosis, diagnosis date and CAM use. RESULTS: The prevalence of CAM use was 25.7%. Patients who were higher educated, held white collar occupations, had longer disease duration, higher DLQI scores or were suffering from psoriasis or eczema were more likely to have used CAM. More than 60% of patients expected dermatologists to provide at least basic CAM advice and 75% were willing to declare their CAM use. Forty percent of dermatologists accurately knew their patients' current CAM use. CONCLUSIONS: Prevalence of CAM use in dermatology patients was high. Many doctors were unaware of patients' CAM use despite most patients being willing to declare it. Patients generally expected dermatologists to provide CAM advice. Dermatologists should make a concerted effort to identify likely CAM users and consider openly discussing CAM use with them.

Predictive value of common serum glycaemic markers on periprosthetic joint infection following Total Joint Arthroplasty: A review of the literature.

It is well established that diabetes mellitus and osteoarthritis commonly exist together and among various treatment modalities for osteoarthritis, Total Joint Arthroplasty (TJA) has been effective. Prosthetic Joint Infection (PJI) is a serious complication of TJA with high costs and morbidity associated with it. The aim of this study is to provide background information and relevance of diabetes on PJI, and to conduct a review on existing literature, to find out if common serum glycaemic markers in diabetes could be used as predictors for PJI after TJA. These markers include measuring pre-operative glucose levels with glycated haemoglobin (HbA1c) or capillary blood glucose, peri-operative or post-operative blood glucose levels. We have found that existing literature studying these markers as predictors of PJI after TJA has been largely contentious. Despite not being used widely in clinical practice, serum fructosamine has been shown to be more reliable and accurate than the above-mentioned markers. Future studies should be carried out to confirm and better understand this association.

Association of the 36-Item Short Form Health Survey Physical Component Summary Score With Patient Satisfaction and Improvement 2 Years After Total Knee Arthroplasty.

Importance: Increases in total knee arthroplasty (TKA) utilization rates suggest that its indications have been expanded to include patients with less severe symptoms. A recent study challenged the cost-effectiveness of TKA in this group of patients. Objective: To determine the association of the 36-Item Short Form Health Survey physical component summary score (SF-36 PCS) with patient satisfaction 2 years after TKA. Design, Setting, and Participants: This cohort study reviewed registry data from 2 years of follow-up of patients who underwent unilateral TKA from January 1, 2010, to December 31, 2014, at a single-center tertiary institution in Singapore. Data were acquired on April 27, 2017, and analyzed from August 15, 2017, to December 22, 2017. Main Outcomes and Measures: Patient satisfaction and SF-36 PCS. Preoperative disability and postoperative function as measured by the SF-36 PCS were correlated with Δ (2-year end point score minus baseline score) and patient satisfaction, scored on a 6-point Likert scale, with lower scores indicating greater satisfaction. Results: Of the 6659 patients, 5234 (78.6%) were female and 5753 (86.4%) were of Chinese ethnicity. Mean (SD) age was 67.0 (7.7) years, and mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 27.7 (4.6). At 2-year follow-up, the mean (SD) SF-36 PCS score improved from 32.2 (10.1) to 48.2 (9.5) (P < .001). There were 1680 patients (25.2%) who described their satisfaction as excellent, 2574 (38.7%) very good, 1879 (28.2%) good, 382 (5.7%) fair, 96 (1.4%) poor, and 48 (0.7%) terrible. The minimal clinically important difference (change in SF-36 PCS of 10 from baseline) was met in 4515 patients (67.8%), and overall satisfaction was 97.8% (6515 patients). Covariance analysis showed significantly higher satisfaction in patients with preoperative scores of 40 to less than 50. Patients who were unlikely to meet the minimal clinically important difference compared with those who were likely to meet it (SF-36 PCS of ≥42.1 vs <42.1) had significantly higher 2-year satisfaction (mean [SD], 2.15 [0.9] vs 2.23 [1.0]; P = .009). Conclusions and Relevance: The findings suggest that a general health score, such as SF-36, is not associated with patient satisfaction 2 years after TKA. Functional assessment, preoperative counseling, and modification of expectations appear to remain vital before TKA.

Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery.

PURPOSE: Surgical site infection (SSI) is a serious complication following total knee arthroplasty (TKA) leading to considerable morbidity. The incidence is reported to be up to 2%. Risk factors continue to be an area of intense debate. Our study aims to report the incidence of SSI and identify possible risk factors in our patients undergoing TKA. METHODS: Prospectively collected data for 905 patients who underwent elective unilateral TKA by a single surgeon from February 2004 to July 2014 were reviewed. Patient demographics and relevant co-morbidities such as diabetes and heart disease were analysed. The presence of superficial wound infections and/or prosthetic joint infections was included. RESULTS: The overall infection rate was 1.10% (10 of 905 patients). Six patients (0.66%) were diagnosed with superficial infections and four with PJI (0.44%). The mean operative duration for TKA with SSI was significantly longer at 90.5 ± 28.2 min, compared to 72.2 ± 20.3 min in TKA without SSI ( p = 0.03). All superficial infections occurred within the first month post-surgery and were self-limiting with oral antibiotics. The four patients with PJI required repeated procedures following TKA, including debridement, implant removal and/or revision arthroplasty. None of the 10 patients had a history of diabetes. There were no significant differences in demographics and co-morbidities between those who developed infection after TKA and those who did not. CONCLUSION: An overwhelming majority had good outcomes with only four deep infections resulting in revision surgery. We report that the risk of infection in TKA was significantly associated with a longer operative duration.