Chloroprocaine 40 mg produces shorter spinal block than articaine 40 mg in day-case knee arthroscopy patients.

BACKGROUND: Articaine and chloroprocaine have recently gained interest as short-acting spinal anaesthetics. Based on previous work comparing articaine 60 mg with chloroprocaine 40 mg, we hypothesised that articaine 40 mg and chloroprocaine 40 mg would produce similar spinal anaesthesa regarding block onset, maximal spread, and recovery. METHODS: In this randomised, double-blind study, adult patients (18-70 years, American Society of Anaesthesiologists physical status I-III, BMI < 36 kg/m(2) ) scheduled for day-case knee arthroscopy received either articaine 40 mg (20 mg/ml) (group A40, n = 16) or chloroprocaine 40 mg (20 mg/ml) (group C40, n = 18) intrathecally. Telephone interviews were performed on the first and seventh postoperative day to disclose possible side effects, e.g. transient neurological symptoms (TNS). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. Surgery could be performed successfully under spinal anaesthesia except once in A40 (insufficient block) and once in C40 (prolonged surgery). Complete recovery was significantly slower in A40 vs. C40 for both motor block (105 (94/120) vs. 75 (71/90) min) [P < 0.001, Mann-Whitney U-test (MW-U)] and sensory block [135 (109/176) vs. 105 min (90/124)] (P < 0.02, MW-U), respectively [data are median (25th/75th percentiles)]. One patient from A40 showed mild TNS. CONCLUSION: Both A40 and C40 provided mainly adequate spinal anaesthesia for day-case knee arthroscopy. While onset and maximal spread were comparable, the recovery from motor block was clearly faster with chloroprocaine after equivalent doses of spinal articaine and chloroprocaine.

Recommendations for standardization and phenotype definitions in genetic studies of osteoarthritis: the TREAT-OA consortium.

OBJECTIVE: To address the need for standardization of osteoarthritis (OA) phenotypes by examining the effect of heterogeneity among symptomatic (SOA) and radiographic osteoarthritis (ROA) phenotypes. METHODS: Descriptions of OA phenotypes of the 28 studies involved in the TREAT-OA consortium were collected. We investigated whether different OA definitions result in different association results by creating various hip OA definitions in one large population based cohort (the Rotterdam Study I (RSI)) and testing those for association with gender, age and body mass index using one-way ANOVA. For ROA, we standardized the hip-, knee- and hand ROA definitions and calculated prevalence's of ROA before and after standardization in nine cohort studies. This procedure could only be performed in cohort studies and standardization of SOA definitions was not feasible at this moment. RESULTS: In this consortium, all studies with SOA phenotypes (knee, hip and hand) used a different definition and/or assessment of OA status. For knee-, hip- and hand ROA five, four and seven different definitions were used, respectively. Different hip ROA definitions do lead to different association results. For example, we showed in the RSI that hip OA defined as "at least definite joint space narrowing (JSN) and one definite osteophyte" was not associated with gender (P =0.22), but defined as "at least one definite osteophyte" was significantly associated with gender (P=3×10(-9)). Therefore, a standardization process was undertaken for ROA definitions. Before standardization a wide range of ROA prevalence's was observed in the nine cohorts studied. After standardization the range in prevalence of knee- and hip ROA was small. CONCLUSION: Phenotype definitions influence the prevalence of OA and association with clinical variables. ROA phenotypes within the TREAT-OA consortium were standardized to reduce heterogeneity and improve power in future genetics studies.

Chloroprocaine vs. articaine as spinal anaesthetics for day-case knee arthroscopy.

BACKGROUND: Chloroprocaine and articaine have recently gained interest as short-acting spinal anaesthetics. They have not, however, previously been compared in an ambulatory surgery setting. METHODS: In this double-blind, randomised, controlled trial, adult patients (≤65 years, ASA I-II, body mass index<36 kg/m2) underwent day-case knee arthroscopy under spinal anaesthesia with either 40 mg of plain chloroprocaine (20 mg/ml) (group C40; n=39) or 60 mg of plain articaine (40 mg/ml) (group A60; n=39). Study parameters included the onset, degree, and regression of both sensory and motor block. Standardised telephone interviews on the first and seventh post-operative day were aimed at detecting any untoward sequelae, e.g., transient neurologic symptoms (TNSs). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. All arthroscopies were performed successfully under spinal anaesthesia, except for one patient (C40, unforeseen delay in the start of surgery). The duration of sensory block≥dermatome L1 was significantly shorter in C40 vs. A60. Correspondingly, complete recovery was significantly faster (P<0.0001, Mann-Whitney U-test) in C40 vs. A60 for both motor [75 (60/90) vs. 135 (105/150) min] and sensory [105 (105/135) vs. 165 (135/180) min] block, respectively [data are median (25th/75th percentiles)]. No TNSs were noted. CONCLUSIONS: Both anaesthetics used provided a rapid onset of spinal anaesthesia of about 1 h and were satisfactory for day-case knee arthroscopy. Recovery, however, was significantly faster in group C40. The data add to earlier results that TNSs seem to be uncommon after spinal chloroprocaine and articaine.

Mid-term results for three contemporary total knee replacement designs - a comparative study of 104 patients with primary osteoarthritis.

AIMS: The purpose of this study was to compare retrospectively the mid-term clinical and radiological results of three contemporary knee designs in cohorts operated on in the same hospital during the same time period. MATERIALS AND METHODS: We evaluated mid-term clinical and radiographic outcome of three contemporary total knee designs (the AGC V2, the Duracon and the Nexgen) in 104 consecutive patients (129 knees) operate on for primary knee osteoarthritis at our hospital. The mean indexed age at the time of the operation was 69.2 years (range, 49.3 to 81.1 years). The mean follow-up time was 6.0 years (range, 0.2 to 7.9). All patients were followed for at least three years or until the first revision. In the survival analyses, the end point was defined as, revision for any reason. RESULTS: The Kaplan-Meier survival analysis showed a 98% (95% CI 94-100) survival rate for the NexGen, a 98% (95% CI 93-100) for the AGC and a 90% (95% CI 81-99) for the Duracon design at six years. Both the mean KSS for pain, KSS for function and the mean clinical knee score improved significantly in all three groups. There was no difference between the three designs in mid-term survivorship. CONCLUSIONS: Most of the revisions could be directly linked to perioperative surgical errors. In conclusion, the most recently introduced knee replacements of the present study (Duracon and Nexgen) did not show any clinically significant benefit over the older design (AGC) in the mid-term.

Post-operative use of knee brace in bone-tendon-bone patellar tendon anterior cruciate ligament reconstruction: 5-year follow-up results of a randomized prospective study.

Sixty patients were prospectively randomized to brace and no-brace groups after bone-tendon-bone patellar tendon anterior cruciate ligament (ACL) reconstruction. The brace group wore a rehabilitation knee brace for 12 weeks post-operatively, while the no-brace group was mobilized immediately, and crutches were discarded 2 weeks post-operatively. The groups were comparable with respect to age, gender, time from injury to surgery and concomitant injuries. There were no differences either pre-operatively or 5 years post-operatively (80% of patients reviewed) between the groups in terms of the knee score (Lysholm), activity level (Tegner), degree of laxity or isokinetic peak muscle torque. Thus it appears that knee braces are not needed in the post-operative rehabilitation after ACL reconstruction with the patellar tendon graft.

Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults.

BACKGROUND: Anterior cruciate ligament rupture is a common knee injury. Surgical treatment, usually involving reconstruction of the ligament, is widely used especially in active individuals. OBJECTIVES: Evaluation of the effect of surgical treatment compared with conservative treatment of anterior cruciate ligament (ACL) rupture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to January Week 3 2005), EMBASE (1988 to 2005 Week 05), MEDIC (1978 to January 1999), Current Contents (9.2.1998 to 1.2.1999), BIOSIS (1970 to December 1998), reference lists of articles and consulted trialists and experts. SELECTION CRITERIA: All randomised and quasi-randomised trials that compared surgical with conservative treatment of ACL rupture in adults. DATA COLLECTION AND ANALYSIS: Two authors independently performed study selection, data extraction and quality assessment. MAIN RESULTS: Two poor quality randomised trials conducted in the early 1980s were included in the review. The two trials differed considerably and no data pooling was done for the few shared outcome measures. One quasi-randomised trial of 167 people with a complete ACL rupture treated with repair or augmented repair versus conservative treatment found no difference in the return to sports activities between people treated surgically and those treated conservatively. Measures of knee stability and functional (Lysholm) knee scores were higher in surgically-treated participants. By the end of the follow-up period (average 55 months), three people treated with repair only and 16 treated conservatively had had ACL reconstruction. The other trial included 157 people with ACL injury. This found that conservatively-treated participants recovered from their injury more rapidly but, at the last follow up (minimum 13 months), the functional outcome was similar in both treatment groups. A large proportion of participants experienced some temporary discomfort after surgery and there were some more serious postoperative complications. There was less knee instability in surgically-treated participants and a tendency to fewer subsequent operations in the longer term. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice. Good quality randomised trials are required to remedy this situation.

Patellofemoral relationships and cartilage breakdown.

We evaluated the association between patellofemoral relationships and cartilage lesions in patients (age range 15-49) with anterior knee pain without patellar dislocation (n = 24) and in patients with isolated meniscal rupture without a high energy trauma (n = 21). The position of the patella was assessed from knee radiographs, and cartilage lesion was graded and mapped at arthroscopy. In subjects with lateral patellar cartilage lesion the patella tilted laterally (p < 0.01) and was clearly laterally displaced (p < 0.001), compared to those without patellar cartilage lesion. In subjects with central patellar cartilage lesion the patella located high according to the Insall-Salvati index (p < 0.01) and was somewhat laterally displaced (p < 0.05). Compared to subjects without cartilage lesion in the femoral trochlea, the patella was laterally displaced in subjects with lesion in the lateral trochlea (p < 0.001). In conclusion, our results suggest that specific malalignments predispose to patellofemoral cartilage lesion, but prospective studies are needed to confirm the finding.

Revision anterior cruciate ligament surgery. A review of the literature and results of our own revisions.

Revision anterior cruciate ligament surgery has become a more commonly performed operation. Reasons for this are an increased number of first-time operations, some with technical faults. Patients can also sustain a new injury severe enough to rupture their reconstructed ligament. Results of the revision operations are not as good as those of well executed primary reconstructions. Re-reconstruction is usually technically feasible but the surgeon has to be prepared to encounter many demanding technical problems.

MRI of anterior cruciate ligament repair with patellar and hamstring tendon autografts.

OBJECTIVE: Several MRI sequences were used to evaluate the 2-year postoperative appearance of asymptomatic knee with a torn anterior cruciate ligament (ACL) reconstructed with bone-patellar tendon-bone (BTB) and semitendinosus and gracilis (STG) tendon autografts. DESIGN AND PATIENTS: Two groups with successful repair of ACL tear with BTB (n = 10) or STG (n = 10) autografts were imaged at 1.5 T with sagittal and oblique coronal proton density-, T2-weighted and sagittal STIR sequences and plain and contrast-enhanced oblique coronal T1-weighted sequences. The appearance of the graft and periligamentous tissues was evaluated. RESULTS: In all 20 cases, the ACL graft showed homogeneous, low signal intensity with periligamentous streaks of intermediate signal intensity on T2-weighted images. In 10 cases, localised areas of intermediate signal intensity were seen in the intra-articular segment of the graft on proton density- and T1-weighted images. The graft itself did not show enhancement in either of the two groups, but mild to moderate periligamentous enhancement was detected in 10 cases. CONCLUSION: The MRI appearance of ACL autograft is variable on proton density- and T -weighted images. Periligamentous tissue showing contrast enhancement is a typical MRI finding after clinically successful ACL reconstruction.

Bone tunnel enlargement after anterior cruciate ligament reconstruction with the hamstring autograft and endobutton fixation technique. A clinical, radiographic and magnetic resonance imaging study with 2 years follow-up.

The aim of this study was to describe the contrast-enhanced magnetic resonance imaging (MRI) appearance of bone tunnel enlargement detected on radiography after anterior cruciate ligament (ACL) reconstruction with semitendinosus and gracilis tendon endobutton (STG-endobutton) fixation technique. Fourteen patients with a STG-endobutton ACL reconstruction were examined 3 months (n = 1), 1 year (n = 1) and 2 years (n = 12) postoperatively. An age- and sex-matched group with a bone-patellar tendon-bone (BTB) autograft ACL reconstruction with similar follow-up was taken as control. Data on clinical examination, laxity and isokinetic muscle torque measurements, anteroposterior and lateral view radiography were obtained, and knee scores (Lysholm and Tegner) were collected. Contrast-enhanced MRI was performed in the STG-endobutton group with a 1.5-T imager. There were no statistical differences between the groups with respect to clinical findings, stability tests, or knee scores. In the STG-endobutton group the average femoral and tibial bone tunnel diameter detected on anteroposterior view radiography had increased at 2-year follow-up by 33% and 23%, respectively. On MRI the ligamentous graft itself was not enhanced by the contrast medium whereas periligamentous tissue within and around the STG graft bundles showed mild contrast enhancement. In conclusion, the MRI results suggest that enhancing periligamentous tissue accumulated in and around the STG graft associated with the tunnel expansion. In spite of the significant bone tunnel enlargement observed on the follow-up radiography the STG-endobutton knees were stable and the patients satisfied.

Instrumented measurement of anterior-posterior translation in knees with chronic anterior cruciate ligament tear.

Anteroposterior translation of the knee joint was measured with a Knee Signature System device on 12 women and 14 men with a unilateral, chronic, isolated, anterior cruciate ligament (ACL) tear. A control group with stable knees consisted of 10 women and 10 men. Anterior translation at 178 N load of the uninjured knees was 8.0 mm (+/-2.2 mm) and in knees with an ACL tear, 14.2 mm (+/-4.2 mm). Corresponding values for anteroposterior translation were 12.1 mm (+/-2.5 mm) and 19.3 mm (+/-4.9 mm), respectively. A difference of 3 mm or more in anteroposterior translation at 178 N load between injured and uninjured knees indicated an ACL tear with 85% specificity and 88% sensitivity.

Local NSAID gel (eltenac) in the treatment of osteoarthritis of the knee. A double blind study comparing eltenac with oral diclofenac and placebo gel.

In a randomized, double blind, multicentre study with 4 weeks follow-up of 290 patients with osteoarthritis of the knee joint, a topical NSAID (eltenac) was compared with oral diclofenac and placebo. The main outcome, Lequesne's Index and pain by VAS showed no statistically significant differences between neither of the active treatments and placebo for the total study population. However, in patients with more severe symptoms, both active groups showed statistically significant differences to placebo. No severe adverse drug reactions were seen but the number of GI reactions were three times higher in the diclofenac group compared to the topical treatment. Local skin reactions were twice as frequent in the eltenac than in the placebo group. Taking into account the nature of the treatment for a chronic disease like OA, our results indicate that eltenac gel could be a safe alternative to oral NSAIDs.

Knee brace after bone-tendon-bone anterior cruciate ligament reconstruction. Randomized, prospective study with 2-year follow-up.

In a prospective study 60 patients were randomized to brace and no-brace groups after bone-tendon-bone anterior cruciate ligament reconstruction. The brace group wore a rehabilitation orthosis for 12 weeks postoperatively, while the no-brace group was mobilized immediately, and crutches were discarded 2 weeks postoperatively. The groups were comparable with respect to age, gender, time from injury to surgery, knee score (Lysholm), activity level (Tegner), degree of laxity and isokinetic muscle torque. Although compared with the preoperative situation patients in both groups had significantly improved, there were no differences between the groups 1 and 2 years postoperatively in terms of functional outcome (Lysholm and Tegner scores), stability of the knee or isokinetic muscle torque.

Lumbar spine in Marfan syndrome.

Lumbar spine radiographs of 28 patients with Marfan syndrome and a gender and age-matched control group were evaluated for scoliosis and morphologic changes of the L2, L3, and L4 vertebrae. No patient or control subject had any serious low back problems. The Marfan patients showed a high incidence of scoliosis (64%). The incidence of lumbosacral transitional vertebra was also high (18%). The end plates of the vertebral bodies in the Marfan patients were more biconcave than in the control group. In addition, the transverse processes were longer in relation to the vertebral body width in the Marfan group than in the controls. These findings indicate that biconcave vertebral bodies can be added to the list of skeletal manifestations of the Marfan syndrome, and Marfan syndrome to the list of differential diagnoses for biconcave vertebrae ("codfish vertebrae").

Good muscle performance does not compensate instability symptoms in chronic anterior cruciate ligament deficiency.

A total of 167 patients with documented anterior cruciate ligament deficiency was examined preoperatively with laxity and isokinetic muscle strength measurements. Functional evaluation with Lysholm knee and Tegner activity level scores were done. Antero-posterior (AP) knee laxity correlated negatively with Tegner activity level (NS), and insignificantly with Lysholm knee score. A marginal correlation was found between the Lysholm score and muscle strength. Patients were divided into four groups depending on whether their AP laxity was greater or less than 20 mm and whether their quadriceps strength was greater or less than 85% of their control knee. No difference in the Lysholm or Tegner scores between the groups was observed. As a conclusion it seems that even a relatively good muscle performance does not compensate severe instability symptoms.

High hydrostatic pressures in traumatic joints require elevated synovial capillary pressure probably associated with arteriolar vasodilatation.

Three out of the four Starling pressures were determined at arthroscopy of traumatic effusions of the knee. The range of the joint fluid hydrostatic pressure Pjoint was 5-83 cmH2O (0.5-8.1 kPa, 4-61 mmHg), that of the colloid osmotic pressure difference COPplasma-COPjoint 0-21.7 cmH2O. In 11 of 15 cases the sum Pjoint+COP difference exceeded 32.6 cmH2O (3.19 kPa, 24 mmHg), a high estimate of average capillary pressure at the level of the heart. The number of 'exceeding' cases was 8/15 if only 80% of the COP difference was considered effective. Pjoint and the COP difference oppose filtration of fluid from plasma into joints, indicating that mean capillary pressure, the only Starling pressure not determined, was elevated unless the effusions were being resorbed back into the blood. The findings can be explained by tamponade compensated by arteriolar vasodilatation, suspected to be metabolically mediated.

Prospective preoperative evaluation of anterior cruciate ligament instability of the knee joint and results of reconstruction with patellar ligament.

Of 54 patients with chronic (n = 49) or acute (n = 5) anterior cruciate ligament instability, 52 were evaluated after mean 16 months' follow-up interval after open (n = 18) or arthroscopic assisted (n = 36) bone-tendon-bone patellar ligament reconstruction. Preoperative Knee Signature System side-to-side difference in anterior displacement decreased from 7.9 mm to 3.5 min at follow-up evaluation (p < 0.0001). An objectively satisfactory limit of 5 mm in side-to-side difference was achieved in 73% of the patients. At follow-up evaluation, there was a positive pivot shift sign in eight knees (one definite and seven trace). Average Lysholm knee scores improved from 69 to 83. The only significant difference between the arthroscopic assisted and open groups was smaller side-to-side anterior displacement difference in the arthroscopic group (2.2 mm versus 4.8 mm, p = 0.002). Results suggest that more accurate and isometric placement of the graft is possible with the arthroscopic-assisted technique.

Revision of the PCA unicompartmental knee. 52 arthrosis knees followed for 2-5 years.

We evaluated 52 unicompartmental PCA arthroplasties for primary (46) or secondary (6) arthrosis after 3 (2-5) years. Cementless fixation was used in 35 femoral and in 28 tibial components. There were indications for revision in 11 cases. Conversion to a total knee had been performed in 4 cases, and 1 tibial as well as 1 femoral component had been exchanged, mainly because of polyethylene wear with increasing deformity. 2 femoral components were loose and 1 had fractured.

MRI for diagnosis of metatarsal osteonecrosis. A case report.

A 12-year-old girl with forefoot pain for 1 month was suspected of having a metatarsal stress fracture. Plain radiographs were negative. MRI revealed the characteristic changes of osteonecrosis of the second metatarsal head.