Association between synovial tissue damage and pain in late-stage knee osteoarthritis: A cross-sectional study.

OBJECTIVE: To identify the presence and distribution of histopathological features of synovial inflammation and tissue damage, and to test their associations with ultrasound (US) imaging measures of synovitis and patient-reported measures of pain in knee osteoarthritis (OA). DESIGN: In the cross-sectional study of 122 patients undergoing surgery for painful late-stage (Kellgren-Lawrence Grade 3 or 4) knee OA, we compared US measures of synovitis (n = 118) and pain (Knee Injury and Osteoarthritis Outcome Score) to histopathological measures of inflammation vs. synovial tissue damage in synovial tissue biopsies. Associations of histopathological features with US measures of inflammation or pain were assessed using linear or logistic regression while controlling for covariates. RESULTS: Histopathological features of inflammation were associated with higher odds of moderate/severe US synovitis (odds ratio [OR] = 1.34 [95%CI 1.04, 1.74), whereas features of synovial tissue damage were associated with lower odds of moderate/severe US synovitis (OR = 0.77 [95%CI 0.57, 1.03]). Worse histopathological scores for synovial tissue damage were associated with more pain (-1.47 [95%CI -2.88, -0.05]), even while adjusting for synovial inflammation (-1.61 [95%CI -3.12, -0.10]). CONCLUSIONS: Synovial tissue damage is associated with pain in late-stage knee OA, independent from inflammation and radiographic damage. These novel findings suggest that preventing synovial tissue damage may be an important goal of disease-modifying OA therapy.

Test-retest reliability and longitudinal validity of drop vertical jump biomechanics during rehabilitation after ACL reconstruction.

Hip and knee biomechanics measured during a drop vertical jump (DVJ) can be used to assess patients undergoing rehabilitation after anterior cruciate ligament (ACL) reconstruction. To confidently interpret such data for use as outcome measures, additional information about reliability and validity is required. Therefore, the objective of this study was to estimate the test-retest reliability and longitudinal validity of selected lower limb biomechanics assessed during a DVJ in patients undergoing rehabilitation after ACL reconstruction. Biomechanical analysis of the DVJ in primary unilateral ACL reconstruction patients (22.3 ± 5.5y) were tested twice within 1 week at 6 months post-surgery (n = 46), and again at 12 months post-surgery (n = 36). Peak and initial contact knee angles and moments, hip impulse, vertical ground reaction forces (VGRF), isokinetic knee extension and flexion strength, and global ratings of change (GRC) were assessed. Reliability was evaluated based on the 6-month post-surgery data using intraclass correlation coefficients (ICC2,1), standard errors of measurement and minimum detectable change. Longitudinal validity was evaluated by assessing change from 6 to 12 months, using standardized response means (SRM), and by assessing the correlation (Pearson's r) of change in landing biomechanics with change in strength, and GRC. ICCs ranged from 0.58 to 0.90 for peak knee abduction and flexion moments, 0.44-0.85 for knee flexion and abduction angles, 0.82-0.93 for VGRFs, and 0.42-0.65 for hip impulse. SRMs and correlations of change ranged from 0.00 to 0.50. Reliability and longitudinal validity of DVJ measures varied, ranging from poor-to-excellent; the present results assist in their interpretation when assessed during rehabilitation after ACL reconstruction.

Incidence of Total Knee Arthroplasty After Arthroscopic Surgery for Knee Osteoarthritis: A Secondary Analysis of a Randomized Clinical Trial.

Importance: It is unclear whether arthroscopic resection of degenerative knee tissues among patients with osteoarthritis (OA) of the knee delays or hastens total knee arthroplasty (TKA); opposite findings have been reported. Objective: To compare the long-term incidence of TKA in patients with OA of the knee after nonoperative management with or without additional arthroscopic surgery. Design, Setting, and Participants: In this ad hoc secondary analysis of a single-center, assessor-blinded randomized clinical trial performed from January 1, 1999, to August 31, 2007, 178 patients were followed up through March 31, 2019. Participants included adults diagnosed with OA of the knee referred for potential arthroscopic surgery in a tertiary care center specializing in orthopedics in London, Ontario, Canada. All participants from the original randomized clinical trial were included. Data were analyzed from June 1, 2021, to October 20, 2022. Exposures: Arthroscopic surgery (resection or debridement of degenerative tears of the menisci, fragments of articular cartilage, or chondral flaps and osteophytes that prevented full extension) plus nonoperative management (physical therapy plus medications as required) compared with nonoperative management only (control). Main Outcomes and Measures: Total knee arthroplasty was identified by linking the randomized trial data with prospectively collected Canadian health administrative datasets where participants were followed up for a maximum of 20 years. Multivariable Cox proportional hazards regression models were used to compare the incidence of TKA between intervention groups. Results: A total of 178 of 277 eligible patients (64.3%; 112 [62.9%] female; mean [SD] age, 59.0 [10.0] years) were included. The mean (SD) body mass index was 31.0 (6.5). With a median follow-up of 13.8 (IQR, 8.4-16.8) years, 31 of 92 patients (33.7%) in the arthroscopic surgery group vs 36 of 86 (41.9%) in the control group underwent TKA (adjusted hazard ratio [HR], 0.85 [95% CI, 0.52-1.40]). Results were similar when accounting for crossovers to arthroscopic surgery (13 of 86 [15.1%]) during follow-up (HR, 0.88 [95% CI, 0.53-1.44]). Within 5 years, the cumulative incidence was 10.2% vs 9.3% in the arthroscopic surgery group and control group, respectively (time-stratified HR for 0-5 years, 1.06 [95% CI, 0.41-2.75]); within 10 years, the cumulative incidence was 23.3% vs 21.4%, respectively (time-stratified HR for 5-10 years, 1.06 [95% CI, 0.45-2.51]). Sensitivity analyses yielded consistent results. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial of arthroscopic surgery for patients with OA of the knee, a statistically significant association with delaying or hastening TKA was not identified. Approximately 80% of patients did not undergo TKA within 10 years of nonoperative management with or without additional knee arthroscopic surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT00158431.

Sex-Differences and Associations Between Complement Activation and Synovial Vascularization in Patients with Late-Stage Knee Osteoarthritis.

Purpose: Synovial inflammation in knee osteoarthritis (OA) causes disorganized synovial angiogenesis and complement activation in synovial fluid, but links between complement and synovial microvascular pathology have not been established. Since complement causes vascular pathology in other diseases and since sex-differences exist in complement activation and in OA, we investigated sex differences in synovial fluid complement factors, synovial tissue vascular pathology, and associations between complement and synovial vascular pathology in patients with late-stage knee OA. Methods: Patients with symptomatic, late-stage radiographic knee OA undergoing total knee arthroplasty or high tibial osteotomy provided matched synovial fluid and tissue biopsies during surgery. Complement factors (C2, C5, adipsin, MBL, and CFI) and terminal complement complex (sC5b-C9) were measured in synovial fluid by multiplex or enzyme-linked immunosorbent assay, respectively. Features of synovial vascular pathology (vascularization, perivascular edema, and vasculopathy) were assessed by histopathology. Multivariate linear regression models were used to assess associations between synovial fluid complement factors and histopathological features of vascular pathology, with adjustment for age, sex, body mass index, and sex interaction. Sex-disaggregated comparisons were completed. Results: Synovial fluid biomarker and histopathology data were included from 97 patients. Most synovial fluid complement factors and synovial tissue histopathological features were similar between sexes. Synovial fluid C5 trended to lower levels in males (-20.93 ng/mL [95%CI -42.08, 0.23] p=0.05). Median vasculopathy scores (0.42 [95%CI 0.07, 0.77] p=0.02) were higher in males. In the full cohort, C5 concentration was associated with lower vascularization scores (-0.005 [95%CI -0.010, -0.0001] p=0.04) while accounting for sex*C5 interaction. In sex-disaggregated analyses, increased C5 concentration was associated with lower vascularization scores (-0.005 [95%CI -0.009, -0.0001] p=0.04) in male patients, but not in female patients. Males had higher sC5b-C9 compared to females. Additionally, males with high C5 had a higher synovial fluid concentration of sC5b-C9 compared to males with low C5. No differences were found in females. Conclusion: Higher synovial fluid C5 levels were associated with increased complement activation and decreased synovial vascularization in males but not in females with OA. Future studies should test whether synovial fluid complement activation suppresses synovial angiogenesis and identify mechanisms accounting for C5-related sex-differences in synovial fluid complement activation in patients with knee OA.

The rate of unnecessary interventions for the management of knee osteoarthritis: a population-based cohort study.

BACKGROUND: Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). METHODS: We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. RESULTS: We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). CONCLUSION: A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.

High tibial osteotomy to neutral alignment improves medial knee articular cartilage composition.

PURPOSE: The purpose of this study was to: (1) test the hypothesis that HTO improves articular cartilage composition in the medial compartment without adversely affecting the lateral compartment and patella, and; (2) explore associations between knee alignment and cartilage composition after surgery. METHODS: 3T MRI and standing radiographs were obtained from 34 patients before and 1-year after HTO. Articular cartilage was segmented from T2 maps. Mechanical axis angle (MAA), posterior tibial slope, and patellar height were measured from radiographs. Changes in T2 and radiographic measures were assessed using paired t tests, and associations were assessed using Pearson correlation coefficients. RESULTS: The mean (SD) MAA before and after HTO was - 6.5° (2.4) and 0.6° (3.0), respectively. There was statistically significant shortening [mean (95%CI)] of T2 in the medial femur [- 2.8 ms (- 4.2; - 1.3), p < 0.001] and medial tibia [- 2.2 ms (- 3.3; - 1.0), p < 0.001], without changes in the lateral femur [- 0.5 ms (- 1.6; 0.6), p = 0.3], lateral tibia [0.2 ms (- 0.8; 1.1), p = NS], or patella [0.5 ms (- 1.0; 2.1), p = NS). Associations between radiographic measures and T2 were low. 23% of the increase in lateral femur T2 was explained by postoperative posterior tibial slope (r = 0.48). CONCLUSION: Performing medial opening wedge HTO without overcorrection improves articular cartilage composition in the medial compartment of the knee without compromising the lateral compartment or the patella. Although further research is required, these results suggest HTO is a disease structure-modifying treatment for knee OA.

Same knee, different goals: patients and surgeons have different priorities related to ACL reconstruction.

PURPOSE: The priorities of patients should be shared by those treating them. Patients and surgeons are likely to have different priorities surrounding anterior cruciate ligament reconstruction (ACLR), with implications for shared decision-making and patient education. The optimal surgical approach for ACLR is constantly evolving, and the magnitude of treatment effect necessary for evidence to change surgical practice is unknown. The aim of this study was to determine (1) the priorities of surgeons and patients when making decisions regarding ACLR and (2) the magnitude of reduction in ACLR graft failure risk that orthopaedic surgeons require before changing practice. METHODS: This study followed a cross-sectional survey design. Three distinct electronic surveys were administered to pre-operative ACLR patients, post-operative ACLR patients, and orthopaedic surgeons. Patients and surgeons were asked about the importance of various outcomes and considerations pertaining to ACLR. Surgeons were asked scenario-based questions regarding changing practice for ACLR based on new research. RESULTS: Surgeons were more likely to prioritize outcomes related to the surgical knee itself, whereas patients were more likely to prioritize outcomes related to their daily lifestyle and activities. Knee instability and risk of re-injury were unanimous top priorities among all three groups. A mean relative risk reduction in ACLR graft failure of about 50% was required by orthopaedic surgeons to change practice regardless of the type of change, or patient risk profile. CONCLUSION: There are discrepancies between the priorities of surgeons and patients, and orthopaedic surgeons appear resistant to changing practice for ACLR. LEVEL OF EVIDENCE: IV.

Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors.

BACKGROUND: An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it. METHODS: We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery. RESULTS: Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%-7%) at 5 years and 21% (95% CI 17%-26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12-3.45), pain (adjusted HR 0.85, 95% CI 0.75-0.96)], female sex (adjusted HR 1.67, 95% CI 1.08-2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17-1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12-1.53). INTERPRETATION: We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

Trends in knee arthroscopy utilization: a gap in knowledge translation.

PURPOSE: To evaluate the longitudinal trends in knee arthroscopy utilization in relation to published negative randomized controlled trials, focusing on annual rates, patient demographics and associated 30-day post-operative complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify arthroscopy cases between 2006 and 2016. 30-day post-operative complications were identified, and potential risk factors analysed using univariate and multivariate analyses. RESULTS: 68,346 patients underwent knee arthroscopy, of which 47,446 (69.5%) represented partial meniscectomies. The annual procedural rate, as a proportion of all reported cases, increased significantly from 2006 (0.3%) to 2016 (1.6%; p < 0.001), along with a significant increase in average patient age (44.3 ± 15.5 to 48.4 ± 14.5; p < 0.001). Specifically focusing on the meniscectomy cohort, average patient age significantly increased from 47.9 ± 15.1 to 50.7 ± 13.5 (p = 0.001). The overall incidence of complications was 2.0% (n = 1333), with major complications in 0.9% (n = 639) and minor complications in 1.0% (n = 701). Common complications included a return to the operating room (0.5%), deep vein thrombosis/thrombophlebitis (0.4%), and superficial infection (0.2%). Operating time > 90 min, diabetes, steroid use, ASA class 2+, and dialysis-dependency were the predictors of overall complication rates. CONCLUSION: Despite the publication of negative trials and new clinical practice guidelines, knee arthroscopy utilization and average patient age continue to increase. Given the high utilization, even low adverse event rates equate to substantial numbers of patients with minor and major complications. The NSQIP data show a gap in knowledge translation to clinical practice and highlight the need for improved clinical guidelines. LEVEL OF EVIDENCE: Cohort study; Level III.

Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis.

OBJECTIVES: We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation. DATA SOURCES: PubMed, CINAHL, Scopus; inception to January 2019. ELIGIBILITY CRITERIA: Randomised clinical trials (RCT), cohort studies, case series. DESIGN: We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models. RESULTS: Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (-3.56 beats per minute; 95% CI -5.60 to -1.52) and DBP (-4.10 mm Hg; 95% CI -4.82 to -3.38) and no change in SBP (-0.36 mm Hg; 95% CI -3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI -0.11 to 0.85). Within-group differences were also small to moderate. CONCLUSIONS: In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA. PROSPERO REGISTRATION NUMBER: CRD42018087859.

Improved Methods to Measure Outcomes After High Tibial Osteotomy.

Observational studies suggest high tibial osteotomy produces substantial improvements in knee loading and stability that can limit the progression of joint damage; decrease pain; improve function and quality of life; and delay the need for knee replacement surgery. It can be cost-effective in knee osteoarthritis. However, systematic reviews and clinical practice guidelines are unable to provide strong recommendations, because limited high-level evidence supports its therapeutic value versus other treatments. We describe findings suggesting it can improve outcomes important to knee joint structure and function, patient quality of life, and health care systems. Future clinical trials are warranted and required.

The importance of costing perspective: an example evaluating the cost-effectiveness of a locking versus nonlocking plate in medial opening wedge high tibial osteotomy

Summary: High tibial osteotomy (HTO) fixation can be achieved using various plate designs. Compared with nonlocking plates, the stability of locking plates allows patients to return to weight-bearing and work sooner and may also decrease postoperative complications, introducing the potential for overall cost savings. However, material costs for locking plates are higher, and the plate bulkiness may lead to additional surgery to remove the plate. We conducted a retrospective study to evaluate the cost-effectiveness of a locking versus a nonlocking plate in HTO from both the health care payer and societal perspectives up to 12 months postoperative. We observed that from a health care payer perspective, the locking plate was not cost-effective. However, the locking plate was cost-effective from the societal perspective (addition of indirect costs, such as time off work). These findings highlight the importance of considering costing perspective in economic evaluations for chronic conditions, particularly in publicly funded health care systems.

Correction to: A case series of lateral opening wedge high tibial osteotomy for valgus malalignment.

Unfortunately, one of the co-author affiliation was incorrect in the original publication of this article. The correct affiliation is given below: Abdulaziz Z. Alomar, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee.

OBJECTIVE: To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA). DESIGN, SETTING AND PARTICIPANTS: We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2). INTERVENTIONS: Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only. MAIN OUTCOME MEASURES: Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups. RESULTS: 168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only. CONCLUSIONS: Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value. TRIAL REGISTRATION NUMBER: NCT00158431.

Medial opening wedge high tibial osteotomy alters knee moments in multiple planes during walking and stair ascent.

Medial opening wedge high tibial osteotomy is a surgical procedure intended to redistribute loads on the knee in patients with medial compartment knee osteoarthritis (OA). The surgery may affect moments in multiple planes during ambulation, with potential beneficial or detrimental effects on joint loads. The objective of this study was to investigate three-dimensional external knee moments before and after medial opening wedge high tibial osteotomy during level walking and during stair ascent. Fourteen patients with varus alignment and osteoarthritis primarily affecting the medial compartment of the tibiofemoral joint were assessed. Three-dimensional motion analyses during level walking and stair ascent was evaluated using inverse dynamics before, 6 and 12 months after surgery. Mean changes at 12 months suggested decreases in the peak knee adduction, flexion and internal rotation moments, with standardized response means ranging from 0.15 to 2.54. These decreases were observed despite increases in speed. Changes in alignment were associated with changes in the adduction and internal rotation moments, but not the flexion moment. Both pre- and postoperatively, the peak knee adduction moment was significantly lower (p=0.001) during stair ascent than during level walking, while the flexion and internal rotation moments were significantly higher (p<0.01). There were no changes in the knee moments on the non-surgical limb. Medial opening wedge high tibial osteotomy is associated with sustained (12 months) changes in knee moments in all three planes of motion during ambulation, suggesting substantial alterations of the loads on the knee during ambulation.

Validity of the QuickDASH in patients with shoulder-related disorders undergoing surgery.

STUDY DESIGN: Validity study. OBJECTIVE: To determine the validity of the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) in comparison to the full DASH in patients undergoing total shoulder arthroplasty (TSA) and rotator cuff repair (RCR). BACKGROUND: The QuickDASH is a shorter version of the DASH that may reduce respondent burden while retaining similar measurement properties. METHODS: One hundred thirty-two patients undergoing TSA or RCR were assessed at baseline and at 3 and 6 months postoperatively. The patients completed the DASH, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form self-report section, and the Western Ontario Rotator Cuff index, and were tested to determine their shoulder range of motion and isometric strength. The differences between scores on the DASH and QuickDASH across the scale range were evaluated using the Bland-Altman technique. Item difficulty, correlations with other patient-reported outcome measures, and physical impairments were used to assess validity. Known group validity was assessed by examining differentiation of work status. Responsiveness was assessed through standardized response means. RESULTS: QuickDASH scores were slightly higher than DASH scores, with a mean difference of 1 to 1.3 points for the TSA group and 1 to 3 points for the RCR group tested preoperatively, and at 3 months and 6 months postoperatively, although limits of agreement were wide (ranging from -10 to 13 across all estimates). The QuickDASH items were distributed across the full DASH, when ranked by item difficulty, for both patient groups. The correlation between the QuickDASH and DASH was almost perfect (r>0.92). Correlations between the DASH/QuickDASH and other patient-reported outcome measures ranged from moderate to very large (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form self-report section, r=0.47-0.85; Western Ontario Rotator Cuff index, r=0.83-0.91), whereas correlations to impairments were small to moderate. Correlation estimates varied by less than 0.07, depending on whether the DASH or QuickDASH was used, suggesting equivalent construct validity. Both the DASH and QuickDASH discriminated between working and nonworking patients, with similar group differences and statistical significance (P<.01). The QuickDASH and DASH showed similar responsiveness between presurgery and 6-month follow-up (standardized response mean, 1.1 following TSA and 0.8 following RCR). CONCLUSION: When substituting the QuickDASH for the full DASH, similar score estimates, discrimination of clinically relevant subgroups, and responsiveness can be expected across patients following TSA and RCR.

An analysis of functional shoulder movements during task performance using Dartfish movement analysis software.

PURPOSE: Video-based movement analysis software (Dartfish) has potential for clinical applications for understanding shoulder motion if functional measures can be reliably obtained. The primary purpose of this study was to describe the functional range of motion (ROM) of the shoulder used to perform a subset of functional tasks. A second purpose was to assess the reliability of functional ROM measurements obtained by different raters using Dartfish software. MATERIALS AND METHODS: Ten healthy participants, mean age 29 ± 5 years, were videotaped while performing five tasks selected from the Disabilities of the Arm, Shoulder and Hand (DASH). Video cameras and markers were used to obtain video images suitable for analysis in Dartfish software. Three repetitions of each task were performed. Shoulder movements from all three repetitions were analyzed using Dartfish software. The tracking tool of the Dartfish software was used to obtain shoulder joint angles and arcs of motion. Test-retest and inter-rater reliability of the measurements were evaluated using intraclass correlation coefficients (ICC). RESULTS: Maximum (coronal plane) abduction (118° ± 16°) and (sagittal plane) flexion (111° ± 15°) was observed during 'washing one's hair;' maximum extension (-68° ± 9°) was identified during 'washing one's own back.' Minimum shoulder ROM was observed during 'opening a tight jar' (33° ± 13° abduction and 13° ± 19° flexion). Test-retest reliability (ICC = 0.45 to 0.94) suggests high inter-individual task variability, and inter-rater reliability (ICC = 0.68 to 1.00) showed moderate to excellent agreement. CONCLUSION: KEY FINDINGS INCLUDE: 1) functional shoulder ROM identified in this study compared to similar studies; 2) healthy individuals require less than full ROM when performing five common ADL tasks 3) high participant variability was observed during performance of the five ADL tasks; and 4) Dartfish software provides a clinically relevant tool to analyze shoulder function.

Adverse event rates and classifications in medial opening wedge high tibial osteotomy.

BACKGROUND: Previously reported complications in medial opening wedge (MOW) high tibial osteotomy (HTO) vary considerably in both rate and severity. PURPOSE: (1) To determine the rates of adverse events in MOW HTO classified into different grades of severity based on the treatments required and (2) to compare patient-reported outcomes between the different adverse event classifications. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients receiving MOW HTO at a single medical center from 2005 to 2009 were included. Internal fixation was used in all cases, with either a nonlocking (Puddu) or locking (Tomofix) plate. Patients were evaluated at 2, 6, and 12 weeks; 6 and 12 months; and annually thereafter. Types of potential surgical and postoperative adverse events, categorized into 3 classes of severity based on the subsequent treatments, were defined a priori. Medical records and radiographs were then reviewed by an independent observer. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were compared in subgroups of patients based on the categories of adverse events observed. RESULTS: A total of 323 consecutive procedures (242 males) were evaluated (age, mean ± standard deviation, 46 ± 9 years; body mass index, mean ± standard deviation, 30 ± 5 kg/m(2)). Adverse events requiring no additional treatment (class 1) were undisplaced lateral cortical breaches (20%), displaced (>2 mm) lateral hinge fracture (6%), delayed wound healing (6%), undisplaced lateral tibial plateau fracture (3%), hematoma (3%), and increased tibial slope ≥10° (1%). Adverse events requiring additional or extended nonoperative management (class 2) were delayed union (12%), cellulitis (10%), limited hardware failure (1 broken screw; 4%), postoperative stiffness (1%), deep vein thrombosis (1%), and complex regional pain syndrome (CRPS) type 1 (1%). Adverse events requiring additional or revision surgery and/or long-term medical care (class 3) were aseptic nonunion (3%), deep infection (2%), CRPS type 2 (1%), and severe hardware failure with loss of correction (1%). Additional surgery rate was 3%. Class 1 and 2 adverse events did not affect patient-reported outcomes at 6, 12, or 24 months postoperatively. Patients with class 3 adverse events had significantly lower total WOMAC scores at 6 months but not at 12 or 24 months postoperatively. CONCLUSION: The most common adverse event in MOW HTO requiring extended nonoperative treatment (class 2) is delayed union (12%). The rate of severe adverse events requiring additional surgery and/or long-term medical care (class 3) is low (7%).

A preference-based single-item measure of quality of life following medial opening wedge high tibial osteotomy: large improvements similar to arthroplasty.

BACKGROUND: Improvements in generic and disease specific scores have been reported with medial opening wedge high tibial osteotomy (MOW HTO). However, meaningful comparisons between competing surgical interventions have been hampered by the lack of a preference based single index of health related quality of life (HRQoL). The primary aim of this study was to derive and report a single index measure of HRQoL for patients undergoing MOW HTO, preoperatively and at 12 and 24 postoperatively. Secondary aims were to evaluate changes in various additional measures of quality of life at these time points. METHODS: The impact of MOW HTO was evaluated using generic and disease specific instruments. One hundred thirty eight patients completed the Medical Outcomes Study short form health survey (SF-12) and Knee Osteoarthritis Outcomes Score (KOOS) before, 12 and 24 months after surgery. A preference-based single index measure of HRQoL was calculated and changes were evaluated. RESULTS: The mean change in the HRQoL suggested large, clinically significant improvements from 0.69 preoperatively to 0.82 (p<0.001) and 0.8 at 12 and 24 months postoperatively respectively. All dimensions of the SF-12, except role mental health, and all dimensions of the KOOS also demonstrated statistically significant improvements between pre and postoperative measurements. CONCLUSIONS: The preoperative HRQoL of young patients with mechanical varus alignment and medial compartment knee osteoarthritis is similar to older patients with knee osteoarthritis. Medial opening wedge high tibial osteomoty results in significant improvements in HRQoL, the magnitude of which is comparable to other surgical interventions for knee osteoarthristis.

Staged medial opening wedge high tibial osteotomy for bilateral varus gonarthrosis: biomechanical and clinical outcomes.

PURPOSE: (1) To evaluate the effect of staged bilateral medial opening wedge high tibial osteotomy (HTO) on established biomechanical risk factors for disease progression and on validated measures of pain and function and (2) To compare outcomes in patients having the second surgery staged within or beyond 12 months of the first surgery. METHODS: Thirty-seven patients with bilateral varus alignment and medial compartment osteoarthritis underwent staged bilateral medial opening wedge HTO (21 within and 16 beyond 12 months). Patients underwent full-limb standing anteroposterior radiographs to determine frontal plane alignment (mechanical axis angle) and three-dimensional gait analysis to estimate the distribution of load across the tibiofemoral compartments (external knee adduction moment). Patients also completed the Knee Injury and Osteoarthritis Outcomes Scores (KOOS), the Lower Extremity Functional Scale, the Short Form Health Survey and the six-minute walk test (6MWT). Patients (both limbs) were evaluated before and approximately 6, 12 and 24 months after each surgery. RESULTS: There were statistically and clinically significant changes in both limbs that were of similar magnitudes and that remained relatively stable over time postoperatively. Mean (95% CI) improvements in outcomes were as follows. Mechanical axis angle: 9.4° (8.4°, 10.4°) (i.e. average change of both limbs), peak knee adduction moment: -1.7%BW*Ht (-2.1, -1.4 %BW*Ht) (i.e. average change of both limbs), 6MWT: 36.7 m (19.4, 54.0 m), SF-12 Physical Component Summary: 12.0 (8.5, 15.5) and KOOS Pain: 25.4 (19.6, 31.2). Other than the shorter time period to reach maximum benefit of both surgeries, there were no remarkable differences at final assessment between patients having surgeries staged within or beyond 12 months. CONCLUSIONS: The present findings demonstrate that patients with bilateral varus gonarthrosis experience marked improvements in established biomechanical risk factors for disease progression bilaterally (mechanical axis angles and external knee adduction moments), as well as clinically important improvements in patient-important outcomes, after staged medial opening wedge HTO. Current findings suggest no difference in outcomes for patients who have the second surgery staged within or beyond 12 months of the first surgery. LEVEL OF EVIDENCE: IV.