Treatment of post-meniscectomy knee symptoms with medial meniscus replacement results in greater pain reduction and functional improvement than non-surgical care.

PURPOSE: Partial meniscectomy is a common orthopedic procedure intended to improve knee pain and function in patients with irreparable meniscal tears. However, 6-25% of partial meniscectomy patients experience persistent knee pain after surgery. In this randomized controlled trial (RCT) involving subjects with knee pain following partial meniscectomy, it was hypothesized that treatment with a synthetic medial meniscus replacement (MMR) implant provides significantly greater improvements in knee pain and function compared to non-surgical care alone. METHODS: In this prospective, multicenter RCT, subjects with persistent knee pain following one or more previous partial meniscectomies were randomized to receive either MMR or non-surgical care. This analysis evaluated the 1-year outcomes of this 2-year clinical trial. Patient-reported knee pain, function, and quality of life were measured using nine separate patient-reported outcomes. The primary outcomes were the pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS) and the average of all five KOOS subscales (KOOS Overall). Treatment cessation was defined as permanent device removal in the MMR group and any surgical procedure to the index knee in the non-surgical care group. RESULTS: Treated subjects had a median age of 52 years old (range 30-69 years) and one or more previous partial meniscectomies at a median of 34 months (range 5-430 months) before trial entry. Among 127 subjects treated with either MMR (n = 61) or non-surgical care (n = 66), 11 withdrew from the trial or were lost to follow-up (MMR, n = 0; non-surgical care, n = 11). The magnitude of improvement from baseline to 1 year was significantly greater in subjects who received MMR in both primary outcomes of KOOS Pain (P = 0.013) and KOOS Overall (P = 0.027). Treatment cessation was reported in 14.5% of non-surgical care subjects and only 4.9% of MMR subjects (n.s.). CONCLUSION: Treatment with the synthetic MMR implant resulted in significantly greater improvements in knee pain, function, and quality of life at 1 year of follow-up compared to treatment with non-surgical care alone. LEVEL OF EVIDENCE: I.

High Rate of Early Revision After Custom-Made Unicondylar Knee Arthroplasty.

BACKGROUND: There has been a recent interest in custom-made partial knee arthroplasties to provide patient-specific instrumentation and better fit of the prosthesis. While unicondylar knee arthroplasties (UKAs) have demonstrated good outcomes and durable results in many studies, there is little evidence on outcomes of these custom-made implants. METHODS: We performed a retrospective review of all custom-made UKAs performed at our institution by one surgeon from 2008 to 2015. We analyzed preoperative demographics, clinical follow-up evaluations, and radiographs and performed an analysis of risk factors including age, gender, height, weight, body mass index, and tibial insert thickness. The incidence of revision surgery, radiographic failures indicating component loosening, and symptomatic clinically failed implants was calculated at an average of 54.0 months of follow-up. RESULTS: We analyzed 115 consecutive custom-made medial UKAs from a single surgeon at our institution and found 29 (25.2%) UKAs had failed at an average of 33.1 months after surgery. Reasons for failure included aseptic femoral loosening (10), aseptic tibial loosening (8), loosening of both components (4), infection (3), progression of osteoarthritis (2), pain (1), and dislodged polyethylene insert (1). We found a significant relationship between implant failure and body mass index; no other study variables were statistically significant. CONCLUSION: We found a relatively high rate of aseptic loosening and particularly femoral component loosening in the short- to intermediate-term follow-up period. While further study of larger numbers of custom-made UKA from multiple institutions may help verify these findings, we recommend careful consideration of the use of this implant.

A snapshot on a journey from frustration to readiness-A qualitative pre-implementation exploration of readiness for technology adoption in Public Health Protection in Ireland.

In an era of emergent infectious disease, the timely and efficient management of disease outbreaks is critical to public health protection. Integrated technologies for case and incident management (CIM) collect real-time health intelligence for decision making in Public Health. In Ireland, a Public Health reform program is preparing for implementation of a health information system for health protection. Project implementers seek to document and understand the readiness and willingness of future users to adopt the new system, prior to system procurement and implementation. Qualitative key informant interviews were conducted (n = 8) with Public Health personnel from a single regional department of Public Health representing medical, nursing, disease surveillance and administrative roles, at managerial and staff levels. A qualitative thematic analysis was performed. Participants were frustrated by weaknesses in the current practice of CIM and were ready and willing to adopt a digital CIM system if it met their needs. However, they were frustrated by lack of clear timelines. We identified 7 enablers and 3 barriers to readiness and willingness to adopt a CIM system. 'Newness of the workforce' was the main enabler of readiness and willingness, while 'lack of knowledge and familiarity with system' was the main barrier to readiness and willingness. Experiences during the COVID-19 pandemic gave a clear understanding of the problems and need for a digital CIM system and the reform program facilitated a culture of change, readying the workforce for the new health information system. New members of the Public Health departments are a likely ready and eager cohort for adoption of a modern, 'fit for purpose' CIM system and the execution of implementation will likely determine how ready and willing the wider network of departments will be to adopt a national CIMS.

Relationship of Subtalar Joint Range of Motion to Ankle Injuries in NBA G League and Collegiate Basketball Players.

BACKGROUND: This study sought to determine whether range of motion (ROM) of the ankle and subtalar joint complex (STJ) is correlated with ankle injuries in National Basketball Association (NBA) G-league and collegiate basketball players to identify an at-risk population that may benefit from participation in an ankle injury prevention program. METHODS: This prospective cohort study encompassed 103 player-seasons (68 collegiate, 35 NBA G-League). Patient demographics, passive ankle and STJ range of motion measurements, anterior drawer, and talar tilt tests were collected at preseason physicals along with plain radiographs. Subtalar eversion and inversion measurements were added to assess the Combination Motion (CM) of the STJ and subtracted to calculate the Subtalar Difference (SD). We defined the ratio of CM to SD as Subtalar Mobility Index (SMI=CM/SD). RESULTS: Twenty-one ankle injuries occurred with 10 405 player exposures yielding an incidence of 2.11/1000 exposures, resulting in 113 days of missed playing time. No direct measures of ankle, subtalar, or combined motion were associated with risk of injury, rejecting our original hypothesis that increased STJ ROM would predispose to ankle injuries. However, we did find that athletes with CM >16 degrees in combination with either SD <6 degrees (P = .025) or SMI >3.75 (P = .032) were nearly 3 times more likely to have an ankle injury (3.14 vs 2.97, respectively). CONCLUSION: Using the predictive subtalar mobility thresholds found in this study may help identify at-risk players that may benefit from targeted ankle injury prevention programs. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Synovial inflammation in patients undergoing arthroscopic meniscectomy: molecular characterization and relationship to symptoms.

OBJECTIVE: Traumatic and degenerative meniscal tears have different anatomic features and different proposed etiologies, yet both are associated with the development or progression of osteoarthritis (OA). In established OA, synovitis is associated with pain and progression, but a relationship between synovitis and symptoms in isolated meniscal disease has not been reported. Accordingly, we sought to characterize synovial pathology in patients with traumatic meniscal injuries and determine the relationships between inflammation, meniscal and cartilage pathology, and symptoms. METHODS: Thirty-three patients without evidence of OA who were undergoing arthroscopic meniscectomy for meniscal injuries were recruited. Pain and function were assessed preoperatively; meniscal and cartilage abnormalities were documented at the time of surgery. Inflammation in synovial biopsy specimens was scored, and associations between inflammation and clinical outcomes were determined. Microarray analysis of synovial tissue was performed, and gene expression patterns in patients with and those without inflammation were compared. RESULTS: Synovial inflammation was present in 43% of the patients and was associated with worse preoperative pain and function scores, independent of age, sex, or cartilage pathology. Microarray analysis and real-time polymerase chain reaction revealed a chemokine signature in synovial biopsy specimens with increased inflammation scores. CONCLUSION: Our findings indicate that in patients with traumatic meniscal injury undergoing arthroscopic meniscectomy without radiographic evidence of OA, synovial inflammation occurs frequently and is associated with increased pain and dysfunction. Synovia with increased inflammation scores exhibit a unique chemokine signature. Chemokines may contribute to the development of synovial inflammation in patients with meniscal pathology; they also represent potential therapeutic targets for reducing inflammatory symptoms.

Preliminary Results From a US Clinical Trial of a Novel Synthetic Polymer Meniscal Implant.

BACKGROUND: At least 760,000 outpatient meniscectomies are performed in the United States each year, making this the most common musculoskeletal procedure. However, meniscal resection can alter the joint biomechanics and overload the articular cartilage, which may contribute to degenerative changes and the need for knee replacement. Avoiding or delaying knee replacement is particularly important in younger or more active patients. Synthetic meniscal implants have been developed in an attempt to restore the natural joint biomechanics, alleviate pain and disability, and potentially minimize degenerative changes in patients who require meniscectomy. PURPOSE: To evaluate the preliminary results from 2 ongoing trials that are evaluating the safety and effectiveness of a synthetic polymer meniscal implant (NUsurface; Active Implants, LLC). STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This was a preliminary analysis of the first 100 patients enrolled across 2 studies for 12 months: a single-arm, intervention-only study and a randomized controlled trial comparing the investigational meniscal implant with nonsurgical therapy. There were 65 patients in the implant group (30 randomized) and 35 in the control group. Outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) and adverse events (AEs) collected at baseline and follow-up visits of 6 weeks, 6 months, and 12 months. RESULTS: No statistically significant differences were found in baseline characteristics between the implant and control groups. At 12 months, follow-up KOOS data were available for 87% of the 100 included patients. Significantly greater improvements from baseline were observed in the implant group compared with controls in all KOOS subcomponents, except for symptoms (119%-177% greater improvement at 12 months). AEs were reported at similar rates between the 2 groups, with 12 AEs among 11 patients in the implant group (16.9%) versus 5 AEs among 5 patients (14.3%) in the control group (P = .99). CONCLUSION: These preliminary results suggest significant improvements in pain and function scores with the implant over nonsurgical therapy and a similar adverse event rate.

Fluid temperatures during radiofrequency use in shoulder arthroscopy: a cadaveric study.

Cadaveric shoulders underwent thermal capsulorrhaphy and subacromial decompression with 3 different commercially available radiofrequency (RF) devices to evaluate local and regional fluid temperatures while arthroscopic procedures were being performed. Fifteen completely thawed fresh-frozen shoulders underwent both thermal capsulorrhaphy and subacromial decompression. During thermal capsulorrhaphy, Fluoroptic mini-thermometer probes (Luxtron model 3000) were placed in the inflow bag; in the glenohumeral joint, near the inferior glenohumeral ligament; and on the RF wand. During subacromial decompression, the temperature probes were placed in the anterior and posterior subacromial space, as well as in the inflow bag and on the RF wand. All data were initially analyzed by use of analysis of variance, followed by pairwise comparison, adjusted for multiple testing by use of the Scheffé method. Mean fluid temperatures (in degrees Celsius [+/- SD]) were highest at the RF wand during both capsulorrhaphy and subacromial decompression. Mean fluid temperatures were much lower at other recorded sites. In this model, we show no deleterious elevation in arthroscopic fluid temperature while performing thermal capsulorrhaphy or subacromial decompression using any of the 3 devices at their recommended settings.

The safe zone for femoral cross-pin fixation: an anatomical study.

Femoral cross-pin fixation in anterior cruciate ligament (ACL) reconstruction has a potential for neurovascular injury, thus a "safe zone" must be defined for safe pin passage with this technique. In this anatomic study, femoral-sided, arthroscopic-assisted ACL reconstruction using the TransFix system (Arthrex, Naples, Fla) was performed on five fresh extended thigh and lower leg cadavers. Using a goniometer, five cross-pin guidewires were sequentially drilled at 0 degrees, -20 degrees, -40 degrees, +20 degrees, and +40 degrees, using the parallel to floor line as 0 degrees. Negative was defined as starting the pin more posteriorly, and positive was defined as starting the pin more anteriorly. Distance from the pin to the peroneal nerve, saphenous nerve, and femoral artery was measured after pin placement, and measurements were averaged. The peroneal nerve was at minimal risk with average distance to the guide pin of 1.87, 2.13, 2.45, 2.74, and 3.05 cm at -40 degrees, -20 degrees, 0 degrees, +20 degrees, and +40 degrees, respectively. The saphenous nerve was an average distance of 2.19, 1.98, 1.41, 1.42, and 1.29 at -40 degrees, -20 degrees, 0 degrees, +20 degrees, and +40 degrees, respectively. The femoral artery was an average distance of 1.81, 1.51, 0.78, 0.46, and 0.08 cm at -40 degrees, -20 degrees, 0 degrees, +20 degrees, and +40 degrees, respectively. Based on this anatomical study, the absolute neurovascular safe zone during cross-pin guidewire placement is from +20 degrees (0 degrees parallel to floor line) and -40 degrees (lowering guide more posterior).

The Krackow stitch: a biomechanical evaluation of changing the number of loops versus the number of sutures.

PURPOSE: The purpose of this study was to biomechanically evaluate several configurations of the Krackow stitch and determine which configuration provided the best fixation with regard to load to failure and elongation. TYPE OF STUDY: Biomechanical study. METHODS: Thirty fresh-frozen porcine Achilles tendons were randomly assigned into 6 groups. For 3 of the groups, 1 suture was used (No. 5 Ethibond; Ethicon, Somerville, NJ) with 2, 4, or 6 Krackow locking loops. For the other 3 groups, 2 sutures (interlocking and at 90 degrees) with 2, 4, or 6 Krackow locking loops were used. Data were evaluated using analysis of variance. RESULTS: There were no statistical differences in peak load to failure and elongation among any of the 1-suture techniques regardless of the number of locking loops (2, 290 N; 4, 302 N; and 6, 298 N; standard deviation, 25.2, 9.0, and 28.6, respectively). Similarly, there were no statistical differences among any of the 2-suture techniques regardless of the number of locking loops (2, 534 N; 4, 492 N; and 6, 505 N; standard deviation, 42.0, 65.4, and 76.3, respectively). There was, however, a significant difference (P < .05) in peak load to failure between the 1-suture and the 2-suture groups. The mechanism of failure was suture rupture in all cases. CONCLUSIONS: Load to failure did increase with the addition of a second interlocking suture placed at 90 degrees to the first. CLINICAL RELEVANCE: Tendon fixation with gap formation or suture rupture is at risk of failure. This study identifies that increasing the number of sutures is more important than increasing the number of locking loops.

Treatment of osteoarthritis of the middle-aged athlete.

Unicompartmental knee arthroplasty (UKA) has increasingly become an attractive alternative to total knee arthroplasty for early intervention. Clinical and biomechanical studies have shown that UKA offers advantages in early recovery, more natural function, and patient satisfaction. The literature has also shown that UKA exhibits a higher rate of revision than total knee arthroplasty, particularly in registry studies that include patients from outside of high-volume specialty centers. Patient-specific UKA offers the potential to close the gap between the known advantages of a partial knee solution and the documented risk of early revision. On the basis of the patient's own imaging data, patient-specific UKA allows for an anatomically matched implant design that provides personalized fit, full coverage of the tibial cortical rim, and preserves the femoral articulating geometry. These design advantages are paired with a patient-specific instrument system that provides reliable component placement and simplified balancing.

Re-innervation of smooth muscle that is transplanted to provide urethral sphincter augmentation.

A number of methods to augment the resistance of the outlet of the urinary bladder and to improve continence have been developed, including the artificial urinary sphincter and the placement of skeletal muscle around the urethra. It has been recently shown in a rabbit model that transplantation of smooth muscle around the proximal urethra reduces incontinence caused by internal sphincter deficiency. In the present work we have investigated the re-innervation of a peri-urethral smooth muscle transplant, and whether re-innervating axons have an appropriate effect when they are stimulated. Detrusor muscle from the dome of the bladder was transplanted to encircle the proximal urethras of rats. Rats tolerated the surgery and transplantation without any signs of compromised health. At 8 weeks the new sphincter was intact and easily recognised. The transplant contracted in response to transmural stimulation (1-5Hz for up to 5min) in a similar way to freshly removed detrusor strips. Contractions were graded with stimulus frequency, they peaked at about 10s and faded to a lower tension that was maintained. The amplitudes of sustained contractions of the transplants were reduced to about 10% by hyoscine and were almost abolished by tetrodotoxin. Histological examination revealed healthy, vascularised smooth muscle in the transplants, similar in appearance to freshly dissected detrusor. Re-innervation was confirmed immunohistochemically for transplanted detrusor muscle and transplants of dartos muscle. We conclude that smooth muscle transplanted to form a new sphincter around the urethra becomes functionally re-innervated and has potential to be used for sphincter augmentation.

Autologous chondrocyte implantation in cartilage lesions of the knee: long-term evaluation with magnetic resonance imaging and delayed gadolinium-enhanced magnetic resonance imaging technique.

BACKGROUND: Various treatment options are available for articular cartilage lesions, but controversy exists regarding the quality of the repair tissue and the durability of the results posttreatment. Noninvasive techniques are needed for the assessment of the repair tissue. HYPOTHESIS: Magnetic resonance imaging (MRI) with delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) can give valuable information regarding the quality and quantity of the repaired cartilage lesion. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Thirty-six knees in 31 patients were assessed 9 to 18 years after treatment with autologous chondrocyte implantation (ACI). All patients had isolated lesions. The knees were clinically evaluated with the Knee injury and Osteoarthritis Outcome Score and the dGEMRIC technique. The T1 value was measured for 2 regions of interest (ROIs), 1 in the repair tissue area (ROI 1) and 1 in the surrounding cartilage (ROI 2), giving information of the content of proteoglycans. RESULTS: The average T1 value in ROI 1 was 467.5 milliseconds and in ROI 2, 495.3 milliseconds, which yielded no significant difference, thus suggesting comparable levels of proteoglycans in the repair tissue and surrounding cartilage. Intralesional osteophytes were in 64% of the lesions, mainly in younger patients with osteochondritis dissecans lesions or a history of subchondral bone surgeries. Medium or large bone marrow edema was found in 14% of the knees and subchondral cysts, in 39%. There was no correlation between the KOOS and any MRI findings. CONCLUSION: Magnetic resonance imaging with dGEMRIC gives valuable information for the macroscopic appearance and micro-molecular quality of the repair tissue after ACI. Nine to 18 years posttreatment, the quality of the repair tissue is similar to the surrounding normal cartilage, although intralesional osteophytes, subchondral cysts, and bone marrow edema were common. The defect area is restored in most patients. However, there was no correlation between the dGEMRIC values and the KOOS outcomes.

Meniscal allografts: biomechanics and techniques.

Arthroscopic partial meniscectomy is one of the most common orthopedic surgical procedures performed. Numerous clinical and biomechanical studies have shown the long-term consequences of the meniscus-deficient knee, which includes increased loading of the cartilage. This leads to chondromalacia, and ultimately pain and dysfunction. Few treatment options are available for the young patient with pain in the tibiofemoral compartment secondary to meniscus deficiency. Meniscal allograft transplantation is a viable treatment option in this group of patients as short-term results have shown pain relief and functional improvement. Biomechanical studies have shown that the allograft meniscal transplant functions most like a native, intact meniscus when specific surgical principles are followed. Surgical techniques for meniscal allograft transplantation have advanced along with instrumentation. An improvement in function and pain relief can be expected when strict criteria are followed in patient selection and surgical technique.

Glycosaminoglycan distribution in cartilage as determined by delayed gadolinium-enhanced MRI of cartilage (dGEMRIC): potential clinical applications.

OBJECTIVE: We sought to describe a range of in vivo observations of glycosaminoglycan distribution in knee cartilage using the delayed gadolinium-enhanced MRI of cartilage technique. CONCLUSION: The index of glycosaminoglycan distribution, T1(Gd), can exceed 500 msec (denoting high glycosaminoglycan) or can be less than 300 msec, with focal areas as low as 240 msec. Compartmental differences, as well as focal defects within the knee, were observed in patients who had sustained injuries to the ligaments and menisci of the knee or who had chronic osteoarthritis. Overall, these results suggest the need for further research into the biochemical changes seen during disease progression and the effects of therapeutic interventions.