Medial patellofemoral ligament reconstruction and tibial tuberosity transfer can be used to successfully manage patellofemoral instability in the setting of trochlea dysplasia.

BACKGROUND: Management of patella instability remains a challenge particularly in the presence of trochlea dysplasia. The aim of this study is to assess the recurrence rates of those with patellar instability who have undergone a combined tibial tuberosity transfer (TTT) and medial patellofemoral ligament reconstruction (MPFLR) in the setting of trochlea dysplasia. METHODS: All skeletally mature patients who underwent combined TTT and MPFLR for recurrent patella instability were identified between January 2009 and December 2019. A retrospective review was conducted, with information regarding re-dislocation/subluxation and complications collected. RESULTS: Seventy patients with a mean age 25.3 years were identified and evaluated. Thirteen patients were found to have low-grade dysplasia (Dejour A), with 57 patients having high-grade dysplasia (Dejour B/C/D). No patients in the low,grade dysplasia group suffered a recurrence of their symptoms, with four in the high-grade group suffering episodes of re-dislocation/subluxation. Three patients subsequently underwent a trochleoplasty, with the other patient managed successfully non-operatively. There were a total of 13 complications in 11 patients. CONCLUSIONS: A combined procedure of MPFLR and TTT can be used to manage patellofemoral instability even in the setting of trochlea dysplasia with a low rate of recurrence. Trochlea dysplasia, however, remains an anatomical risk factor for recurrence and patients should be counselled accordingly. The anatomical risk factors should be assessed in all patients to allow for the development of the most appropriate management plan, of which this combined procedure represents a potentially successful option. LEVEL OF EVIDENCE: IV (Case Series).

A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee.

BACKGROUND: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION: International Standard Randomised Controlled Trial Number: 48911177.

Effect of the systemic inflammatory response, as provoked by elective orthopaedic surgery, on HbA1c.

Background In acutely ill patients with new onset hyperglycaemia, plasma glucose cannot reliably distinguish between stress hyperglycaemia and undiagnosed diabetes mellitus. We, therefore, investigated the diagnostic reliability of glycated haemoglobin (HbA1c) in acute illness by prospectively evaluating the effect of the systemic inflammatory response, as provoked by elective orthopaedic surgery, on HbA1c. Methods HbA1c and serum C-reactive protein concentrations were compared before and two days after elective knee or hip surgery in 30 patients without diabetes. C-reactive protein was used to assess the systemic inflammatory response. Results The mean (standard deviation) serum C-reactive protein increased following surgery (4.8 [7.5] vs. 179.7 [61.9] mg/L; P<0.0001). HbA1c was similar before and after surgery (39.2 [5.4] vs. 38.1 [5.1] mmol/moL, respectively; P = 0.4363). Conclusions HbA1c is unaffected within two days of a systemic inflammatory response as provoked by elective orthopaedic surgery. This suggests that HbA1c may be able to differentiate newly presenting type 2 diabetes mellitus from stress hyperglycaemia in acutely ill patients with new onset hyperglycaemia.

Modified Technique of Tibial Tuberosity Transfer.

Tibial tuberosity transfer is a well-established procedure in the treatment of patellar instability and in selected cases of anterior knee pain. Several techniques have been advocated in the literature. Some of the common complications associated with this procedure have been pain and discomfort due to prominent screw heads, necessitating their removal; nonunion and delayed union of the osteotomy; and failure of fixation. Tibial fractures have also been reported in some case reports. We present our technique of tibial tuberosity transfer using two 4-mm cannulated screws for stabilization of the tuberosity fragment. We have used this technique either for isolated tibial tuberosity transfer or as part of a combined procedure along with medial patellofemoral ligament reconstruction in treating patellar instability. Using this technique, we have encountered no patients with wound problems, nonunion, delayed union, or loss of fixation and only 1 patient with a metal work problem needing a second procedure for its removal. We attribute our good outcomes to the preservation of the soft-tissue attachments to the tuberosity fragment; minimal soft-tissue dissection, which allows rapid bony consolidation of the osteotomy, which in turn allows accelerated rehabilitation; and the use of 4-mm cannulated screws for fixation of the osteotomy, minimizing the potential for metal work problems.

Vitamin D: a negative acute phase reactant.

OBJECTIVE: We evaluated the effect of the systemic inflammatory response (SIR), as provoked by elective orthopaedic surgery, on serum vitamin D [25-(OH)D]. METHODS: Serum 25-(OH)D, serum vitamin D binding protein (VDBP) and urinary VDBP were measured in 30 patients before and 48-hours after knee or hip arthroplasty. C-reactive protein (CRP) was measured to assess the SIR. RESULTS: The mean (SD) CRP increased following surgery [5.0 (5.5) vs 116.0 (81.2) mg/L; P<0.0001] as did urine VDBP/Creatinine ratio [8 (9) vs 20 (25) pg/mmol; p=0.0004]. Serum 25-(OH)D [56.2 (30.3) vs 46.0 (27.6) nmol/L; p = 0.0006] and serum VDBP [334 (43) vs 298 (37) mg/L]; P<0.0001] decreased. CONCLUSIONS: Serum 25-(OH)D is a negative acute phase reactant, which has implications for acute and chronic inflammatory diseases. Serum 25-(OH)D is an unreliable biomarker of vitamin D status after acute inflammatory insult. Hypovitaminosis D may be the consequence rather than cause of chronic inflammatory diseases.

The effect of the systemic inflammatory response, as provoked by elective orthopaedic surgery, on serum uric acid in patients without gout: a prospective study.

OBJECTIVE: Acute gout is associated with a decrease in serum uric acid (SUA) that is considered to be in response to acute inflammation but it may be a feature of gout itself. We, therefore, aimed to investigate the effect of the acute systemic inflammatory response (SIR) on SUA concentrations in subjects without gout. METHODS: SUA and urinary excretion of uric acid (UA) (expressed as fractional excretion of UA; FEua%) were measured in 30 patients before and 48 h after elective knee or hip surgery. The SIR was assessed by measuring serum CRP and urine microalbumin excretion [expressed as the albumin-creatinine ratio (ACR)] before and after surgery in the same patients. RESULTS: The mean (s.d.) serum CRP increased following surgery [5.0 (5.5) vs 116.0 (81.2) mg/l; P < 0.0001) as did urine ACR [0.85 (1.03) vs 2.10 (2.60) mg/mmol; P = 0.004]. SUA decreased following surgery [312 (64) vs 282 (82) µmol/l; P = 0.0033] but FEua% was unchanged [6.4 (2.3) vs 7.3 (3.3)%; P = 0.1726]. CONCLUSION: The SIR is associated with a decrease in SUA concentrations in normouricaemic patients without gout. The decrease in SUA concentrations is not due to increased urinary excretion of UA. This study supports the notion that the decrease in SUA during acute gout is due to the associated SIR rather than gout per se.