Efficacy and safety of hylan G-F 20 injection in treatment of knee osteoarthritis in Chinese patients: results of a prospective, multicentre, longitudinal study.

OBJECTIVE: To study the efficacy and safety of single intra-articular injection of 6-mL hylan G-F 20 in Chinese patients with symptomatic knee osteoarthritis. DESIGN: Prospective case series. SETTING: Six government hospitals in Hong Kong. PATIENTS: Patients with primary knee osteoarthritis were recruited from six government hospitals from 1 October 2010 to 31 May 2012. All patients received 6-mL intra-articular injection of hylan G-F 20. MAIN OUTCOME MEASURES: Pain visual analogue scale, functional visual analogue scale, and 5-point Likert scale on change of pain and function were assessed. Adverse events were checked. Radiographs were taken pre-injection and at 3 months and 1 year. RESULTS: A total of 110 knees of 95 patients with primary knee osteoarthritis were treated. The mean age of the patients was 62 (standard deviation, 9.8) years. All patients completed 1 year of follow-up. The mean pain visual analogue scale, functional visual analogue scale, and Likert value for pain and function showed statistically significant improvements at 6 weeks, 3 months, 6 months, and 1 year compared with the pre-injection values. No significant correlations were found between changes in visual analogue scale and age, body mass index, pre-injection radiological osteoarthritis severity, serum erythrocyte sedimentation rate, or C-reactive protein. Serial radiographs did not show any changes in the radiological severity of knee osteoarthritis. Overall, 16.4% of the patients experienced mild and self-limiting adverse events. CONCLUSION: Hylan G-F 20 is a safe and effective therapy to relieve pain and improve function for up to 1 year in Chinese patients with knee osteoarthritis.

Nurse-led orthopaedic clinic in total joint replacement.

OBJECTIVES: To introduce the practice of a nurse-led orthopaedic clinic for managing stable patients after total hip or knee replacement and to evaluate its efficacy. DESIGN: Case series. SETTING: A public hospital in Hong Kong. PATIENTS: Patients who had stable primary total knee replacement or total hip replacement done for longer than 2 years were managed in a nurse-led total joint replacement pilot clinic. RESULTS: From July 2012 to March 2014, 431 patients (including 317 with total knee replacement and 114 with total hip replacement) were handled, and 408 (94.7%) nurse assessments were independently performed. Six cases of prosthesis-related complications were diagnosed. One patient was hospitalised for prosthetic complications within 3 months after follow-up. The satisfaction rate was 100%. From November 2012 to April 2013, an advanced practice nurse, one resident specialist, and one associate consultant independently charted Knee Society Knee Score or Harris Hip Score for the patients attending preoperative assessment clinic to check the inter-observer reliability. Overall, 23 patients with 37 knees and 11 patients with 17 hips were examined. The mean correlation coefficient between assessments by the associate consultant and advanced practice nurse was 0.912 for Knee Society Knee Score, and 0.761 for Harris Hip Score. The advanced practice nurse could achieve better or equally good correlation with associate consultant when compared with the correlation between resident specialist and associate consultant (0.866 and 0.521 for Knee Society Knee Score and Harris Hip Score, respectively) and with international standard. CONCLUSION: Nurse-led total joint replacement clinic was safe, reliable, and well accepted by patients.

Disseminated amyloidosis presenting with right proximal femur pathological fracture in a haemodialysis end-stage renal failure patient.

Osteoarticular amyloidosis can be one of the musculoskeletal system manifestations related to dialysis. We share our experience in dealing with a case of disseminated haemodialysis-associated amyloidosis in a 74-year-old end-stage renal failure patient. This patient suffered from a serious complication, namely an unprovoked pathological fracture at the basal neck region of the right femur. Polyarticular cystic and lytic lesions over the contralateral proximal femur, bilateral proximal humerus and the right lunate were noted on further imaging. In view of extensive amyloidotic infiltration into the proximal femur as well as the acetabulum, a cemented total hip arthroplasty operation was performed for pain relief and restoration of function. The radiological investigations, diagnostic challenges, operative as well as histopathological findings are discussed. This disease should be considered in the differential diagnosis of pathological juxta-articular fracture in patients undergoing haemodialysis.

Cost, safety, and rehabilitation of same-stage, bilateral total knee replacements compared to two-stage total knee replacements.

BACKGROUND: Many patients experience bilateral knee osteoarthritis and require bilateral total knee replacement (TKR). Same-stage, bilateral TKR is proposed to be a cost-effective and safe solution compared to two-stage, but conflicting results in the literature are reported. We aim to compare the costs, safety, and rehabilitation performance of patients in same-stage versus two-stage, bilateral TKR with our centre's perioperative protocol. MATERIALS AND METHODS: We retrospectively reviewed 175 patients (95 same-stage, 80 two-stage) who had undergone bilateral TKR in our centre. Patient selection for same-stage, bilateral TKR was strictly protocol-driven and required fulfilment of all criteria, including age < 75 years, American Society of Anesthesiologists (ASA) grade 1 or 2, body mass index (BMI) < 40, and having non-complex arthritis. All patients followed a standardised pre-operative, intra-operative, and post-operative Enhanced Recovery After Surgery (ERAS) protocol. The cost, safety profiles, and rehabilitation outcomes were compared between the same-stage and two-stage groups. RESULTS: The same-stage, bilateral TKR reduced the length of hospital stays by 5.71 days per patient, decreased the operation time by 27.4 min, saved 3.34 (18.6%) physiotherapy sessions, and 3.78 (51.5%) occupational therapy sessions. The same-stage group experienced a higher haemoglobin drop but no significant difference in transfusion percentage, transfusion volume, complication rate, and readmission rate. The two-stage subgroup with anaesthetic risk, age, and BMI similar to the same-stage group showed the same results. Same-stage, bilateral TKR patients experienced no significant difference in final post-operative pain levels and rehabilitation outcomes as two-stage TKR patients. CONCLUSION: This study showed that same-stage, bilateral TKR can reduce costs, with similar safety profiles and rehabilitation outcomes compared to the two-stage, bilateral TKR.

Satisfactory long-term survival, functional and radiological outcomes of open-wedge high tibial osteotomy for managing knee osteoarthritis: Minimum 10-year follow-up study.

BACKGROUND: This prospective cohort study was designed to evaluate the survivorship and functional outcomes associated with long-term results of medial open-wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis in the Chinese population. Although MOWHTO is a well-established procedure in the management of medial osteoarthritis of the knee, the long-term outcome in the Chinese population has not been reported in current literature. We hypothesised that MOWHTO would result in long-term preservation of knee function in Chinese, similar to that reported in the Caucasian population. METHODS: A cohort of 22 young adult patients (age < 55 years old) undergoing MOWHTO for the treatment of symptomatic medial compartment knee osteoarthritis between 2002 and 2008 was retrospectively surveyed with a minimum follow-up of 10 years. Kaplan-Meier survival analysis was performed, and the failure modes were investigated. The outcomes on survival (not requiring arthroplasty), clinical outcome (Knee Society Knee Score and Knee Society Function Score) and range of motion (numeric rating scale) at preoperative, 1-year postoperative follow-up and at last follow-up (>10 years) were evaluated. In addition, the mechanical tibiofemoral angle was also measured. The Wilcoxon signed-rank test was used for statistical evaluation of nonparametric data in these related samples. RESULT: A total of 31 knees in these 22 cases were included. The follow-up rate was 100% at 13.4 ± 1.9 years (11-17). Mean age at time of surgery was 45.8 ± 9.5 years (18-53). At 10-year follow-up, four knees converted to require total knee arthroplasty (survival: 87.1%). Preoperative varus alignment with mechanical tibiofemoral angle of -9.26 ± 2.83 was corrected to 2.58 ± 2.46 after surgery and remained 2.01 ± 3.52 at the latest follow-up. Knee Society Knee Score increased significantly from 53.7 ± 11.1 preoperatively to 93.8 ± 6.8 at 1-year follow-up and 91.8 ± 9.7 at latest follow-up. Similarly, the functional score also increased significantly from 67.4 ± 21.0 preoperatively to 86.3 ± 14.5 at 1-year follow-up and 82.1 ± 16.6 at latest follow-up (p < 0.01). Whereas, the range of motion significantly decreased from 122.7 ± 6.6 preoperatively to 116.1 ± 15.5 at the latest follow-up. CONCLUSION: Even in cases of severe medial osteoarthritis and varus malalignment, MOWHTO would be a good treatment option for management in active Chinese population less than 55 years. Although the long-term survival and functional outcome after MOWHTO was proven to be satisfactory in our cohort during the 10-year follow-up, a larger cohort to illustrate the long-term functional outcome is still warranted. TRANSLATIONAL POTENTIAL: The finding in this study indicated MOWHTO is a feasible treatment option for young adult patients with osteoarthritis to achieve long-term satisfactory results.

Infection in primary total knee replacement.

OBJECTIVES: To determine the infection rate and identify the risk factors of primary total knee replacement in a general hospital and discuss possible preventive measure. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: All cases of primary total knee replacement performed between the period July 1997 and June 2006 were reviewed. MAIN OUTCOME MEASURES: Infection rate of primary total knee replacement and its relationship to risk factors. RESULTS: In the defined period, 479 total knee replacements were performed in 353 patients (291 female and 62 male); 105 women and 21 men had bilateral replacements. The mean patient age was 69 (range, 40-88) years. In all, 447 knees had osteoarthritis, and 32 had rheumatoid arthritis. The mean follow-up period was 46 (range, 1-107) months; 345 knees were followed up longer than 24 months, but seven had no postoperative follow-up. Wound infection was defined by clinical, bacteriological, and/or histological examination. Primary total knee replacement was invariably performed in a theatre with vertical laminar flow, under prophylactic antibiotic cover, and body exhaust suits, water impermeable gowns, and double gloves were always used. The overall infection rate was 3.0% (14/472); the acute deep infection rate (within 4 weeks) was 0.2% (1/472), the delayed deep infection rate (4 weeks-2 years) was 0.6% (2/345). The superficial infection rate was 1.9% (9/472) and the late deep infection rate (after 2 years) was 0.6% (2/345). Diabetic patients had a three-fold higher risk of infection than non-diabetic patients, though this difference did not attain statistical significance (P=0.077). CONCLUSIONS: Our infection rates for primary total knee replacement were comparable to those encountered internationally.

Open wedge high tibial osteotomy: cause of patellar descent.

This was a retrospective review of the nine open wedge high tibial osteotomy (HTO) done in a regional hospital in Hong Kong from 2006 to 2008. The mechanical hip-knee-ankle angle improved from average 169.5°(164°-175°) to average 183.9° (179°-187°). Patellar descent was noted in all patients postoperatively, with Blackburne-Peel (BP) index significantly changing from 0.78 (0.64-0.93) to 0.59 (0.38-0.78) (p < 0.05). This change was strongly correlated with the size of anterior bone graft (r = -0.766; p = 0.016). The patellar tendon length as measured by Insall-Salvati index was not changed (pre-operative: 1.02 (0.88-1.25), final: 1.09 (0.8-1.22) (p = 0.683)), inferring that scarring contracture of patellar tendon was not related to patellar descent.