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.

Dual-energy CT of pancreatic adenocarcinoma: reproducibility of primary tumor measurements and assessment of tumor conspicuity and margin sharpness.

PURPOSE: To determine the inter- and intra-reader agreement of size, conspicuity, and margin sharpness of pancreatic adenocarcinoma on monochromatic, polychromatic, and iodine map dual-energy CT (DECT) images. METHODS: Retrospective review of DECT images from 61 patients with untreated pancreatic adenocarcinoma was performed by three radiologists independently. Pancreatic parenchymal phase images were generated as 50 and 70 keV, 140 kVp quality control (QC), and iodine map images. These were analyzed in a blinded randomized order during four reading sessions separated by 5-7 days. For each image set, readers recorded the longest axial and perpendicular primary tumor dimensions, and qualitatively scored tumor conspicuity and edge sharpness on 5-point scales. Linear mixed model was used to estimate and compare tumor measurements, tumor conspicuity, and tumor edge sharpness scores between readers and image sets. Kappa statistics were used to determine inter-observer agreement for tumor conspicuity and edge sharpness. RESULTS: The range of tumor measures (mean of longest dimension ± standard deviation) was 3.18 ± 1.41 to 3.83 ± 1.57 cm. Reproducibility of tumor measurements was very high with mild variability (s (2) = 0.01-0.10) between readers for the different image sets. Inter-observer agreement values for tumor conspicuity (κ = 0.01-0.17) and edge sharpness (κ = 0.12-0.25) were low for all image sets, although two of three readers scored tumor conspicuity and edge sharpness higher on monochromatic and iodine map DECT images than on 140 kVp QC images (p < 0.05). CONCLUSIONS: Pancreatic adenocarcinoma measurements were highly reproducible on DECT images, and subjective reader preference trended toward monochromatic and iodine images rather than polychromatic images.

Mortality and re-operation rate after proximal femoral fracture surgery by trainees.

PURPOSE: To review records of 761 patients who underwent surgery for proximal femoral fractures to determine whether surgeon's experience and volume was associated with 6-month mortality and reoperation rates. METHODS: Records of 761 patients who underwent surgery for proximal femoral fractures were reviewed. Patients operated on by a consultant or trainees with supervision of a scrubbed consultant were classified as the consultant group (n=214). Patients operated on by trainees alone (n=516) or trainees with supervision of an unscrubbed consultant (n=31) were classified as the trainee group (n=547). A total of 21 trainees were identified. They had different levels of experience, which was quantified according to the total number of operations performed for proximal femoral fractures from the start of their training to the start of the study. RESULTS: Patients in the trainee group were older (80 ± 12 vs. 77 ± 14 years, p<0.001), and the fractures were more complex in the consultant group. The 6-month mortality rate was 24.2% (n=184). The odds of dying within 6 months after operation was 80% higher in patients operated on by trainees without supervision of a scrubbed consultant (odds ratio, 1.8; 95% confidence interval, 1.1-2.7). Variables associated with the 6-month mortality rate were age (p<0.001), American Society of Anesthesiologists grade (p<0.001), pre-injury activity level (p<0.001), and the surgeon's grade (p<0.05). The 6-month reoperation rate was 3.8% (n=29) and did not differ significantly in the 2 groups. The experience level of the trainees was not associated with the 6-month reoperation rate. CONCLUSION: The odds of dying within 6 months after a surgery for proximal femoral fractures was 80% higher in patients operated on by trainees without supervision of a scrubbed consultant.

Wound complications following rivaroxaban administration: a multicenter comparison with low-molecular-weight heparins for thromboprophylaxis in lower limb arthroplasty.

BACKGROUND: The oral anticoagulant rivaroxaban is recommended for venous thromboembolic prophylaxis following lower limb arthroplasty. Concerns regarding high rates of wound complications following its use have prompted this multicenter comparison with low-molecular-weight heparins. METHODS: English hospital trusts that replaced a low-molecular-weight heparin with rivaroxaban for thromboprophylaxis in lower limb arthroplasty during 2009 were identified. Prospectively collected national data for these units were analyzed to determine the thirty-day rates of wound complications and major bleeding (cerebrovascular event or gastrointestinal hemorrhage) and the ninety-day rates of symptomatic deep venous thrombosis (proximal or distal), symptomatic pulmonary embolism, and all-cause inpatient mortality before and after the change to rivaroxaban. A total of 2762 patients prescribed rivaroxaban following knee or hip arthroplasty were compared with 10,361 patients prescribed a low- molecular weight heparin. Data were analyzed with use of odds ratios (ORs). RESULTS: There were significantly fewer wound complications in the low-molecular-weight heparin group (2.81% compared with 3.85%; OR = 0.72, 95% confidence interval [CI] = 0.58 to 0.90; p = 0.005). There were no significant differences between the low-molecular-weight heparin and rivaroxaban groups in the rates of pulmonary embolism (0.55% compared with 0.36%; OR = 1.52, 95% CI = 0.78 to 2.98), major bleeding (OR = 0.73, 95% CI = 0.48 to 1.12), or all-cause mortality (OR = 0.93, 95% CI = 0.46 to 1.89). There were significantly more symptomatic deep venous thromboses in the low-molecular-weight heparin group (0.91% compared with 0.36%; OR = 2.51, 95% CI = 1.31 to 4.84; p = 0.004). CONCLUSIONS: The rivaroxaban group had a higher wound complication rate and a lower deep venous thrombosis rate; there were no differences in symptomatic pulmonary embolism or all-cause mortality. Longer follow-up is needed to assess any potential relationship between wound complications and joint stiffness, latent infection, and limb consequences of deep venous thrombosis.

An electromyographic exploratory study comparing the difference in the onset of hamstring and quadriceps contraction in patients with anterior knee pain.

Idiopathic anterior knee pain in teenagers and young adults is a common condition. Patellar maltracking has been considered as a causative factor. The aim of our study was to investigate whether there was a difference in the timing of electromyographic (EMG) activity in the medial and lateral hamstring and quadriceps muscles of patients with anterior knee pain compared to asymptomatic control participants. This was a cross sectional observational study measuring EMG activation patterns. Two groups of participants were tested, one patient (mean age 15 years, n = 20) and one asymptomatic control (mean age 16 years, n = 17). Surface EMG (sampling rate 1000 Hz) was recorded from vastus medialis obliqus, vastus lateralis, and the medial and lateral hamstrings during three repetitions of maximal voluntary isometric contractions. The relative timing of the medial and lateral quadriceps and hamstrings was evaluated. The mean (95% confidence interval) difference between the groups in the lateral-medial hamstring onset timing was 53.8(1.9 to 105.6)ms during the maximal contraction. An independent t test showed that this difference was statistically significant (p = 0.043). The differences between the groups in the relative VMO to VL onset did not reach statistical significance. The results of this study suggest that the lateral hamstrings contract significantly earlier in patients with AKP compared to healthy controls for this small cohort. This altered activation pattern could produce external rotation of the tibia on the femur and cause lateral patella tracking.

Idiopathic anterior knee pain in the young. A prospective controlled trial.

Idiopathic anterior knee pain is a common condition in adolescents. The aim of this study was to compare the biometric parameters such as hamstring tightness, hip and knee movements and joint laxity in patients with idiopathic anterior knee pain with a control population of similar age and gender. Patients (n = 34) and controls (n = 34) (age and sex matched) between the age of 11 and 25 were recruited for the study. The mean follow-up of the patient group was 20 months. The patients showed a statistically significant improvement in their symptoms (SF-36 physical component, p = 0.001) despite the fact that half of them did not attend physiotherapy sessions. Patients had statistically significant hamstring tightness (p = 0.04) and increased external hip rotation (p = 0.001) as compared to the control group. These findings support the theory of idiopathic anterior knee pain being a self-limiting condition that is associated with hamstring tightness.

Interobserver and intraobserver variations in tibial pilon fracture classification systems.

BACKGROUND: Tibial pilon injuries are a complex group of fractures, whose classification and radiological assessment has been under constant reform. Till date, there is no universally accepted classification system. OBJECTIVE: To determine the interobserver agreement and intraobserver reproducibility of Ruedi and Allgower, AO, and Topliss et al. classification systems for tibial pilon fractures, with CT scans. METHOD: Forty-seven CT scans of tibial pilon fractures were evaluated independently by 5 orthopaedic surgeons. Fractures were classified according to Ruedi and Allgower, AO and Topliss et al. types. Assessment was done on two occasions, eight weeks apart. RESULTS: The interobserver reliability and intraobserver reproducibility for Ruedi and Allgower, AO and Topliss et al. classifications showed only moderate agreement. The interobserver agreement was dependent on the familiarity and specificity of the classification system. CONCLUSION: Currently used classification systems for tibial pilon fracture have moderate interobserver and intraobserver agreements, even with the help of CT scans. Therefore Tibial pilon fracture classification still remains largely undetermined.

Functional outcome of PFC Sigma fixed and rotating-platform total knee arthroplasty. A prospective randomised controlled trial.

The aim of this study was to determine whether there is a difference in functional outcome between the PFC Sigma fixed-bearing and rotating-platform total knee replacement systems. One hundred twenty patients were randomised to receive either a fixed-bearing or rotating-platform PFC Sigma total knee replacement. Range of movement (ROM), Oxford knee score (OKS) and Knee Society score (KSS) were assessed independently before and one year after surgery. Weight-bearing X-rays were taken immediately and one year post surgery to determine the incidence of osteolysis and loosening. At a mean follow-up of 13.4 months there was no statistically significant difference in mean ROM, OKS and KSS between the two groups. There was no evidence of osteolysis or loosening in either of the groups and no revision for infection or implant failure. This study shows that there is no statistically significant difference in functional outcome between the two types of implants at short-term follow-up.

Comparison of autologous transfusion drains versus no drain in total knee arthroplasty.

Primary total knee arthroplasty is associated with blood loss both during surgery and in the immediate postoperative period, that may require allogenic blood transfusion. In view of the risks and financial implications of using allogenic blood, an accepted solution has been to utilise autotransfusion drains in the postoperative period thus allowing re-infusion of a patient's own blood. A number of studies have compared retransfusion techniques with standard drain use, but few report comparison with no drain use at all. We analysed data from patients undergoing primary total knee arthroplasty within our unit over an 18-month period. A total of 121 patients were included in the study: 53 received retransfusion drains whilst the remaining 68 received no drain at all. The mean postoperative haemoglobin drop was not significantly different between the two groups (p > 0.05). In the retransfusion group only one patient (2%) required allogenic blood transfusion postoperatively, whilst 4 of the 68 (6%) did so in the control group. This difference was not statistically significant either. This study showed a low rate of allogenic blood use postoperatively (< 5%) where either a retransfusion drain or no drain was used at all. However because there was no measurable difference between the two, we conclude that using a retransfusion technique does not appear to be of significant financial or clinical benefit with regards to allogenic blood transfusions compared with using no drain.