Safety and early results of Subchondroplasty® for the treatment of bone marrow lesions in osteoarthritis: a systematic review.

PURPOSE: Subchondroplasty® is a novel minimally invasive procedure for painful subchondral bone marrow lesions (BMLs). The aim of this systematic review was to characterize the clinical outcomes of the Subchondroplasty® procedure, a novel minimally invasive procedure for the treatment of BMLs. The hypothesis tested was that patients experience improvements in pain and functional outcomes following the Subchondroplasty® procedure. METHODS: MEDLINE, Embase, Web of Science, and Clinicaltrials.gov were searched from database inception to search date (June 10, 2020) for all clinical studies which discussed Subchondroplasty®. Two reviewers independently screened 45 unique results and 17 studies were included in the final analysis. Data were collected regarding patient demographics, indications, pain, functional scores, conversion to TKA, and complications of the procedure. RESULTS: All but one study were level IV evidence; the mean MINORS score was 9 ± 2. There were 756 patients included, 45.1% were female, and the mean age was 54 years (range 20-85). Thirteen studies investigated the effect Subchondroplasty® to the knee, while four studied the impact on the foot and ankle. Median length of follow-up was 12 months. The most common indication for Subchondroplasty® was joint pain with corresponding BML. Major contraindications to Subchondroplasty® included severe OA, joint instability, and malalignment. Mean pain score on visual analogue scale (VAS) prior to Subchondroplasty® was 7.8 ± 0.6, but decreased to 3.4 ± 0.7 postoperatively. All studies investigating functional scores reported improvement following Subchondroplasty® (IKDC 31.7 ± 1.9-54.0 ± 4.2 and KOOS 38.1 ± 0.6-70.0 ± 4.1). There were consistently high levels of patient satisfaction; 87 ± 8% of patients would be willing to undergo the procedure again. Seven cases of complications were reported, most seriously osteomyelitis and avascular necrosis. Conversion to knee arthroplasty ranged from 12.5 to 30% with length of follow-up ranging from 10 months to 7 years. CONCLUSIONS: Existing low-quality studies show Subchondroplasty® to benefit patients with BMLs through reduction in pain and improvement in function, along with a high degree of satisfaction following the procedure. The low short-to-medium term conversion rate to arthroplasty suggests that Subchondroplasty® may play a role in delaying more invasive and expensive procedures in patients with BMLs. Subchondroplasty® is a novel procedure that has promising initial findings, but requires further high-quality, comparative studies with long-term follow-up to better understand the outcomes of the procedure and impact clinical practice recommendations. LEVEL OF EVIDENCE: Systematic Review of Level III and IV Studies, Level IV.

The learning curve for the direct anterior total hip arthroplasty: a systematic review.

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) is a muscle-sparing approach thought to have less post-operative pain and quicker recovery, with similar functional outcomes to other approaches. However, it is technically challenging and transitioning surgeons may experience increased complication rates. The purpose of this systematic review is to identify reported learning curves associated with the DAA. METHODS: Three databases (MEDLINE, Embase, and Web of Science) were searched using terms including "total hip arthroplasty," "direct anterior approach," and "learning curve." Study characteristics, patient demographics, learning curve analyses, and complications were abstracted. RESULTS: Twenty-one studies met inclusion criteria, with a total of 9738 patients (60% female), an average age of 63.7 years (range: 13-94), body mass index of 27.0 kg/m2 (range: 16.8-58.9), and follow-up of 19 months (range: 1.5-100). There were five retrospective cohort studies and 13 case series representing fair methodological quality. Six studies depicted a true learning curve, with mean operative time of 156.59 ± 41.71 minutes for the first case, 93.18 ± 14.68 minutes by case 30, and 80.45 ± 12.28 minutes by case 100. Mean complication rate was 20.8 ± 12.7% in early groups and decreased to 7.6 ± 7.1% in late groups. CONCLUSION: This review demonstrated a substantial learning curve associated with the DAA to THA. Operative time plateaued after approximately 100 cases. Complication rates decreased substantially from early to late groups.

Neutrophil to Lymphocyte Ratio as an Indicator of Periprosthetic Joint Infection: A Retrospective Cohort Study.

INTRODUCTION: Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is a serious complication posing notable clinical implications for patients and substantial economic burdens. Neutrophil to lymphocyte ratio (NLR) is an emerging biomarker of inflammation, which may better predict PJI. The objective of this review was to evaluate NLR changes in patients with confirmed PJI, to compare NLR between an aseptic revision and a revision for PJI, and to establish whether an NLR of 2.45 is an appropriate cutoff for predicting infection. METHODS: A retrospective review of patients who underwent revision TJA for PJI at a single center between January 1, 2005, and December 31, 2018, was performed and compared with an aseptic cohort who underwent aseptic revision TJA. NLR was calculated from complete blood counts performed at index surgery and at the time of revision surgery. Receiver operating characteristic curves were analyzed, along with sensitivity, specificity, and positive and negative likelihood ratios. RESULTS: There were 89 patients included in each cohort. Mean NLR in patients who underwent revision for PJI was 2.85 (± 1.27) at the time of index surgery and 6.89 (± 6.64) at the time of revision surgery ( P = 0.017). Mean NLR in patients undergoing revision for PJI (6.89) was significantly higher than aseptic revisions (3.17; P < 0.001). DISCUSSION: In patients who underwent revision surgery for PJI, NLR was markedly elevated at time of revision compared with the time of index surgery. Because it is a cost-effective and readily available test, these findings suggest that NLR may be a useful triage test in the diagnosis of PJI. LEVEL OF EVIDENCE: Level III Diagnostic Study.

Do stair climbing exercise "snacks" improve cardiorespiratory fitness?

We investigated the effect of stair climbing exercise "snacks" on peak oxygen uptake. Sedentary young adults were randomly assigned to perform 3 bouts/day of vigorously ascending a 3-flight stairwell (60 steps), separated by 1-4 h of recovery, 3 days/week for 6 weeks, or a nontraining control group (n = 12 each). Peak oxygen uptake was higher in the climbers after the intervention (P = 0.003), suggesting that stair climbing "snacks" are effective in improving cardiorespiratory fitness, although the absolute increase was modest.