Wild goose chase - no predictable patient subgroups benefit from meniscal surgery: patient-reported outcomes of 641 patients 1 year after surgery.

BACKGROUND: Despite absence of evidence of a clinical benefit of arthroscopic partial meniscectomy (APM), many surgeons claim that subgroups of patients benefit from APM. OBJECTIVE: We developed a prognostic model predicting change in patient-reported outcome 1 year following arthroscopic meniscal surgery to identify such subgroups. METHODS: We included 641 patients (age 48.7 years (SD 13), 56% men) undergoing arthroscopic meniscal surgery from the Knee Arthroscopy Cohort Southern Denmark. 18 preoperative factors identified from literature and/or orthopaedic surgeons (patient demographics, medical history, symptom onset and duration, knee-related symptoms, etc) were combined in a multivariable linear regression model. The outcome was change in Knee injury and Osteoarthritis Outcome Score (KOOS4) (average score of 4 of 5 KOOS subscales excluding the activities of daily living subscale) from presurgery to 52 weeks after surgery. A positive KOOS4 change score constitutes improvement. Prognostic performance was assessed using R2 statistics and calibration plots and was internally validated by adjusting for optimism using 1000 bootstrap samples. RESULTS: Patients improved on average 18.6 (SD 19.7, range -38.0 to 87.8) in KOOS4. The strongest prognostic factors for improvement were (1) no previous meniscal surgery on index knee and (2) more severe preoperative knee-related symptoms. The model's overall predictive performance was low (apparent R2=0.162, optimism adjusted R2=0.080) and it showed poor calibration (calibration-in-the-large=0.205, calibration slope=0.772). CONCLUSION: Despite combining a large number of preoperative factors presumed clinically relevant, change in patient-reported outcome 1 year following meniscal surgery was not predictable. This essentially quashes the existence of 'subgroups' with certain characteristics having a particularly favourable outcome after meniscal surgery. TRIAL REGISTRATION NUMBER: NCT01871272.

The association between smoking and knee osteoarthritis in a cohort of Danish patients undergoing knee arthroscopy.

BACKGROUND: It has been suggested that smoking is associated with reduced risk of knee osteoarthritis (OA). However, supplementary studies are needed to further investigate any such potential association. Thus, our aim was to examine the relationship between smoking and early or more established knee OA in a cohort of relatively young patients with meniscal tears. METHODS: This cross-sectional study included 620 participants from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing knee arthroscopy for a meniscal tear (mean age 49.2 (18.0-76.8) years). Recruitment of patients was performed between February 1, 2013, and January 31, 2015, at four different hospitals in Denmark. We defined early or more established knee OA as the combination of patient-reported frequent knee pain, degenerative meniscal tissue and presence of cartilage defects assessed by the operating surgeons. The relationship between smoking status and knee OA was examined by risk ratio (RR) with a 95% confidence interval (CI), estimated from logistic regression adjusted for age, sex, BMI, education, work status and level of physical activity. RESULTS: The prevalence of early or more established knee OA was 37.7% in current smokers and 45.0% in non-smokers. We found no statistically significant association between current smoking and knee OA (adjusted RR 1.09, 95% CI 0.91-1.30). CONCLUSIONS: This study found no relationship between current smoking and early or more established knee OA in a cohort of patients undergoing arthroscopic meniscal surgery. Thus, the inverse association between smoking and knee OA that has been suggested by previous studies was not confirmed.

Conundrum of mechanical knee symptoms: signifying feature of a meniscal tear?

BACKGROUND: Mechanical knee symptoms are often considered important in the decision to perform knee arthroscopy on the suspicion of a meniscal tear. We investigated if presence of a meniscal tear at knee arthroscopy in adults is associated with presence of preoperative self-reported mechanical knee symptoms. METHODS: We used data from Knee Arthroscopy Cohort Southern Denmark (KACS). KACS consists of patients aged 18 years or older referred to knee arthroscopy on the suspicion of a meniscal tear at four recruiting hospitals between 1 February 2013 and 31 January 2015. Of 1259 invited patients, 908 (72%) replied to the baseline questionnaire. With 91 patients excluded, the study sample consisted of 641 and 176 patients with and without a meniscal tear confirmed at surgery, respectively. Exposure was meniscal tear as determined by the knee surgeon during arthroscopy. Main outcomes were preoperative mechanical knee symptoms defined as self-reported catching/locking or self-reported inability to straighten knee fully. RESULTS: 55% of all patients reported symptoms of catching/locking and 47% were unable to straighten their knee fully. Preoperative mechanical symptoms were equally prevalent in patients with and without a meniscal tear (prevalence ratio catching/locking 0.89, 95% CI 0.77 to 1.03, and inability to straighten knee fully, prevalence ratio 1.02, 95% CI 0.84 to 1.23). INTERPRETATION: Patient-reported mechanical symptoms were equally common irrespective of presence or absence of a meniscal tear in patients undergoing arthroscopy for suspicion of a meniscal tear. Our findings suggest that mechanical knee symptoms have a limited value when considering indication for meniscal surgery. TRIAL REGISTRATION NUMBER: NCT01871272; Results.

Patient-reported symptoms and changes up to 1 year after meniscal surgery.

Background and purpose - Detailed information on the symptoms and limitations that patients with meniscal tears experience is lacking. This study was undertaken to map the most prevalent self-reported symptoms and functional limitations among patients undergoing arthroscopic meniscal surgery and investigate which symptoms and limitations had improved most at 1 year after surgery. Patients and methods - Patients aged 18-76 years from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic meniscal surgery were included in this analysis of individual subscale items from the Knee Injury and Osteoarthritis Outcome Score and 1 question on knee stability. Severity of each item was scored as none, mild, moderate, severe, or extreme. Improvements were evaluated using Wilcoxon's signed-rank test and effect size (ES). Results - The most common symptoms were knee grinding and clicking, knee pain in general, pain when twisting and bending the knee and climbing stairs (88-98%), while the most common functional limitations were difficulty bending to the floor, squatting, twisting, kneeling, and knee awareness (97-99%). Knee pain in general and knee awareness improved most 1 year after meniscal surgery (ES -0.47 and -0.45; p < 0.001), while knee instability and general knee difficulties improved least (ES 0.10 and -0.08; p < 0.006). Interpretation - Adults undergoing surgery for a meniscal tear commonly report clinical symptoms and functional limitations related to their daily activities. Moderate improvements were observed in some symptoms and functional limitations and small to no improvement in others at 1 year after surgery. These findings can assist the clinical discussion of symptoms, treatments, and patients' expectations.

Structural pathology is not related to patient-reported pain and function in patients undergoing meniscal surgery.

BACKGROUND: The relationship between meniscal tears and other joint pathologies with patient-reported symptoms is not clear. We investigated associations between structural knee pathologies identified at surgery with preoperative knee pain and function in patients undergoing arthroscopic meniscal surgery. METHODS: This study included 443 patients from the Knee Arthroscopy Cohort Southern Denmark (KACS), a prospective cohort following patients 18 years or older undergoing arthroscopic meniscal surgery at 4 hospitals between 1 February 2013 and 31 January 2014. Patient-reported outcomes, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), were obtained by online questionnaires prior to surgery. Knee pathology was assessed by the operating surgeons using a modified version of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears questionnaire, supplemented with information extracted from surgery reports. Following hypothesis-driven preselection of candidate variables, backward elimination regressions were performed to investigate associations between patient-reported outcomes and structural knee pathologies. RESULTS: Regression models only explained a small proportion of the variability in self-reported pain and function (adjusted R2=0.10-0.12) and this association was mainly driven by age, gender and body mass index. CONCLUSIONS: Specific meniscal pathology and other structural joint pathologies found at meniscal surgery were not associated with preoperative self-reported pain and function in patients with meniscal tears questioning inferences made about a direct relationship between these. Our findings question the role of arthroscopic surgery to address structural pathology as a means to improve patient-reported outcomes in patients having surgery for a meniscal tear.

Signs of knee osteoarthritis common in 620 patients undergoing arthroscopic surgery for meniscal tear.

Background and purpose - Recent evidence has questioned the effect of arthroscopic knee surgery for middle-aged and older patients with degenerative meniscal tears with or without concomitant radiographic knee osteoarthritis (OA). We investigated the prevalence of early or more established knee OA and patients' characteristics in a cohort of patients undergoing arthroscopic surgery for a meniscal tear. Patients and methods - 641 patients assigned for arthroscopy on suspicion of meniscus tear were consecutively recruited from February 2013 through January 2015. Of these, 620 patients (mean age 49 (18-77) years, 57% men) with full datasets available were included in the present study. Prior to surgery, patients completed questionnaires regarding onset of symptoms, duration of symptoms, and mechanical symptoms along with the knee injury and osteoarthritis outcome score (KOOS). At arthroscopy, the operating surgeon recorded information about meniscal pathology and cartilage damage. Early or more established knee OA was defined as the combination of self-reported frequent knee pain, cartilage damage, and the presence of degenerative meniscal tissue. Results - 43% of patients (269 of 620) had early or more established knee OA. Of these, a large proportion had severe cartilage lesions with almost half having a severe cartilage lesion in at least 1 knee compartment. Interpretation - Based on a definition including frequent knee pain, cartilage damage, and degenerative meniscal tissue, early or more established knee OA was present in 43% of patients undergoing knee arthroscopy for meniscal tear.

Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery.

Background and purpose - Patients' expectations of outcomes following arthroscopic meniscus surgery are largely unknown. We investigated patients' expectations concerning recovery and participation in leisure-time activities after arthroscopic meniscus surgery and the postoperative fulfillment of these. Patients and methods - The study sample consisted of 491 consecutively recruited patients (mean age 50 (SD 13) years, 55% men) who were assigned for arthroscopy on suspicion of meniscus injury and later verified by arthroscopy. Before surgery, patients completed questionnaires regarding their expectations of recovery time and postoperative participation in leisure activities. 3 months after surgery, the patients completed questionnaires on their actual level of leisure activity and their degree of satisfaction with their current knee function. We analyzed differences between the expected outcome and the actual outcome, and between fulfilled/exceeded expectations and satisfaction with knee function. Results - 478 patients (97%) completed the follow-up. 91% had expected to be fully recovered within 3 months. We found differences between patients' preoperative expectations of participation in leisure activities postoperatively and their actual participation in these, with 59% having unfulfilled expectations (p < 0.001). Satisfaction with current knee function was associated with expectations of leisure activities being fulfilled/exceeded. Interpretation - In general, patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations of recovery time and regarding participation in leisure-time activities after meniscal surgery.

The Effect of Progressive Resistance Exercise on Knee Muscle Strength and Function in Participants with Persistent Hamstring Deficit Following ACL Reconstruction: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of progressive resistance exercise compared with low-intensity home-based exercises on knee-muscle strength and joint function in people with anterior cruciate ligament (ACL) reconstruction and persistent hamstring strength deficits at 12-24 months after surgery. DESIGN: Randomized controlled superiority trial with parallel groups, balanced randomization (1:1), and blinded outcome assessment. METHODS: People with ACL reconstruction (hamstring autograft) and persistent hamstring muscle strength asymmetry were recruited 1 to 2 years postsurgery and randomized to either 12 weeks of supervised progressive strength training (SNG), or 12 weeks of home-based, low-intensity exercises (CON). The primary outcome was between-group difference in change in maximal isometric knee flexor muscle strength at 12-week follow-up. RESULTS: Fifty-one participants (45% women, 27 ± 6 years) were randomized to SNG (n = 25) or CON (n = 26), with 88% follow-up rate at 12 weeks. People in the SNG group improved their knee flexor muscle strength (0.18 N·m/kg, 95% confidence interval [CI]: 0.07, 0.29; P = .002) more than the CON group, from baseline to 12 weeks. The SNG group also had superior Knee Injury and Osteoarthritis Outcome Scores for Pain (4.6, 95% CI: 0.4, 8.7; P = .031) and daily living function (4.7, 95% CI: 1.2, 8.2; P = .010) compared to the CON group. CONCLUSION: In people with persistent hamstring muscle strength deficits after ACL reconstruction, 12 weeks of supervised progressive strength training was superior to low-intensity home-based exercises for improving maximal knee flexor muscle strength and some patient-reported outcomes. J Orthop Sports Phys Ther 2023;53(1):40-48. Epub: 17 October 2022. doi:10.2519/jospt.2022.11360.

Association of specific meniscal pathologies and other structural pathologies with self-reported mechanical symptoms: A cross-sectional study of 566 patients undergoing meniscal surgery.

OBJECTIVES: We explored associations between specific meniscal pathologies and other concurrent structural knee pathologies with presence of self-reported mechanical symptoms in patients undergoing meniscal surgery. DESIGN: Cross-sectional study. METHODS: We included patients undergoing surgery for a meniscal tear from Knee Arthroscopy Cohort Southern Denmark (KACS). Pre-surgery, patients completed online questionnaires including self-reported presence of mechanical symptoms. At arthroscopy, surgeons recorded information about specific meniscal pathologies and other concurrent structural knee pathologies. Relative risks (RR) were estimated to assess associations between specific meniscal pathologies and other structural knee pathologies with preoperative mechanical symptoms from multivariable logistic regression. RESULTS: 566 of 641 patients (mean age 48.6[SD 12.9] years, 57% men) with complete data were included. 386 (68%) patients reported mechanical symptoms of knee catching/locking and/or extension deficit. Most evaluated joint pathologies were not associated with mechanical symptoms of any kind with RRs close to 1.0. Meniscal tears involving both the posterior and anterior horn (n=22) were associated with knee catching/locking (RR: 1.49[95%CI:1.15-1.93]), and a tear in both menisci (n=49) was associated with extension deficit of the knee (RR: 1.32[95%CI:1.01-1.73]). A partial (n=29) and total ACL rupture (n=37) were each associated with extension deficit (RR: 1.83[95%CI:1.47-2.28] and RR: 1.44[95%CI:1.05-1.98], respectively). CONCLUSIONS: Limited associations between specific meniscal pathology and other concurrent knee joint pathologies with presence of self-reported mechanical symptoms were found in patients undergoing meniscal surgery. The findings question the clinical importance of mechanical symptoms as an indicator for arthroscopy for specific meniscal tears with the specific aim to relieve such symptoms.

Changes in bone mineral density (BMD) around the cemented Exeter stem: a prospective study in 18 women with 5 years follow-up.

BACKGROUND AND PURPOSE: THA changes the pattern of strain distribution in the proximal femur. We quantified the changes in BMD for 5 years after insertion of the cemented Exeter stem in women. METHODS: 18 women aged 55-79 years, undergoing unilateral THA with the cemented Exeter stem, were included in the study. The BMD was measured in 7 femoral regions of interest according to Gruen, and the contralateral hip and spine using dual-energy X-ray absorptiometry postoperatively, at 18 and at 60 months of follow-up. Results were tested using Wilcoxon matched-pairs signed-rank test. RESULTS: During the first 18 months, a significant decrease in BMD was seen in zones 2, 3, 6, and 7. No significant changes were seen in zones 4 and 5, in the contralateral hip, or at the spine. In zone 1, there was a small but significant rise in BMD. From 18 to 60 months, we observed a statistically significant rise in BMD in all zones except 4 and 7. Despite this, the total periprosthetic BMD decreased during the follow-up relative to the immediate postoperative situation. There was no significant reduction in BMD in the contralateral hip. In the spine, we observed a significant rise in BMD. INTERPRETATION: 18 months after THA, BMD had decreased in Gruen zones 2, 3, 6, and 7. The bone loss was similar to that seen after other implants and appears to be related to the changes in stress pattern within the proximal femur. At 5 years, BMD had increased again in these zones. It remained lower than baseline, however.

The effect of targeted exercise on knee-muscle function in patients with persistent hamstring deficiency following ACL reconstruction - study protocol for a randomized controlled trial.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction, using hamstring auto-graft is a common surgical procedure, which often leads to persistent hamstring muscle-strength deficiency and reduced function. The purpose of this randomized controlled trial (RCT) is to investigate the effect of a combined, progressive, strength and neuromuscular exercise intervention on knee muscle strength, functional capacity and hamstring muscle-tendon morphology in ACL-reconstructed patients with persistent hamstring muscle-strength deficiency compared with controls. METHODS/DESIGN: The study is designed as a multicenter, parallel-group RCT with balanced randomization (1:1) and blinded outcome assessments (level of evidence: II) and will be reported in accordance with the CONSORT Statement. Fifty ACL-reconstructed patients (hamstring auto-graft) with persistent limb-to-limb knee-flexor muscle-strength asymmetry at 12-24 months' post surgery, will be recruited through outpatient clinics and advertisements. Patients will be randomized to a 12-week progressive, strength and neuromuscular exercise group (SNG) with supervised training twice weekly or a control intervention (CON) consisting of a home-based, low-intensity exercise program. Outcome measures include between-group change in maximal isometric knee-flexor strength (primary outcome) and knee-extensor muscle strength, hamstring-to-quadriceps strength ratios of the leg that has been operated on and Knee injury and Osteoarthritis Outcome Score (KOOS) (secondary outcomes). In addition, several explorative outcomes will be investigated: The International Knee Documentation Committee Subjective Knee Form (IKDC), the Tegner Activity Score, rate of force development (RFD) for the knee flexors and extensors, tendon regeneration and potential muscle hypertrophy at graft harvest site evaluated by magnetic resonance imaging (MRI), postural control, kinetic/kinematic gait characteristics and knee-related functional capacity. DISCUSSION: This RCT is designed to investigate the effect of combined, progressive-resistance and neuromuscular exercises on knee-flexor/extensor strength, in the late rehabilitation phase following ACL reconstruction. Reduced hamstring strength represents a potential risk factor for secondary ACL rupture and accelerated progression of osteoarthritis. If deemed effective, the intervention paradigm introduced in this study may help to improve current treatment strategies in ACL-reconstructed patients. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02939677 (recruiting). Registered on 20 October 2016.

Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study.

OBJECTIVES:  To compare patient reported outcomes from before surgery to 52 weeks after surgery between individuals undergoing arthroscopic partial meniscectomy for traumatic meniscal tears and those for degenerative meniscal tears. DESIGN:  Comparative prospective cohort study. SETTING:  Four public orthopaedic departments in the Region of Southern Denmark. Participants were recruited between 1 February 2013 and 31 January 2014, and at one of the original four hospitals from 1 February 2014 to 31 January 2015. PARTICIPANTS:  Individuals selected from Knee Arthroscopy Cohort Southern Denmark, aged 18-55, and undergoing arthroscopic partial meniscectomy for a traumatic or degenerative meniscal tear (defined by a combination of age and symptom onset). INTERVENTIONS:  Both participant groups underwent arthroscopic partial meniscectomy for a meniscal tear, with operating surgeons recording relevant information on knee pathology. Patient reported outcomes were recorded via online questionnaires. MAIN OUTCOME MEASURES:  Primary outcome was the average between-group difference in change on four of five subscales of the knee injury and osteoarthritis outcome score (KOOS). The four subscales covered pain, symptoms, sport and recreational function, and quality of life (KOOS4). A 95% confidence interval excluding differences greater than 10 KOOS points between groups was interpreted as absence of a clinically meaningful difference. Analyses adjusted for age, sex, and body mass index. RESULTS:  397 eligible adults (42% women) with a traumatic or degenerative meniscal tear (n=141, mean age 38.7 years (standard deviation 10.9); n=256, 46.6 years (6.4); respectively) were included in the main analysis. At 52 weeks after arthroscopic partial meniscectomy, 55 (14%) patients were lost to follow-up. Statistically, participants with degenerative meniscal tears had a significantly larger improvement in KOOS4 scores than those with traumatic tears (adjusted between-group difference -5.1 (95% confidence interval -8.9 to -1.3); P=0.008). In the analysis including KOOS4 score at all time points, a significant time-by-group interaction was observed in both the unadjusted (P=0.025) and adjusted analysis (P=0.024), indicating better self-reported outcomes in participants with degenerative tears. However, the difference between groups was at no time point considered clinically meaningful. CONCLUSIONS:  These results question the current tenet that patients with traumatic meniscal tears experience greater improvements in patient reported outcomes after arthroscopic partial meniscectomy than patients with degenerative tears.Trial registration ClinicalTrials.gov identifier NCT01871272.

[Treatment of meniscal pathology].

The menisci play a major role in knee function regarding joint movement, stability, load distribution and load transmission. Injuries to the menisci cause pain, and meniscal tears are a common reason for patient referral. In Denmark, partial meniscectomy increased significantly until 2010, and several studies have questioned the long-term effect of meniscectomy as an overall procedure. A Danish national clinical guideline on knee meniscal pathology was published in May 2016, and this article is a short summary of updated knowledge on meniscal pathology and relevant conclusions from the guideline.

P2X7Rs are involved in cell death, growth and cellular signaling in primary human osteoblasts.

The ionotropic ATP-gated P2X7 receptor (P2X7R) is involved in the regulation of many physiological functions including bone metabolism. Several studies on osteoblasts from rodents and human osteoblast-like cell lines have addressed the expression and function of P2X7R on these bone-forming cells however; its role in human primary osteoblasts has not yet been reported. The aim of this study was to assess the expression of the P2X7R in bone marrow-derived stromal cells and in primary human trabecular osteoblasts and to determine the function in bone formation and cell signaling. We report that osteoblasts derived from human trabecular explants express a functional P2X7R capable of agonist-induced increase in intracellular calcium concentration and a positive permeability to fluorescent dyes. These osteoblasts are fully differentiated cells with alkaline phosphatase activity and the ability to form mineralized nodules. We show that the transcriptional regulation of osteoblastic markers can be modulated by P2X7R activity or blockade thereby influencing the differentiation, proliferation and bone matrix formation by these primary human osteoblasts. Finally, we demonstrate that the P2X7R is involved in propagation of mechanically-induced intercellular signaling in addition to the known mechanisms involving calcium signaling via P2Y2 receptors and gap junction.

Prolonged single-agent versus combination chemotherapy in indolent follicular lymphomas: a study of the cancer and leukemia group B.

PURPOSE: The array of options for the initial management of follicular small cleaved lymphoma (FSCL) and follicular mixed lymphoma (FML) ranges from little or no therapy to the use of intensive combinations of drugs. The Cancer and Leukemia Group B (CALGB) compared two contrasting approaches: a single agent, and combination chemotherapy capable of curing diffuse aggressive lymphomas. PATIENTS AND METHODS: A total of 228 patients with stage III or IV FSCL or FML were randomized to cyclophosphamide or the combination of cyclophosphamide, doxorubicin, vincristine, prednisone, and bleomycin (CHOP-B). Treatment was continued in responders for 2 years beyond maximal response. The primary end point was survival in the most common subtype, FSCL. RESULTS: Ninety-one percent of all patients responded; complete responses were seen in 66% of those treated with cyclophosphamide and in 60% treated with CHOP-B (P =.36). At 10 years with either cyclophosphamide or CHOP-B, respectively, overall time to failure (25% failure free v 33%; P =.107) and survival (44% alive v 46%; P =.79) were similar by treatment. Outcomes in FSCL also were similar. In 46 patients with FML, at 10 years the combination was associated with better failure-free (9% v 48%; P =.005) and overall (25% v 61%; P =.024) survival. Acute toxic effects were more common with combination chemotherapy. Second malignancies, which might be attributed to treatment, were seen with both approaches. CONCLUSION: There is no advantage to the initial use of the relatively intensive combination, CHOP-B, for patients with FSCL compared with the less toxic single agent, cyclophosphamide. However, in an unplanned subgroup analysis, patients with FML who received the combination experienced improved disease control and survival.

[Reconstruction of the anterior cruciate ligament in patients over 40 years of age]. / Rekonstruktion af forreste korsbånd hos patienter over 40 år.

INTRODUCTION: The treatment of an ACL lesion in patients who are above 40 years of age remains controversial. The aim of this study is to report the subjective impression of the result after ACL reconstruction in 24 such patients. MATERIAL AND METHODS: The records of 24 patients, who were aged 40 or older when they had ACL reconstruction were reviewed. The average age was 43 years (40-49), 10 women and 14 men. The mean interval between injury and operation was 35 months (6-185). All 24 patients completed a self-administered questionnaire to evaluate A) preoperative status, B) the rehabilitation period, and C) postoperative status and their overall view of the treatment. Status was made 16 months postoperatively (5-41). RESULTS: Preoperatively, 23 out of 24 patients had instability problems in daily living (ADL) and at work. One had not experienced the knee giving way. All the patients had experienced pain. Postoperatively, 21 out of the 24 experienced no instability and 14 are free of pain. Eighteen have increased activity, five have no change in activity, and one has decreased activity. Sixteen are satisfied with the level of postoperative activity. Twenty-two find their knee status better postoperatively than preoperatively. One finds it unchanged, and one finds it worse. Overall 15 patients find result very satisfying, seven find it satisfying, and two find it poor. Twenty-two would advise others in a similar situation to have the operation done, whereas one is in doubt and one would not recommend the operation. DISCUSSION: We conclude that the results of ACL reconstruction in patients above the age of 40 are as good as those in younger patients.

[Osteosarcoma in the patella in a patient with Rothmund-Thomson syndrome]. / Osteosarkom i patella hos patienter med Rothmund-Thomsons syndrom.

Rothmund-Thomson syndrome (RTS) is a rare autosomal recessive genodermatosis. We describe a 31-year-old male known with RTS who had a rare presentation of osteosarcoma in the patella. He initially fractured the patella, and had surgery. On suspicion infection he was treated with antibiotics several times. His condition did not improve, and a biopsy was made consequently. Pathology showed osteosarcoma. The patella was removed, but later the patient had a femur amputation. This case emphasises that patients with rare genetic defects associated with high risk of cancer must be treated by specialists.

Knee Arthroscopy Cohort Southern Denmark (KACS): protocol for a prospective cohort study.

BACKGROUND: Meniscus surgery is a high-volume surgery carried out on 1 million patients annually in the USA. The procedure is conducted on an outpatient basis and the patients leave the hospital a few hours after surgery. A critical oversight of previous studies is their failure to account for the type of meniscal tears. Meniscus tears can be categorised as traumatic or non-traumatic. Traumatic tears (TT) are usually observed in younger, more active individuals in an otherwise 'healthy' meniscus and joint. Non-traumatic tears (NTT) (ie, degenerative tears) are typically observed in the middle-aged (35-55 years) and older population but the aetiology is largely unclear. Knowledge about the potential difference of the effect of arthroscopic meniscus surgery on patient symptoms between patients with traumatic and NTT is sparse. Furthermore, little is known about the natural time course of patient perceived pain, function and quality of life after meniscus surgery and factors affecting these outcomes. The aim of this prospective cohort study is to investigate the natural time course of patient-reported outcomes in patients undergoing meniscus surgery, with particular emphasis on the role of type of symptom onset. METHODS/DESIGN: This prospective cohort study enrol patients assigned for meniscus surgery. At the baseline (PRE surgery), patient characteristics are assessed using an email-based questionnaire also comprising several validated questionnaires assessing general health, knee-specific characteristics and patient's expectations of the surgery. Follow-up will be conducted at 12 and 52 weeks after meniscus surgery. The major outcomes will be differences in changes, from before to 52 weeks after surgery, in each of the five domains on the Knee injury and Osteoarthritis Outcome Score (KOOS) between patients undergoing surgery for traumatic compared with non-traumatic meniscus tears. DISSEMINATION: The study findings will be disseminated in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT01871272.

Costs of informal care for people suffering from dementia: evidence from a danish survey.

BACKGROUND/AIMS: Around 70,000-80,000 Danes suffer from dementia. As average life expectancy increases, the number of people suffering from dementia is expected to increase in the future with informal care provided by family and friends becoming more important. The aim of this study was to estimate the time spent by family and friends on informal care of persons suffering from dementia in a Danish setting and calculate the economic implications. METHODS: Information on informal care time was collected in a postal survey of members of the Danish Alzheimer's Association. Data from 469 informal caregivers were obtained corresponding to an adjusted response rate of 62%. RESULTS: On a typical day, informal care time was 4.97-6.91 h for primary caregivers and 0.70-1.06 h for other caregivers. Using the proxy good method to value informal care, daily costs ranged between EUR 160 and 223 for primary caregivers and between EUR 23 and 34 for others. CONCLUSION: Informal care delivered by family and friends is significant. The value of informal care constitutes an important part of the societal cost of dementia in Denmark.