New modified Achilles tendon allograft for treatment of chronic patellar tendon ruptures following total knee arthroplasty.

INTRODUCTION: Patellar tendon rupture is an infrequent but debilitating lesion. Several surgical repairs have been suggested for patellar tendon rupture. Our aim is to propose a modified technique from the classic Achilles allograft procedure. MATERIALS AND METHODS: Five consecutive patients diagnosed with chronic patellar tendon rupture following total knee arthroplasty (TKA) were included in the presented study. All patients were operated with a modified Achilles allograft technique, dividing the Achilles tendon into two bundles and overcrossing these through the distal part of the quadricipital tendon. RESULTS: All patients regained their extension mechanism and have discontinued using crutches. No complications were observed. CONCLUSIONS: The modified Achilles allograft has shown to be a safe, time-reducing repair for chronic patellar tendon ruptures following TKA, and should be considered as an alternative surgical repair.

Factors influencing health-related quality of life after TKA in patients who are obese.

BACKGROUND: Although the health-related quality of life (HRQL) for patients who are obese seems to improve after TKA, the magnitude of improvement and the associated factors remain controversial. We previously found body mass index was not associated with changes in HRQL after TKA. QUESTIONS/PURPOSES: The purposes of this secondary analysis were to determine which patient characteristics and surgical factors were associated with worse health status after TKA in patients who are severe or morbidly obese. METHODS: We assessed 60 patients (53 females; mean age, 70 years) 12 months after surgery. The mean number of comorbidities was 2.5. Mean lower limb anthropometric index scores were: suprapatellar, 1.6; infrapatellar, 2; and suprapatellar/infrapatellar, 1.2. Intraoperative difficulty (IOD) was Grade 0, 40%; Grade 1, 48%; and Grade 2, 12%. Ten patients (17%) had complications. We measured HRQL using the disease-specific WOMAC questionnaire. Patient characteristics (sociodemographic variables, BMI, comorbidity, lower limb anthropometry) and surgical factors (IOD, complications, postoperative medical data) were collected. Associations between WOMAC dimension scores at 12 months and patient characteristics and surgical factors were analyzed using linear regression models. RESULTS: Factors associated with worse WOMAC dimension scores in patients who were obese included the number of comorbidities, an infrapatellar index percentile less than 75, IOD Grade 2, and the number of complications after discharge. CONCLUSIONS: For patients with knee osteoarthritis who were severe or morbidly obese, various lower limb anthropometric features, degree of IOD, and postoperative complications negatively influenced postoperative WOMAC scores. LEVEL OF EVIDENCE: Level II Prognostic Study. See Guidelines for a complete description of levels of evidence.

Cryopreserved and frozen hyaline cartilage imaged by environmental scanning electron microscope. An experimental and prospective study.

OBJECTIVE: To obtain images of the articular surface of osteochondral grafts (fresh, frozen, and cryopreserved in RPMI) using an environmental scanning electron microscope (ESEM). To evaluate and compare the main morphological aspects of the chondral surface of the fresh, frozen, and cryopreserved grafts as visualized via ESEM. METHODS: The study was based on osteochondral fragments from the internal condyle of the knee joint of New Zealand rabbits, corresponding to the chondral surface from fresh, frozen, and cryopreserved samples. One hundred ESEM images were obtained from each group and then classified according to a validated system. The kappa index and the corresponding concordance index were calculated, and the groups were compared by Pearson's chi-squared test (p < 0.05). RESULTS: The articular surface of cryopreserved osteochondral grafts had fewer even surfaces and filled lacunae and a higher number of empty lacunae as compared to fresh samples; these differences correspond to images of cell membrane lesions that lead to destruction of the chondrocyte. Frozen grafts showed more hillocky and knobby surfaces than did fresh grafts; they also had a greater number of empty chondrocyte lacunae. CONCLUSION: ESEM is useful for obtaining images of the surface of osteochondral grafts. When compared to fresh samples, cryopreservation in RPMI medium produces changes in the surface of hyaline cartilage, but to a lesser extent than those produced by freezing.

Prevalence of knee osteoarthritis and analysis of pain, rigidity, and functional incapacity.

Knee osteoarthritis is one of the most prevalent health problems in our society. It accounts for 10% of all primary care visits in general medicine and 30% of outpatient appointments. The objectives of this cross-sectional descriptive study of 100 patients suffering from gonarthritis were to assess pain, functional capacity, and joint damage in patients diagnosed with knee osteoarthritis, as well as the possible repercussions for subsequent surgical treatment. Sociodemographic, clinical, and radiological data were collected, and pain and functional capacity were evaluated by using the Western Ontario and McMaster Universities Osteoarthritis Index. The majority (71) of patients were women, mean age 71 years (SD=7.84), of low educational (66%) and financial (89%) status, with mean disease duration of 11.8 years. Of the total, 87% presented with comorbidity. Radiographs revealed a varus malalignment in 31% of patients and a valgus malalignment in 17%, with bone collapse in 39% of these. The factors that most affect surgery and subsequent rehabilitation are closely linked to social status, the general state of the patient, and the radiological severity of gonarthritis. Most of the patients were obese and suffered from comorbid conditions, and some presented with psychopathology. These factors may influence surgery, and thus improvements in primary care should be made as a way of offering a simpler and more effective treatment for gonarthritis.

Mejora del acceso a la artroplastia total de rodilla: experiencia de una unidad monográfica / Improved accessibility in total knee arthroplasty: experience of a specialized unit

Introducción: En mayo de 2004 se implantó un programa específico para la cirugía protésica de rodilla, dada la alta demanda para este tipo de cirugía. El objetivo de este trabajo es evaluar los resultados de los indicadores asistenciales y de calidad obtenidos en una unidad monográfica de prótesis de rodilla (UEPR), y compararlos con los obtenidos previamente en una unidad asistencial convencional de cirugía ortopédica y traumatología (UCOT). Material y metodo: La población objeto de este ensayo comunitario no controlado (antes-después) han sido los primeros 124 pacientes atendidos en la UEPR y los últimos 124 pacientes a quienes se había realizado este mismo tipo de intervención en la UCOT. Edad, sexo, días de estancia, dolor, deambulación al alta, flexión de la rodilla, comorbilidades y complicaciones han sido las variables analizadas. Resultados: Los pacientes atendidos en la UEPR estaban menos tiempo ingresados (p < 0,0001) y presentaban una mayor flexión de la rodilla intervenida al alta (p < 0,0001). En general la UEPR atendió a enfermos con un mayor número de comorbilidades que la UCOT. Conclusiones: El diseño y la puesta en funcionamiento de unidades monográficas y especializadas en la atención de pacientes quirúrgicos de alta prevalencia puede ser una alternativa satisfactoria en la resolución de este problema endémico de la sanidad pública. Estas unidades deben desarrollar su actividad según una guía clínica específica y evaluar la calidad asistencial conforme a una serie de indicadores y objetivos que posibiliten su mejora continua

Introduction: In May 2004 a specific program for knee prosthesis surgery was established, due to the high demand for this type of surgery. The aim of this study was to assess the outcomes of clinical and quality indicators obtained in a monographic hospitalization unit specialized in knee prosthesis surgery compared with the outcomes previously obtained in a standard orthopedic surgery hospitalization unit. Material and method: The sample of this non-controlled community trial (before-after) consisted of the first 124 patients treated in the specialized unit and the last 124 patients treated in the standard unit for the same type of surgery. Age, gender, pain, length of hospital stay in days, movement at discharge, knee bending, comorbidity and complications were analyzed. Results: Patients admitted to the specialized unit spent less time in the hospital (p < 0.0001) and showed better knee bending at discharge (p < 0.0001). In general the specialized unit attended patients with a greater number of comorbidities than the standard unit. Conclusions: Creating a monographic unit specialized in the care of surgical patients with high prevalence could be a possible solution to this chronic problem in public hospitals. These units should follow a specific clinical pathway and should assess quality according to a group of indicators and objectives that allow continuous improvement

Hoffa's fat pad resection in total knee arthroplasty.

The authors have studied the consequences of resection of Hoffa's fat pad during total knee arthroplasty (TKA). Sixty eight patients undergoing primary TKA were randomised to have Hoffa's fat pad either resected or preserved. Biopsy specimens of Hoffa's fat pad were taken for pathological study in all patients. Radiological, functional and clinical evaluation was made after surgery, before discharge from hospital, after one month and after six months. Thirty six percent of the patients were found to present inflammatory infiltration of Hoffa's fat pad, and severe fibrosis was found in 33 %. A progressive decrease in postoperative anterior knee pain was found in 95% of the patients in both groups. Hoffa's fat pad resection did not appear to result in a change in patellar tendon length during the first six months after TKA. Preoperative fibrosis of Hoffa's fat pad may play a role in postoperative pain and range of motion.