Increased risk of intraoperative and early postoperative periprosthetic femoral fracture with compaction compared with broaching in cementless THA: a single-center study of 6,788 hips.

BACKGROUND AND PURPOSE:  Periprosthetic femoral fracture (PFF) is a significant complication of total hip arthroplasty (THA). Although biomechanical studies have indicated that the technique by which the femoral canal is prepared plays a role, few clinical studies have reported on how this might affect the fracture risk. This study compares the fracture risk between compaction and broaching with toothed instruments in cementless THA. METHODS: Prospectively collected data from the quality register of a high-volume hospital was used. All primary arthroplasties using the Corail stem (DePuy Synthes) were included. All femoral fractures occurring within the first 90 days after the operation were included in the analysis. We determined the relative risk of sustaining PFF with compaction compared with broaching and adjusted for confounders (sex, age group, BMI, and use of a collared stem) using multivariable Poisson regression. RESULTS:  6,788 primary THAs performed between November 2009 and May 2023 were available for analysis. 66% were women and the mean age was 65.0 years. 129 (1.9%) fractures occurred during the first 90 days after the operation, 92 (2.3%) in the compaction group and 37 (1.3%) in the broaching group. The unadjusted relative risk of fracture in the compaction group compared with the broaching group was 1.82 (95% confidence interval [CI] 1.25-2.66), whereas the adjusted relative risk was 1.70 (CI 1.10-2.70). CONCLUSION: Compaction was associated with more periprosthetic fractures than broaching (2.3% versus 1.3%) within 90 days after surgery.

Patients with total hip arthroplasty were more physically active 9.6 years after surgery: a case-control study of 429 hip arthroplasty cases and 29,272 participants from a population-based health study.

BACKGROUND AND PURPOSE: Few studies report on long-term levels of physical activity after THA compared with a control population. This case-control study aimed to find the long-term habitual level of leisure-time physical activity after THA and compare it with a large control group. PATIENTS AND METHODS: A randomized sample of 856 patients, treated with primary THA, were identified from the Norwegian Arthroplasty Register. 429 (50%) responded to a questionnaire with a mean follow-up time of 9.6 years. We compared them with a control group of 29,272 (64%) from a population-based health study. Physical activity was measured with a questionnaire and categorized into groups according to the general recommendations for physical activity. RESULTS: 245 (63%) of the THA cases reported a level of leisure-time physical activity meeting the general recommendations, compared with 10,803 (39%) in the control group. The difference persisted at all ages (50-90 years). In sex, age, and BMI-adjusted regression models the chance of meeting the physical activity recommendations was higher in the THA group than in the control group (OR 2.9, 95% confidence interval 2.4-3.6). CONCLUSION: The majority of the patients with THA reported a level of leisure-time physical activity meeting the general recommendations for physical activity. THA patients were more physically active in their leisure time than a control group representing a normal population.

Peroneal Nerve Palsy After Total Knee Arthroplasty.

Background: Common peroneal nerve palsy (CPNP) is a rare complication of total knee arthroplasty (TKA). It may lead to impaired function and pain. The purpose of this study was to determine the frequency and outcome of CPNP in a single orthopedic unit and to identify potential risk factors. Methods: This is a single-center study using the hospital's prospectively collected quality registry. All TKAs from 2002 to 2022 were included and followed up from 3 to 24 months with a follow-up rate of 98.4%. The local joint register was reviewed to identify patients with CPNP and used to extract data regarding the operation and the patients with and without CPNP. The groups were compared to identify possible risk factors for nerve injury. The medical records of the patients with CPNP were reviewed to determine the CPNPs' severity and outcome, and their preoperative radiographs were analyzed and compared to a control group with no nerve injury. Results: A total of 7704 TKAs were included, and 25 CPNPs were identified (0.32%). Complete palsies occurred in 18 cases, and partial palsies in 7. Postoperative epidural anesthesia, preoperative excessive valgus, and female sex were significant risk factors. Body mass index and age were not associated with CPNP. Two-thirds of the complete palsies had complete recovery, and four-fifths of the partial palsies recovered. Conclusions: The incidence of CPNP was 0.32%, and risk factors were epidural anesthesia, excessive valgus, and female sex. Most patients with CPNP recovered completely. Partial palsies had better outcomes than complete palsies in our cohort.

The Dugdale planning method for high tibial osteotomies underestimates the correction angle compared to the Miniaci method.

PURPOSE: The purpose of this study was to compare the planning methods of Dugdale and Miniaci for high tibial osteotomies (HTO) and to assess how their use could influence on the degree of correction and thus the postoperative weight bearing line (WBL). METHODS: Pre- and postoperative standing hip-knee-ankle (HKA) radiographs were obtained from 70 patients that underwent HTO. The correction angles were determined using Dugdale's and Miniaci's methods, and for the latter, both for an opening wedge as well for a closing wedge osteotomy. In a subset of 50 patients, the calculations were performed twice by two observers to calculate inter- and intra-rater reliability. Regression analysis and Bland-Altman plots were used to compare the methods. Whereas the Dugdale method had been used in the planning of the real operations, a regression model was used to predict how the obtained correction would have been if the Miniaci method had been used instead. RESULTS: Intra- and inter-rater reliability was excellent for the correction angle for both Dugdale's (0.992 and 0.991) and Miniaci's methods (0.988 and 0.987). When planning for an opening wedge osteotomy (OW) and a closing wedge osteotomy (CW), using the Miniaci method and comparing the correction angle with the angle obtained by the Dugdale method, the Miniaci OW and CW angles were larger by a factor of 1.07 (95% CI 1.06-1.08) and 1.10 (95% CI 1.09-1.11). Postoperatively, a mean undercorrection of 2.9° (SD = 2.3) was found. Predicting the correction with use of the calculated Miniaci angles resulted in an undercorrection of 2.5°, indicating that use of the Dugdale method accounted for 14% of the undercorrection. CONCLUSION: It is more likely to underestimate the correction angle when using the Dugdale method compared to the Miniaci method. This could lead to poorer correction accuracy. As the inter-rater reliability is excellent for both methods, choosing to use the Dugdale method on basis of simplicity is not justified. LEVEL OF EVIDENCE: III, Diagnostic study.

Recurrent lateral patella dislocation affects knee function as much as ACL deficiency - however patients wait five times longer for treatment.

BACKGROUND: Surgical treatment of young patients with recurrent lateral patella dislocation (RLDP) is often recommended because of loss of knee function that compromises their level of activity or even their daily life functioning. This situation is comparable to young patients with an anterior cruciate ligament (ACL) rupture. The purpose of this study was therefore to explore the time from injury to surgery and the pre-operative symptoms and knee function of young RLPD patients scheduled for stabilizing surgery and compare this group to age and sex-matched ACL-deficient patients. METHOD: Forty-seven patients with unilateral RLPD listed for isolated medial patellofemoral ligament reconstruction were included in the study (RLPD-group). This group was compared to an age, sex and BMI matched ACL patient group obtained from the Norwegian knee ligament registry (ACL-group) for the following outcome measures: the knee injury and osteoarthritis outcome score (KOOS) assessed on the day of surgery and time from injury to surgery. RESULTS: The RLPD-group scored significantly lower than the ACL-group for the three KOOS subscales "Pain" (73.6 vs. 79.8, p < 0.05), "Symptoms" (71.7 vs. 79.3, p < 0.05) and "ADL" (84.7 vs 89.5, p < 0.05). The lowest KOOS values were found for Sports/Recreation (53.5 vs. 51.3, p = 0.65) and Quality of life (37.6 vs. 36.7, p = 0.81). The average time from primary injury to surgery was 6 months for the ACL group and 31 months for the RLPD group. CONCLUSION: RLPD affected knee function as much as ACL deficiency, and was associated with more pain. Still the RLDP patients waited on average 5 times longer for surgery. TRIAL REGISTRATION: The patients with RLPD consisted of patients who were examined for possible recruitment for a concurrent prospective randomized controlled trial comparing conservative treatment and isolated surgical medial patellofemoral ligament (MPFL) reconstruction (Clinical trials no: NCT02263807 , October 2014).

No Association Between Risk of Anterior Cruciate Ligament Rupture and Selected Candidate Collagen Gene Variants in Female Elite Athletes From High-Risk Team Sports.

BACKGROUND: Several single-nucleotide variants (SNVs) in collagen genes have been reported as predisposing factors for anterior cruciate ligament (ACL) tears. However, the evidence is conflicting and does not support a clear association between genetic variants and risk of ACL ruptures. PURPOSE: To assess the association of previously identified candidate SNVs in genes encoding for collagen and the risk of ACL injury in a population of elite female athletes from high-risk team sports. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 851 female Norwegian and Finnish elite athletes from team sports were included from 2007 to 2011. ACL injuries acquired before inclusion in the cohort were registered by interview. The participants were followed prospectively through 2015 to record new complete ACL injuries. Six selected SNVs were genotyped ( COL1A1: rs1800012, rs1107946; COL3A1: rs1800255; COL5A1: rs12722, rs13946; COL12A1: rs970547). RESULTS: No associations were found between ACL rupture and the SNVs tested. CONCLUSION: The study does not support a role of the 6 selected SNVs in genes encoding for collagen proteins as risk factors for ACL injury. CLINICAL RELEVANCE: Genetic profiling to identify athletes at high risk for ACL rupture is not yet feasible.

Radiological outcomes in a randomized trial comparing opening wedge and closing wedge techniques of high tibial osteotomy.

PURPOSE: The aim of the present study was to examine changes in radiological variables in a prospective randomized study comparing opening wedge (OW) and closing wedge (CW) techniques of high tibial osteotomy (HTO). Our hypothesis was that there would be no differences in joint line angles or correction accuracy between the two groups, that patellar height would increase after CW HTO and decrease after OW HTO, and that leg length and posterior tibial slope would decrease after CW HTO and increase after OW HTO. METHODS: Radiological data were collected from 70 patients participating in an ongoing prospective randomized clinical trial comparing OW and CW HTOs. Digital standing hip-knee-ankle (HKA) radiographs as well as lateral radiographs in 30° of flexion were obtained preoperatively and at 6 months for each patient. Joint line angles, HKA angle, leg length, Insall-Salvati index, Miura-Kawamura index and posterior tibial slope were measured using medical planning software. The complete preoperative radiological examinations of the first 50 patients were used in a study of intra- and inter-rater reliability of the measurements. RESULTS: The mean posterior slope was reduced by 2.5° in CW HTO, whereas it remained unchanged in OW HTO (p < 0.001). Mean leg length decreased 5.7 mm in CW HTO and increased 3.1 mm in OW HTO (p < 0.001). Changes in joint line angles, patellar height indexes and the correction accuracy showed no significant differences comparing the two techniques. Frontal plane reliability measurement intra- and inter-rater intraclass correlation coefficient (ICC) varied from 0.81 to 0.99. Sagittal plane intra- and inter-rater ICC varied from 0.60 to 0.87. Posterior tibial slope intra- and inter-rater ICC showed the lowest values (0.70 and 0.60, respectively) corresponding to a smallest real difference of 4.5° and 5.5°, respectively. CONCLUSIONS: Posterior tibial slope and leg length changes were significantly different in CW compared to OW HTOs. We recommend that possible alterations in tibial slope and leg length are considered when the technique of HTO is to be chosen. Landmark-based medical planning software shows good reliability and can be used in preoperative planning and postoperative evaluations of HTOs. LEVEL OF EVIDENCE: I.

Norwegican Cartilage Project - a study protocol for a double-blinded randomized controlled trial comparing arthroscopic microfracture with arthroscopic debridement in focal cartilage defects in the knee.

BACKGROUND: Focal lesions to the articular cartilage in the knee might have demolishing consequences to the knee. There exists a wide range of possible surgical procedures targeting these injuries, however no significant differences have been found between these procedures. This may support that the improvement is a result of rehabilitation, and not the surgery itself. Arthroscopic microfracture (MF) treatment has gained popularity, and has become the treatment of choice in patients with knee cartilage defects globally. In this study we want to increase knowledge, both clinical and economic, about arthroscopic microfracture (AF) compared to arthroscopic debridement (AD) and physical rehabilitation both in the short run, and in the long run. METHODS/DESIGN: To compare arthroscopic microfracture with arthroscopic debridement and physiotherapy for the treatment of focal cartilage lesions in the knee, a long-term, double-blinded, randomized controlled multicenter trial will be conducted. A total of 114 men and non-pregnant women with a symptomatic focal full thickness cartilage lesion in the knee less than 2 cm2 will be included in the study. The two treatment allocations will receive identical rehabilitation, which is made up of 3 phases: accommodation, rehabilitation and return to activity. Follow up is 24 months, where all will be invited to participate in late follow ups after 5 and 10 years. The Knee Injury and Osteoarthritis Outcome Score (KOOS) knee-related quality of life (QoL) subscore is the primary endpoint. Clinical parameters, questionnaires and radiologic modalities (Magnetic Resonance Imaging (MRI) and x-ray) will be used as secondary endpoints. DISCUSSION: This is an ongoing multicenter study with a high level of evidence to compare arthroscopic microfracture with arthroscopic debridement and physiotherapy for the treatment of isolated symptomatic full thickness cartilage lesions in the knee joint. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02637505 (December 15, 2015).

Evaluation of focal cartilage lesions of the knee using MRI T2 mapping and delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC).

BACKGROUND: Assessment of degenerative changes of the cartilage is important in knee cartilage repair surgery. Magnetic Resonance Imaging (MRI) T2 mapping and delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) are able to detect early degenerative changes. The hypothesis of the study was that cartilage surrounding a focal cartilage lesion in the knee does not possess degenerative changes. METHODS: Twenty-eight consecutive patients included in a randomized controlled trial on cartilage repair were evaluated using MRI T2 mapping and dGEMRIC before cartilage treatment was initiated. Inclusion was based on disabling knee problems (Lysholm score of ≤ 75) due to an arthroscopically verified focal femoral condyle cartilage lesion. Furthermore, no major malalignments or knee ligament injuries were accepted. Mean patient age was 33 ± 9.6 years, and the mean duration of knee symptoms was 49 ± 60 months. The MRI T2 mapping and the dGEMRIC measurements were performed at three standardized regions of interest (ROIs) at the medial and lateral femoral condyle, avoiding the cartilage lesion RESULTS: The MRI T2 mapping of the cartilage did not demonstrate significant differences between condyles with or without cartilage lesions. The dGEMRIC results did not show significantly lower values of the affected condyle compared with the opposite condyle and the contra-lateral knee in any of the ROIs. The intraclass correlation coefficient (ICC) of the dGEMRIC readings was 0.882. CONCLUSION: The MRI T2 mapping and the dGEMRIC confirmed the arthroscopic findings that normal articular cartilage surrounded the cartilage lesion, reflecting normal variation in articular cartilage quality. STUDY IDENTIFIER: NCT00885729 , registered April 17 2009.

Effect on Patient-Reported Outcomes of Debridement or Microfracture of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament-Reconstructed Knees: A Nationwide Cohort Study From Norway and Sweden of 357 Patients With 2-Year Follow-up.

BACKGROUND: The treatment of concomitant cartilage lesions in anterior cruciate ligament (ACL)-injured knees is debatable. PURPOSE: To evaluate the effect of debridement or microfracture (MF) compared with no treatment of concomitant full-thickness (International Cartilage Repair Society [ICRS] grades 3-4) cartilage lesions on patient-reported outcomes after ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Six hundred forty-four patients who underwent primary unilateral ACL reconstruction and had a concomitant full-thickness cartilage lesion treated simultaneously by debridement (n = 129) or MF (n = 164), or underwent no treatment (n = 351) of the cartilage lesion, registered in the Norwegian and Swedish National Knee Ligament Registries from 2005 to 2008 were included. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to measure patient-reported outcomes. At a mean follow-up of 2.1 ± 0.2 years after surgery, 357 (55%) patients completed the KOOS. Linear regression analyses were used to evaluate the effect of debridement or MF on the KOOS. RESULTS: No significant effects of debridement were detected in the unadjusted or adjusted regression analyses on any of the KOOS subscales at 2-year follow-up. The MF treatment of the cartilage lesions had significant negative effects at 2-year follow-up on the KOOS Sport and Recreation (Sport/Rec) (regression coefficient [ß] = -8.9; 95% confidence interval [CI], -15.1 to -1.5) and Knee-Related Quality of Life (QoL) (ß = -8.1; 95% CI, -14.1 to -2.1) subscales in the unadjusted analyses. When adjusting for confounders, MF had significant negative effects on the same KOOS subscales of Sport/Rec (ß = -8.6; 95% CI, -16.4 to -0.7) and QoL (ß = -7.2; 95% CI, -13.6 to -0.8). For the remaining KOOS subscales of Pain, Symptoms, and Activities of Daily Living, there were no significant unadjusted or adjusted effects of MF. CONCLUSION: MF of concomitant full-thickness cartilage lesions showed adverse effects on patient-reported outcomes at 2-year follow-up after ACL reconstruction. Debridement of concomitant full-thickness cartilage lesions showed neither positive nor negative effects on patient-reported outcomes at 2-year follow-up after ACL reconstruction.

Patients With Isolated PCL Injuries Improve From Surgery as Much as Patients With ACL Injuries After 2 Years.

BACKGROUND: Reports on outcome after posterior cruciate ligament (PCL) reconstruction often contain both isolated PCL and combined knee ligament injuries. This makes it difficult to conclude on the outcome after reconstruction of isolated PCL injuries. PURPOSE: To investigate the outcome after PCL reconstruction in patients with an isolated PCL injury and to compare this with the outcome of patients treated with reconstruction after isolated anterior cruciate ligament (ACL) injuries. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Seventy-one patients with an isolated PCL injury that was reconstructed surgically and who had registered in the Norwegian Knee Ligament Registry between 2004 and 2010 were included in this study. Patients with isolated ACL reconstructions (n = 9661) who had registered in the same period were included for comparison. Knee Injury and Osteoarthritis Outcome Score (KOOS) was used as the patient-reported outcome measure. Preoperative and 2-year postoperative KOOS scores were compared. Changes in KOOS score reported by the PCL patients were compared with changes reported by the ACL patients. RESULTS: At the 2-year postoperative follow-up of the PCL-reconstructed patients, the patient-reported outcome was improved, measured by KOOS as follows: pain, 15.1 (95% CI, 8.5-21.8; P < .001); symptoms, 0.9 (95% CI, -6.6 to 8.3; P = .82); activities of daily living, 13.2 (95% CI, 6.6-13.9; P < .001); sports, 20.7 (95% CI, 11.8-29.4; P < .001); and quality of life, 26.6 (95% CI, 18.9-34.2; P < .001). According to the KOOS, the incremental improvements were similar for PCL and ACL patients. Time from injury to surgery was longer for the PCL patients compared with ACL patients (median, 21.5 vs 8.0 months; P < .001). CONCLUSION: Patients undergoing PCL reconstruction can expect the same improvements in KOOS score as patients undergoing ACL reconstruction. However, PCL patients start out with an inferior score on average and consequently end up at a lower score compared with ACL patients for all KOOS subscales.

All-inside suture device is superior to meniscal arrows in meniscal repair: a prospective randomized multicenter clinical trial with 2-year follow-up.

PURPOSE: Multiple techniques and implants are available for all-inside meniscal repair, but the knowledge about their failure rates and functional outcome is still incomplete. The hypothesis was that there might be differences between meniscal arrows and suture devices regarding reoperation rates and functional outcome. Thereby, the aim of this study was to compare clinical results following repair with the Biofix(®) arrows or the FasT-Fix(®) suture devices. METHODS: In this RCT, 46 patients were treated either by Biofix(®) (n = 21) or FasT-Fix(®) (n = 25). The main outcome was reoperation within 2 years. Knee function and activity level were evaluated by KOOS and Tegner activity scale. RESULTS: Twelve out of 46 (26%) patients were reoperated within 2 years, nine out of 21 (43%) in the Biofix(®)-group versus three out of 25 (12%) in the FasT-Fix(®)-group (p = 0.018). The relative risk of reoperation was 3.6 times higher for Biofix(®) compared to FasT-Fix(®) (95% confidence interval 1.1-11.5). Both treatment groups had significant increase in all KOOS subscales, but there were no major differences between the groups. The subgroup of reoperated patients differed from the other patients with higher Tegner score preoperatively (median 5 vs. 4) (p = 0.037) and at 3-month follow-up (median 4 vs. 3) (p = 0.010). CONCLUSIONS: These results indicate that FasT-Fix(®) suture is superior to Biofix(®) arrows with significant lower failure rate. Functional outcome did not depend on repair technique. Higher activity score preoperatively and at 3-month follow-up in the reoperated patients indicates that activity level may influence on the risk of reoperation. LEVEL OF EVIDENCE: I.

Acetabular wall augmentation in selected patients with recurrent dislocation after THA.

We reviewed 42 patients operated with PMMA augmentation of the acetabular wall for recurrent posterior dislocation of cemented total hip arthroplasties with a cemented all-poly acetabular component. 38 patients never experienced subsequent dislocations after the procedure. 4 patients had recurrent dislocations, and two additional patients underwent a revision procedure due to aseptic loosening of the acetabular component. 1, 5 and 10 years survival of the prosthesis free of dislocation were 95%, 95% and 64% respectively. 90% of the patients were satisfied, four patients experienced pain and 3 patients sustained an infection. The procedure is simple, effective, takes less time and results in less blood loss compared to full revision surgery. It should be considered in cases of recurrent posterior dislocation in elderly patients.

Fractures in children: epidemiology and activity-specific fracture rates.

BACKGROUND: Approximately one-third of pediatric fractures occur during sport or recreational activity. In this paper, we investigate the incidence and causes of pediatric fractures in our region and quantify the fracture rate per exposure time for the most common sport and recreational activities. METHODS: We prospectively evaluated all children younger than sixteen years who presented to our institution with a new fracture within a twelve-month period. Exposure time to the most common childhood activities was measured by means of interviewing random parents from the study population. The main outcome measures were the annual fracture incidence in the population and fracture rates per 10,000 hours of exposure to various sports and recreational activities. RESULTS: A total of 1403 fractures were included. The overall annual incidence was 180.1 fractures per 10,000 children younger than sixteen years. The distal part of the radius was most often fractured (436 fractures, 31.1%). Snowboarding was associated with the highest activity-specific fracture rate, estimated to be 1.9 (95% confidence interval [CI], 1.16 to 2.60) fractures per 10,000 hours of exposure. In comparison, the fracture rate per 10,000 hours of exposure was 0.79 (CI, 0.42 to 1.09) for handball, 0.44 (CI, 0.35 to 0.52) for soccer, and 0.35 (CI, 0.23 to 0.47) for trampolining. CONCLUSIONS: The distal part of the radius is the most common fracture site in childhood. Fracture rates differ between various physical activities. The fracture rate for snowboarding was four times higher compared with that for other common childhood sport and recreational activities in our region.

An isolated rupture of the posterior cruciate ligament results in reduced preoperative knee function in comparison with an anterior cruciate ligament injury.

PURPOSE: To investigate differences in preoperative knee function (Knee Injury and Osteoarthritis Outcome Score, KOOS), the time period from injury to surgery, and associated injuries when comparing primary isolated posterior cruciate ligament (PCL) and primary anterior cruciate ligament (ACL) reconstructions. METHODS: Isolated primary ACL and PCL reconstructions registered in the Norwegian National Knee Ligament Registry from 2004 through 2010 were included (n = 71 primary PCLs and 9,649 primary ACLs). Linear regression analysis was used to evaluate the preoperative KOOS subscale values. RESULTS: The preoperative KOOS in the PCL group (n = 71) and ACL group (n = 9,649) was significantly different for the subscales symptoms (mean difference, -8.4; 95% CI: -12.8 to -4.0), pain (mean difference, -15.9; 95% CI: -20.3 to -11.4), activities of daily living (mean difference, -12.9; 95% CI: -17.4 to -8.4), sport and recreation (mean difference, -15.9; 95% CI: -22.6 to -9.3), and quality of life (mean difference, -7.9; 95% CI: -12.4 to -3.5). The primary isolated PCL-reconstructed knees had a median time from injury to surgery of 21 months in comparison with 8 months for ACL injuries. The ACL-injured knees had more associated injuries (meniscus and full-thickness cartilage lesions) than the PCL-injured knees. CONCLUSION: Surgically treated knees with an isolated rupture of the PCL exhibited worse knee function preoperatively compared with knees with an isolated ACL injury; in addition, the delay to surgery was longer. Meniscal lesions were found more frequently in ACL-injured knees. LEVEL OF EVIDENCE: Prospective cohort study, evidence Level I.

Agreement in Arthroscopic and Arthrotomy Assessment of Full-Thickness Articular Cartilage Lesions of the Knee in a Clinical Setting in 33 Consecutive Patients.

OBJECTIVE: To evaluate the accuracy of arthroscopic measurement of full-thickness (International Cartilage Repair Society grades 3-4) cartilage lesions of the knee. DESIGN: In 33 consecutive arthroscopically evaluated cartilage lesion knees the lesion size was routinely estimated. At the final treatment, a knee arthrotomy was performed, and the lesion was reestimated. The 2 estimates were then compared by paired t test and the area estimated by knee arthrotomy was used as the gold standard. Results. The mean area of the cartilage lesion estimated by arthroscopic surgery was 3.5 cm(2) (standard deviation [SD] = 1.7) whereas in the open surgery the mean area was 3.2 cm(2) (SD = 1.5). The mean difference was 0.3 cm(2), indicating a tendency toward overestimation by the arthroscopic evaluation, but the difference was not significant (P = 0.09). Additional MRI assessment of the area demonstrated a mean area of 2.3 cm(2) (SD = 1.6). This underestimated the size of the lesion by 1.2 cm(2) (SD = 0.8; P = 0.015). CONCLUSION: Knee arthroscopic examination estimated a cartilage full-thickness lesion with an error of less than 25 % in the majority of the patients.

[Supracondylar fractures of the humerus in children]. / Suprakondylære humerusfrakturer hos barn.

BACKGROUND: Supracondylar humerus fractures are common in children. Severe complications are rare. We present an overview of treatment options and prognosis. MATERIAL AND METHODS: The article is based on a non-systematic search in PubMed and experience from our own clinical research. RESULTS: The injury is usually caused by falling from a height with the arm in extension. The mean age is about 6 years. Undisplaced fractures are treated conservatively with a cast. Displaced fractures should not be treated with a cast alone, as this may cause malunions and permanent neurovascular complications. The rate of complications after traction of displaced fractures is substantially lower than for immobilisation in cast alone. Traction and percutaneous pinning yield similar results, but percutaneous pinning is less expensive--mainly because it shortens the hospital stay. In addition, the risk of cubitus varus deformity seems to be reduced. Today the treatment of choice is closed reduction and percutaneous pinning. Choice of pin configuration is at the surgeon's discretion. Crossed pins are more common than two lateral pins, although medial pins can affect the ulnar nerve. However, the affection is almost always transient. Deep infection after percutaneous pinning is very rare. INTERPRETATION: Percutaneous pinning of displaced supracondylar humerus fractures in children is cheap and the results are good.

[The Gross Clinic--portrait of a pioneer]. / The Gross Clinic--portrett av en pioner.

THE GROSS CLINIC: is an 1875 painting by Thomas Eakins which is counted among the world's most famous doctor's portraits. This picture became more topical when it was sold to the Philadelphia Museum of Art for 68 million USD in 2006. We here present aspects of how this picture can help to document surgical practice in the USA at the time it was made. A comparison with a later doctor's portrait, THE AGNEW CLINIC: painted by Eakins in 1889, : shows that many changes occurred during a short time in the end of the 19 th century. This is especially the case within infection prevention, anaesthesia and development of the surgical profession as such. From an art historical perspective it has been common to compare the portrait with the old masters' group portraits of surgeons in surgical theatres. The most known of these is Rembrandt's DR. NICOLAES TULP'S ANATOMY LECTURE: (1632). In our opinion it is more interesting to consider THE GROSS CLINIC: in connection with concomitant photographies of medical practice. The realistic motive for the painting was assessed as inappropriate and unsuitable for a piece of art at the time. Despite of this, Eakins himself regarded the picture as one of his best, and during the 20 th century THE GROSS CLINIC: has been increasingly acknowledged. Today, the picture is the piece of art that Thomas Eakins is mainly associated with.

PI3K/Akt-dependent Epo-induced signalling and target genes in human early erythroid progenitor cells.

Erythropoietin (Epo) is the major regulator of differentiation, proliferation and survival of erythroid progenitors, but the Epo-induced changes in gene expression that lead to these effects are not fully understood. The aim of this study was to examine how Epo, via activation of phosphatidylinositol 3-kinase (PI3K)/Akt, exerts its role in the development of erythroid progenitors from CD34+ cells, and to identify early Epo target genes in human erythroid progenitors. In CD34+ progenitor cells, Epo alone was able to induce cell cycle progression as demonstrated by upregulation of cyclin D3, E and A leading to hyperphosphorylation of the retinoblastoma protein (RB). These effects were completely counteracted by the PI3K inhibitor LY294002. Furthermore, enforced expression of an activated form of Akt kinase highly augmented Epo-induced erythropoiesis. Fluorescent-activated cell sorting (FACS)-sorted CD34+CD71+CD45RA-GPA- erythroid progenitors stimulated with Epo in the presence or absence of LY294002 were subjected to gene expression profiling. Several novel target genes of Epo were identified, and the majority were regulated in a PI3K-dependent manner, including KIT (CD117) and CDH1 (E-cadherin). FACS analysis of Epo-stimulated erythroid progenitors showed that the increased mRNA expression of KIT and CDH1 was accompanied by an induction of the corresponding proteins CD117 and E-cadherin.