Intra-operative assessment of the vascularisation of a cross section of the meniscus using near-infrared fluorescence imaging.

PURPOSE: The purpose of this study was to assess whether the vascularisation of the meniscus could be visualised intra-operatively using near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) in patients undergoing total knee arthroplasty (TKA). METHODS: The anterior horn (i.e., Cooper classification: zones C and D) of the meniscus that was least affected (i.e., least degenerative) was removed during TKA surgery in ten patients to obtain a cross section of the inside of the meniscus. Thereafter, 10 mg of ICG was injected intravenously, and vascularisation of the cross section of the meniscus was assessed using the Quest spectrum NIRF camera system. We calculated the percentage of patients in whom vascularisation was observed intra-operatively using NIRF imaging compared to immunohistochemistry. RESULTS: Meniscal vascularisation using NIRF imaging was observed in six out of eight (75%) patients in whom vascularisation was demonstrated with immunohistochemistry. The median extent of vascularisation was 13% (interquartile range (IQR) 3-28%) using NIRF imaging and 15% (IQR 11-23%) using immunohistochemistry. CONCLUSION: This study shows the potential of NIRF imaging to visualise vascularisation of the meniscus, as vascularisation was observed in six out of eight patients with histologically proven meniscal vascularisation. LEVEL OF EVIDENCE: IV.

Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: a randomized controlled trial in 100 patients with 1-year follow-up.

PURPOSE: The purpose of this study was to compare clinical outcomes in the first postoperative year of patients with full-thickness small to medium-sized tears undergoing all-arthroscopic (AA) versus mini-open (MO) rotator cuff repair. METHODS: One hundred patients were randomized to either AA or MO rotator cuff repair at the time of surgery on an intention-to-treat basis. Patients were evaluated before and 6, 12, 26, and 52 weeks after surgery using the Disabilities of the Arm, Shoulder, and Hand (DASH) score as a primary outcome score and the Constant-Murley score, visual analog scale (VAS)-pain/impairment score, and measurement of active forward flexion/external rotation as secondary outcome measures. Ultrasound evaluation was used to assess structural integrity of the repair 1 year postoperatively. RESULTS: Forty-seven patients were analyzed in the AA group and 48 in the MO group. Five patients were lost to follow-up. Mean age was 57.2 (SD 8.0) years in the AA group and 57.8 (SD 7.9) years in the MO group. Primary and secondary outcome measures significantly improved in both groups postoperatively. Overall mean primary and secondary postoperative outcome scores did not statistically significantly differ between the treatment groups (DASH between-group mean difference: -3.4; 95% confidence interval [CI], -10.2 to 3.4; P = .317). However, at the 6-week follow-up, DASH score, VAS-pain and -impairment, and active forward flexion were significantly more improved in the AA group than in the MO group. A retear was seen in 8 patients (17%) in the AA group and 6 patients (13%) in the MO group. Five patients in the AA group (11%) and 6 patients (13%) in the MO group developed adhesive capsulitis. CONCLUSIONS: Functional outcome, pain, range of motion, and complications do not significantly differ between patients treated with all-arthroscopic repair and those treated with mini-open repair in the first year after surgery. Patients do attain the benefits of treatment somewhat sooner (6 weeks) with the arthroscopic procedure. LEVEL OF EVIDENCE: Level II, randomized controlled trial without postoperative blinding.

Preoperative agreement on the geometric classification and 2-dimensional measurement of rotator cuff tears based on magnetic resonance arthrography.

PURPOSE: To determine the intraobserver and interobserver agreement on the geometric classification and 2-dimensional measurements of rotator cuff tears based on magnetic resonance arthrography. METHODS: We retrospectively reviewed preoperative magnetic resonance arthrograms of 73 consecutive patients who were surgically treated for their full-thickness rotator cuff tears. The images were blinded and evaluated by 2 orthopaedic shoulder surgeons and 2 musculoskeletal radiologists using the geometric classification of rotator cuff tears (type 1, crescent-shaped tear; type 2, longitudinal U- or L-shaped tear; type 3a, massive tear measuring between 20 and 30 mm; and type 3b, massive contracted tear measuring >30 mm) and measuring the sagittal/coronal dimensions of the tear. Review was performed twice with an interval of at least 8 weeks. Agreement was calculated using the linear weighted κ coefficient and the intraclass correlation coefficient (ICC). RESULTS: The intraobserver agreement was excellent for both the geometric classification and the sagittal/coronal dimension measurement (κ, 0.81 to 0.92; ICC, 0.84 to 0.98). The ICC for the interobserver agreement was excellent for all sagittal and coronal dimension measurements (ICC, 0.95 to 0.97). The interobserver agreement for the geometric classification was good for the orthopaedic surgeons (κ, 0.75 for round 1 and 0.73 for round 2). The interobserver agreement for the radiologists was excellent in observation round 1 (κ, 0.82) and good in observation round 2 (κ, 0.71). The interobserver agreement between orthopaedic surgeons and radiologists was found to be moderate to good (κ, 0.52 to 0.66). The Fleiss κ was 0.66 for round 1 and 0.62 for round 2. CONCLUSIONS: The geometric classification and the 2-dimensional measurement of rotator cuff tears using magnetic resonance arthrography have good to excellent intraobserver agreement and moderate to good interobserver agreement among experienced observers. LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients without consistently applied gold standard.

The Occurrence of Meniscal and Chondral Injury in Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Consecutive Case Series.

Two-stage revision anterior cruciate ligament (ACL) reconstruction is an effective way to revise suboptimal tunnel-placement allowing for proper graft fixation. However, prolonged increased laxity of the knee may increase the risk of meniscal or chondral injury. It was hypothesized that no additional meniscal or chondral lesions occur in between the two stages of the two-stage revision ACL reconstruction. In this retrospective study, 42 patients undergoing a two-stage revision ACL reconstruction were included. Surgical notes for both stages were screened for meniscal and chondral status, interventions to any concurrent injury, surgery dates, along with basic patient characteristics. In 4 of the 42 patients, a new meniscal tear occurred in between the two stages, of which three required partial meniscectomy during the second stage of the ACL revision. One patient experienced a new small degenerative tear that did not require intervention. Two out of the four menisci that were repaired during the first stage had failed and required partial meniscectomy. No significant difference was found in the time between the two stages with respect to the occurrence of meniscal tears. No significant differences in chondral status were found. In conclusion, approximately 10% of patients developed a new meniscal tear and no difference in macroscopic chondral injury was observed between the first and second stages.

The Effect of an App for Day-to-Day Postoperative Care Education on Patients With Total Knee Replacement: Randomized Controlled Trial.

BACKGROUND: Patients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient's self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it. OBJECTIVE: This study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed. METHODS: A multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures. RESULTS: In total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P<.001) and pain at night (mean 4.18 vs mean 5.21; P=.003). Additionally, significant differences were demonstrated in favor of the intervention group for all secondary outcomes. CONCLUSIONS: In the four weeks following TKR, the active and day-to-day education of patients via the app significantly decreased their level of pain and improved their physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption compared to standard patient education. Given the rising number of TKR patients and the increased emphasis on self-management, we suggest using an app with timely postoperative care education as a standard part of care. TRIAL REGISTRATION: Netherlands Trial Register NTR7182; https://www.trialregister.nl/trial/6992.

Time Interval between Trauma and Arthroscopic Meniscal Repair Has No Influence on Clinical Survival.

Arthroscopic meniscal repair is the gold standard for longitudinal peripheral meniscal tears. The time interval between trauma and meniscal repair remains controversial. The aim of this study was to evaluate failure rates and clinical outcome of arthroscopic meniscal repair in relation to chronicity of injury. A total of 238 meniscal repairs were performed in 234 patients. Anterior cruciate ligament (ACL) was reconstructed in almost all ACL-deficient knees (130 out of 133). Time interval between injury and repair was divided into acute (< 2 weeks), subacute (> 2 to < 12 weeks), and chronic (> 12 weeks). Patients completed postal questionnaires to evaluate clinical outcome and failure rates. Study instruments included Lysholm, Knee injury and Osteoarthritis Outcome Score (KOOS), and Tegner scoring systems. At a median follow-up of 41 months (interquartile range [IQR], 34-53 months) 55 medial and 10 lateral meniscal repairs failed (overall failure rate, 27%). There was a significant higher failure rate for medial meniscal repair (p < 0.05) and ACL-deficient knees without ACL reconstruction. Functional outcome scores showed only significant differences on the KOOS subscale "function in daily living" (95% confidence interval, 1.05-15.27, p < 0.05). No significant difference was found for any interval between trauma and repair. The interval between trauma and arthroscopic meniscal repair has no influence on the failure rate. Differences in survival rate of meniscal repair are more dependent on location of the lesion and ACL status, rather than chronicity of injury.

[Diagnosis and treatment of rotator cuff tears]. / Rupturen in de rotatorcuff: diagnose en behandeling.

A rotator cuff tear is a highly prevalent disorder, occurring in 25% of people over 60 years of age. In two thirds of patients the tear is small and asymptomatic. Acute, symptomatic cuff tears may occur in active sportsmen and women aged 30-50. There is often a considerable delay in diagnosis in this group, due to a lack of recognition by either the patient or the doctor. Recently identified risk factors for the development of cuff tear are nicotine abuse, hypercholesterolaemia, contralateral cuff tear and genetic predisposition. Conservative treatment can be very successful and consists of physical therapy and effective analgesics. Repeated steroid injections are harmful to the tendinous tissue and should be avoided. The aim of surgery is anatomical reinsertion of the ruptured tendon using an open or arthroscopic procedure. The arthroscopic procedure enables the surgeon to perform a more extensive evaluation and treatment of the joint. The arthroscopic procedure is technically more demanding than the open procedure, but seems to have a shorter rehabilitation period.