The Sphygmomanometer Pain Test: A Simple Method for Identifying Patients at Risk of Excessive Pain after Total knee Arthroplasty.

BACKGROUND: Despite the overall success of total knee arthroplasty (TKA), a relatively large proportion of patients remain dissatisfied with the outcome. We hypothesized that patients with a lower threshold for pain were more likely to have worse outcomes after TKA. METHODS: Forty-eight consecutive patients with primary knee osteoarthritis graded a standardized painful stimulus caused by inflating a sphygmomanometer placed on the forearm, on a visual analog scale (VAS) scale before their TKA. We compared the VAS scores to patients' Knee Society scores and Knee Society function scores 2 years after TKA. RESULTS: Patients with a severe VAS score (>74 mm) had significantly worse Knee Society scores compared to patients with mild (0-44 mm) and moderate (45-74 mm) VAS scores (55 ± 20.5 vs 81.5 ± 11.1 and 84.8 ± 13, respectively, P = .04) and worse Knee Society Function scores (34 ± 20.7 vs 75.2 ± 17.3 and 77 ± 17.4, respectively, P = .027) at 2 years after TKA. CONCLUSIONS: Patients with a lower threshold for pain, as determined by a standardized painful stimulus, are more likely to have lower Knee Society pain and function scores after TKA.

Simultaneous Bilateral Femoral Osteonecrosis in Gaucher Disease.

Gaucher disease (GD) is one of the most common lysosomal storage disorders. Bone complications are the most critical irreversible consequence of GD. Osteonecrosis (ON) of the femoral head inevitably leads to osteoarthritis and may be managed by hip arthroplasty. The introduction and worldwide use of therapeutic agents (specifically enzyme replacement therapies (ERT)) lowered the prevalence of osteonecrosis events per patient. We present the cases of two female patients who sustained simultaneous bilateral femoral head osteonecrosis after receiving ERT for long periods while exposed to concomitant risk factors related to femoral head ON. Both patients suffered severe pain and deterioration of their daily activity capabilities, and thus, were offered bilateral hip arthroplasty. Surgery was performed in both hip joints during the same procedure. The current report highlights several key aspects of femoral head ON in young patients with GD.

Minimum 2-Year Radiographic and Clinical Outcomes of Kinematic Alignment Total Knee Arthroplasty in the Valgus Knee.

Kinematic alignment (KA) total knee arthroplasty (TKA) has gained popularity in the past decade, but outcomes of KA-TKA in the valgus knee have never been specifically evaluated. In this retrospective single institution study, we analyzed patient reported outcomes and radiographic measurements at minimum 2 years following KA-TKA for valgus knees (n = 51) and compared the results to KA-TKA performed for non-valgus knees (n = 275). The same approach, technique, and implants were used in both groups without the need to release soft tissues or use constrained implants. Surgery duration was similar between groups (p = 0.353). Lateral distal femoral angle was lower in the valgus group postoperatively (p = 0.036). In both groups significant improvement was seen in relieving pain and improving function, while average scores were superior in the non-valgus group for visual analog score (p = 0.005), oxford knee score (p = 0.013), and knee injury and osteoarthritis outcome score (p = 0.009). However, these differences did not translate to statistically significant differences in minimal clinical important difference achievement rates. In conclusion, KA-TKA is efficient in relieving pain and improving function, as reported in subjective questionnaires, and holds advantage in patients with valgus alignment by avoiding soft tissue releases and use of constrained implants. Future studies should examine whether bone loss occurs in the lateral distal femur.

Excessive Sagittal Slope of the Tibia Component during Kinematic Alignment-Safety and Functionality at a Minimum 2-Year Follow-Up.

The aim of this study was to assess the safety and functional outcomes of excessive sagittal alignment in the unrestricted kinematic alignment technique for total knee arthroplasty (TKA). A retrospective, single-center study was conducted between 2018 and 2020, including patients undergoing primary TKA with a minimum 2-year follow-up. EOS imaging conducted before and after surgery was reviewed for overall alignment, and a number of measurements were taken, including sagittal tibial slope and other tibia and femur component positioning. Patients were interviewed and asked to fill out several questionnaires including a visual analog scale, the Oxford Knee Score, and the Knee Injury and Osteoarthritis Outcome Score. Overall, 225 patients (66.7%) had a sagittal tibial slope angle above 5° (excessive) and 112 (33.3%) patients had an angle under 5° (moderate). A significant improvement in pain and function scores was observed in both groups following the surgery (p < 0.001). There were no significant differences between the moderate and excessive groups in the average VAS, OKS or the various subtypes of the KOOS score. However, there was a slight but significant difference in the number of patients achieving MCID in KOOS symptoms. There were no cases of early failure or loosening. Unrestricted KA and the excessive sagittal alignment of the tibial component seem to be reliable and safe in terms of restoring daily function and alleviating pain after a minimum of 2 years following the surgery.

Minimum 2-Year Radiographic and Clinical Outcomes of Unrestricted Kinematic Alignment Total Knee Arthroplasty in Patients with Excessive Varus of the Tibia Component.

Kinematic alignment (KA) total knee arthroplasty (TKA) has gained much attention in recent years. However, debate remains on whether restrictions should be made on the tibia cut. The purpose of this study was to assess the safety and functional outcomes of excessive varus cuts. A single-center, retrospective analysis of consecutive patients undergoing TKA between 2018 and 2020 who had a minimum 2-year follow-up was conducted. EOS™ imaging conducted before and after surgery was analyzed for overall alignment, as well as for tibia and femur component positioning on the coronal planes. Patients were interviewed and asked to fill several questionnaires, including the visual analog score, Oxford knee score, and knee injury and osteoarthritis outcome score. Overall, 243 patients (71.9%) had a coronal tibial plate angle under 5° (moderate) and 95 patients (28.1%) had an angle above 5° (excessive). There were no significant differences between the moderate and excessive groups in patient-reported outcomes, nor were there differences in the number of patients achieving the minimal clinical difference. There were no cases of catastrophic failure or loosening. Unrestricted KA and excessive varus of the tibial component appears to be safe and efficient in relieving pain and restoring function for a minimum of 2 years following surgery.

Reliability and validity of the Hebrew version of the forgotten joint score for assessing the outcomes of total knee arthroplasty.

BACKGROUND: This prospective study aimed to assess the reliability and validity of the Hebrew version of the forgotten joint score-12 in patients undergoing total knee arthroplasty, because it is going to be used in the Hebrew-speaking populations in Israel. METHODS: The English version of forgotten joint score-12 was translated into Hebrew version by using the standard procedures and in collaboration with its authors. The consecutive patients who had undergone total knee arthroplasty in a single hospital were asked to fill out the Hebrew version of forgotten joint score-12, Oxford knee score, Short Form 12, and visual analog scale. A random subgroup of 60 patients were then asked to fill out a second Hebrew version of forgotten joint score-12 at a minimum of 2-week interval. The reliability was assessed in terms of internal consistency, test-retest reliability and split-half reliability. The validity was measured in terms of the outcomes as mentioned above. RESULTS: A total of 102 patients participated in the study. The Hebrew version of forgotten joint score-12 showed high reliability. The internal consistency was excellent (Cronbachs' α = 0.943) and test-retest reliability was high (Intraclass correlation = 0.97). The forgotten joint scores were correlated with the Oxford knee score, Short Form 12, and visual analog scale (r = 0.86, r = 0.72, and r=-0.8, respectively), indicating a high validity. CONCLUSIONS: The Hebrew version of forgotten joint score-12 has excellent reliability, excellent test-retest reliability and good validity. It can be safely used for assessing outcomes of TKA.

A treatment applying a biomechanical device to the feet of patients with knee osteoarthritis results in reduced pain and improved function: a prospective controlled study.

BACKGROUND: This study examined the effect of treatment with a novel biomechanical device on the level of pain and function in patients with knee OA. METHODS: Patients with bilateral knee OA were enrolled to active and control groups. Patients were evaluated at baseline, at 4 weeks and at the 8-week endpoint. A novel biomechanical device was individually calibrated to patients from the active group. Patients from the control group received an identical foot-worn platform without the biomechanical elements. Primary outcomes were the WOMAC Index and ALF assessments. RESULTS: There were no baseline differences between the groups. At 8 weeks, the active group showed a mean improvement of 64.8% on the WOMAC pain scale, a mean improvement of 62.7% on the WOMAC function scale, and a mean improvement of 31.4% on the ALF scale. The control group demonstrated no improvement in the above parameters. Significant differences were found between the active and control groups in all the parameters of assessment. CONCLUSIONS: The biomechanical device and treatment methodology is effective in significantly reducing pain and improving function in knee OA patients.The study is registered at clinicaltrials.gov, identifier NCT00457132, http://www.clinicaltrials.gov/ct/show/NCT00457132?order=1.

The Missing Piece: A Subtrochanteric Hip Fracture Presenting with Abdominal Pain: A Case Report.

CASE: A 33-year-old man presented with acute abdominal and left hip pain after being struck by a motor vehicle. Radiographs revealed a comminuted left subtrochanteric femoral fracture. Computed tomography demonstrated a large pelvic hematoma and a radiopaque mass in the abdomen. Laparoscopy revealed the mass to be a large bone fragment lying within the greater omentum. The bone fragment, which seemed to be a femoral fracture fragment, was removed, and the fracture was repaired with a short cephalomedullary nail. CONCLUSION: Rarely, subtrochanteric fracture fragments can penetrate the pelvis or abdomen because of high-energy trauma. Recognizing this possibility is important to assure a correct diagnosis and subsequent treatment.

The correlation between pes planus and anterior knee or intermittent low back pain.

BACKGROUND: Anterior knee pain and intermittent low back pain are among the most common orthopedic complaints of adolescents. However, little is known about pes planus and its relative risk for these symptoms. The goal of the study was to track the prevalence of pes planus in adolescents, and examine its associated risk to anterior knee pain and intermittent low back pain, respectively. MATERIALS AND METHODS: A retrospective study of 97,279 military recruits presenting to recruitment centers was conducted. Pes planus was graded by an orthopedist as mild, moderate or severe according to the flattening of the plantar arch and its rigidity to standing on one's toes. Anterior knee pain was diagnosed when symptoms were attributed to the patellofemoral joint. Intermittent low back pain was diagnosed when there was pain but neither abnormal clinical nor radiographic findings. RESULTS: Pes planus was present in 15,698 (16%) individuals. 11,549 (74%), 3,341 (21%) and 808 (5%) were diagnosed as having mild, moderate and severe pes planus, respectively. The prevalence of intermittent low back pain was 5% in both the control and mild pes planus groups, while it was 10% in the moderate and severe pes planus groups (p < 0.0001). The prevalence of anterior knee pain was 4% in both the control and mild pes planus groups, while it was 7% in the moderate and severe pes planus groups (p < 0.0001). CONCLUSION: Moderate and severe pes planus was associated with nearly double the rate of anterior knee pain and intermittent low back pain, while mild pes planus was associated with no higher rate for these problems. Prophylactic measures may be helpful only in those adolescents with moderate and severe pes planus.

Severe vascular complications and intervention following elective total hip and knee replacement: A 16-year retrospective analysis.

INTRODUCTION: Iatrogenic vascular injuries associated with elective orthopaedic joint procedures are relatively rare, however when they do occur they carry a risk of significant morbidity and mortality. The aim of this study was to investigate the incidence of vascular complications and resultant need for specialist intervention following elective total hip replacement (THR) and total knee replacement(TKR). METHODS: This was a retrospective analysis of prospectively collected data. The primary outcome measure was vascular complication requiring an interventional radiology procedures or vascular surgery. As a secondary outcome measure postoperative Modified Knee Society Scores and Harris Hip Scores were analysed to assess long term clinical outcome. RESULTS: Six cases of vascular injury requiring specialist intervention were identified. From 2073 total TKRs there were one cases of popliteal artery injury, one case of venous injury and two case of lateral geniculate artery injury (0.19%). From 1601 THRs there were two cases (0.12%) of arterial injury. All patients were treated successfully by a vascular surgeon or an interventional radiologist. Patient outcome varied considerably with the poorest results seen in the THR group. CONCLUSIONS: Iatrogenic vascular complications following elective THR and TKR carry a risk of significant morbidity and mortality. It is important that surgeons and trainees performing these procedures are conscious of these risks and able to identify vascular injuries promptly when they occur. Detailed preoperative assessment, an awareness of anatomical variants and close liaison with a vascular surgeon may all help to reduce the number and severity of adverse outcomes.

New approach for the rehabilitation of patients following total knee arthroplasty.

PURPOSE: To investigate the effect of a biomechanical therapy on gait, function and clinical condition in patients following total knee arthroplasty (TKA). METHODS: Seventeen TKA patients participated in the study. Patients received a biomechanical therapy AposTherapy). Patients underwent a gait test, clinical examination and an assessment of pain, function and quality of life (QOL). Patients were examined again at one, three and six month follow-ups. RESULTS: A significant improvement over time was found in most gait measurements. Significant improvements were also found in pain, function and QOL. CONCLUSIONS: The examined biomechanical therapy may help in the rehabilitation process following TKA.

Long-Term Effects of AposTherapy in Patients with Osteoarthritis of the Knee: A Two-Year Followup.

Several biomechanics treatments for knee osteoarthritis (OA) have emerged with the goal of reducing pain and improving function. Through this, researchers have hoped to achieve a transition from the pathological gait patterns to coordinated motor responses. The purpose of the study was to determine the long-term effects of a therapy using a biomechanical device in patients with knee OA. Patients with knee OA were enrolled to active and control groups. The biomechanical device used in therapy (AposTherapy) was individually calibrated to each patient in the active group. Patients in the control group received standard treatment. Outcomes were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), Aggregated Locomotor Function (ALF), Short Form 36 (SF-36), and Knee Society Score assessments. The active and control groups were similar at the baseline (group difference in all scores P > 0.05). The active group showed a larger improvement over time between groups in all three WOMAC categories (F = 16.8, 21.7, and 18.1 for pain, stiffness, and function; all P < 0.001), SF-36 Physical Scale (F = 5.8; P = 0.02), Knee Society Knee Score (F = 4.3; P = 0.044 ), and Knee Society Function Score (F = 6.5; P = 0.014 ). At the two-year endpoint, the active group showed significantly better results (all P ≤ 0.001). The groups showed a difference of 4.9, 5.6, and 4.7 for the WOMAC pain, stiffness, and function scores, respectively, 10.8 s in ALF score, 30.5 in SF-36 Physical Scale, 16.9 in SF-36 Mental Scale, 17.8 in Knee Society Knee Score, and 25.2 in Knee Society Function Score. The biomechanical therapy examined was shown to significantly reduce pain and improve function and quality of life of patients with knee OA over the long term.

A non-invasive biomechanical device and treatment for patients following total hip arthroplasty: results of a 6-month pilot investigation.

BACKGROUND: The purpose of the study was to examine the effect of a foot-worn biomechanical device on the clinical measurements and gait patterns of patients with total hip arthroplasty (THA). METHODS: Nineteen patients, up to 3 months post-THA, were enrolled to the study. Patients underwent a computerized gait analysis to calculate spatiotemporal parameters and completed the Western Ontario and McMaster Universities osteoarthritis index and the SF-36 health survey. Patients then began therapy with a non-invasive foot-worn biomechanical device coupled with a treatment methodology (AposTherapy). Patients received exercise guidelines and used the device daily during their regular activities at their own environment. Follow-up examinations were conducted after 4, 12, and 26 weeks of therapy. Repeated measures ANOVA was used to evaluate changes over time. The clinical significance of the treatment effect was evaluated by computing the Cohen's effect sizes (ES statistic). RESULTS: After 26 weeks of therapy, a significant improvement was seen in gait velocity (50.3%), involved step length (22.9%), and involved single limb support (16.5%). Additionally, a significant reduction in pain (85.4%) and improvement in function (81.1%) and quality of life (52.1%) were noted. CONCLUSIONS: Patients following THA demonstrated a significant improvement in gait parameters and in self-assessment evaluations of pain, function, and quality of life. We recommend further RCTs to examine the effect of this therapy compared to other rehabilitation modalities following THA and compared to healthy matched controls. TRIAL REGISTRATION: Clinical trial registration number NCT01266382.

The outcome of a novel biomechanical therapy for patients suffering from anterior knee pain.

BACKGROUND: This study was devised to examine the effect of a novel biomechanical therapy for patients suffering from anterior knee pain (AKP). METHODS: A retrospective analysis of 48 patients suffering from AKP was performed. Patients underwent a gait evaluation, using an electronic walkway mat, and completed the SF-36 health survey and the WOMAC questionnaire at baseline and after 3 and 6months of therapy. A special biomechanical device was individually calibrated for each patient. AposTherapy is a functional, non-invasive rehabilitation therapy consisting of a biomechanical foot-worn device that is used during activities of daily living. Repeated measures analyses were performed to compare gait parameters and self-evaluation questionnaires between baseline, 3months and 6months. RESULTS: Walking velocity significantly increased by 5.7cm/s, cadence increased by 1.6 steps/minute, and stride length increased by 3.4cm in relation to pretreatment testing (p<0.001 for all). End-point evaluation revealed additional improvement of these parameters; however these did not significantly differ from that of mid-treatment. Pain decreased by 36.6% and 49.2% following 13 and 26 weeks of treatment, respectively (P<0.01) and function improved by 25.2% and 41.7% following 13 and 26 weeks of treatment, respectively (P=0.01). CONCLUSIONS: Based on the current study's results it may be concluded that this therapy might have a positive effect for patients with AKP.

Differences in gait pattern parameters between medial and anterior knee pain in patients with osteoarthritis of the knee.

BACKGROUND: Patients with osteoarthritis of the knee have unique spatiotemporal gait alterations. These gait changes have not yet been differentiated according to the location of knee pain. The purpose of this study was to compare the gait patterns of patients with symptomatic knee osteoarthritis that exhibit either anterior or medial joint pain. METHODS: 240 Patients with knee osteoarthritis were evaluated at one therapy center. Patients were divided into two groups according to the location of greatest pain in their worse knee. Patients underwent a computerized spatiotemporal gait analysis. Differences in gait patterns between the two knee pain locations were also examined within each gender. FINDINGS: Compared with patients with pain in the anterior knee compartment, those with pain in the medial knee compartment exhibited a significantly slower walking speed (P<0.01), shorter step length (P<0.01), lower single-limb-support phase (P<0.01). These differences are witnessed mainly between the females in each group, whereas males differed only in single-limb-support. INTERPRETATION: The results of this study suggested underlying gait differences in the nature of medial and anterior knee pain. Furthermore, gender differences in gait may exist between patients with medial knee pain compared to patients with anterior knee pain.

The effect of hyaluronan injections into human knees on the number of bone and cartilage wear particles captured by bio-ferrography.

Osteoarthritis is characterized by degradation of cartilage and subchondral bone, releasing wear particles into the synovial fluid. Intra-articular injections of exogenous hyaluronan are often given to patients suffering from osteoarthritis in order to compensate for the reduction in the level of endogenous hyaluronan and to restore the rheological properties of the synovial fluid. The exact effect of these injections is still ambiguous. In this work bio-ferrography was used to capture magnetically labeled cartilage and bone debris from the synovial fluid in human knees before each of four injections (Euflexxa). The wear particles were counted and characterized microscopically and chemically. WOMAC, VAS, SF-36 and KS questionnaires indicated significant pain relief during the treatment, but suffered from inconsistency. Bio-ferrography showed a reduction in the concentration of both cartilage and bone particles, with a minimum after the third hyaluronan injection. The advantages of bio-ferrography as a primary assessment tool are discussed. The results indicate that while hyaluronan treatment may temporarily slow the wear rate to an extent beyond a placebo effect, it does not prevent joint degradation altogether.

The Chondrogenic Potential of Mesenchymal Cells and Chondrocytes from Osteoarthritic Subjects: A Comparative Analysis.

OBJECTIVE: The multipotential nature of stem or progenitor cells apparently makes them the ideal choice for any cell therapy, but this as yet remains to be proven. This study (30 subjects) was designed to compare the potential to repair articular cartilage of chondrocytes taken from different regions in osteoarthritic cartilage with that of mesenchymal stem cells prepared from bone marrow of the same subject. DESIGN: Cartilage biopsies, bone marrow, and blood samples were taken from each of 30 individuals with chronic osteoarthritis (aged 62-85 years) undergoing total knee replacement. The chondrogenic potential of chondrocytes isolated from cartilage biopsies taken from different regions of osteoarthritic cartilage was compared with that of mesenchymal cells by quantitative analysis of several chondrocyte specific markers and an ex vivo cartilage differentiation assay. RESULTS: Cartilage-derived articular chondrocytes are superior to bone marrow-derived cells when compared for their ex vivo chondrogenic potential. Interestingly, there was marked and significant difference in the expression of chondrocytic markers between chondrocytes derived from adjacent, visually distinct regions of the diseased cartilage. When cultured in the presence of a fibroblast growth factor 2 variant, all cell samples from both tissues showed a high degree of chondrogenic potential. CONCLUSIONS: Although bone marrow-derived mesenchymal cells, when supplemented with the appropriate chondrogenic factors, are a suitable source for autologous cartilage implantation, adult chondroprogenitor cells, particularly those from moderately affected regions of the osteoarthritic joints, demonstrate superior chondrogenic potential.

The use of dynamic CT surview for cervical spine clearance in comatose trauma patients: a pilot prospective study.

BACKGROUND: Bedside flexion and extension fluoroscopy was proposed for detecting occult ligamentous instability in comatose trauma patients. Nevertheless, a recent study showed that the C7-T1 motion segment is rarely visualised by this technique. We propose a new method for clearing the cervical spine in comatose patients. METHODS: We conducted a prospective clinical pilot study on 31 consecutive comatose trauma patients to evaluate a new dynamic imaging technique for cervical spine clearance in comatose trauma patients. All patients were examined by a fine-cut helical CT scan of the entire cervical spine (C-spine) and by four-stage flexion-extension examination using the surview function of the CT scanner. The mean range of motion between extension and full flexion, the lowest visualised vertebrae, complications, positive findings, and the time from arrival to clearance was recorded. RESULTS: The mean range of motion of the subaxial cervical spine was 39 degrees . The C7-T1 segment was fully visualised at the CT surview in 15 patients. The C6-C7 segment was visualised in all patients. No complication directly related to the study protocol was observed. C-spine clearance was completed in less than 6h from arrival in 26 patients. CONCLUSION: The CT surview allows better visualisation of the C6-C7 and cervicothoracic junctions during flexion and extension. A short series of CT cuts can be used when visualisation is inadequate. Further studies are needed to assess the risks and benefits of the suggested protocol.