Orthobiologics in knee osteoarthritis, dream or reality?

Cartilage restoration or repair, also known as orthobiologic therapy, is indicated after the failure of conservative or supportive treatment. However, there is paucity in evidence supporting the efficacy of orthobiologic therapy. The blood-derived products, such as platelet-rich plasma (PRP), is one of the commonly used orthobiologic therapy for knee osteoarthritis. Several studies have shown that PRP is superior to other treatments, but the anatomic changes are scarce. Treatment with mesenchymal stem cells (MSCs) offers the greatest potential for curing degenerative disease due to their self-renewal ability, ability to migrate towards injured tissues (homing/trafficking), and ability to promote repair and regeneration of osteochondral defects. However, ethical concerns and high costs remain major challenges associated with MSC therapy. Gene therapy, another promising orthobiologic therapy, is currently in phase II clinical trial and has shown promising results. The key factors for successful orthobiologic therapy include patient selection, appropriate dosing, treatment of underlying mechanical problems, age, severity, and cost-effectiveness.

Role of the Gut Microbiota in Osteoarthritis, Rheumatoid Arthritis, and Spondylarthritis: An Update on the Gut-Joint Axis.

Dysregulation of the gut microbiota and their metabolites is involved in the pathogenic process of intestinal diseases, and several pieces of evidence within the current literature have also highlighted a possible connection between the gut microbiota and the unfolding of inflammatory pathologies of the joints. This dysregulation is defined as the "gut-joint axis" and is based on the joint-gut interaction. It is widely recognized that the microbiota of the gut produce a variety of compounds, including enzymes, short-chain fatty acids, and metabolites. As a consequence, these proinflammatory compounds that bacteria produce, such as that of lipopolysaccharide, move from the "leaky gut" to the bloodstream, thereby leading to systemic inflammation which then reaches the joints, with consequences such as osteoarthritis, rheumatoid arthritis, and spondylarthritis. In this state-of-the-art research, the authors describe the connections between gut dysbiosis and osteoarthritis, rheumatoid arthritis, and spondylarthritis. Moreover, the diagnostic tools, outcome measures, and treatment options are elucidated. There is accumulating proof suggesting that the microbiota of the gut play an important part not only in immune-mediated, metabolic, and neurological illnesses but also in inflammatory joints. According to the authors, future studies should concentrate on developing innovative microbiota-targeted treatments and their effects on joint pathology as well as on organizing screening protocols to predict the onset of inflammatory joint disease based on gut dysbiosis.

The influence of gut microbiome on periprosthetic joint infections: State-of-the art.

Early periprosthetic joint infection constitutes one of the most frightening complications of joint replacement. Recently, some evidence has highlighted the potential link between dysregulation of the gut microbiota and degenerative diseases of joints. It has been hypothesized that microbiome dysbiosis may increase the risk of periprosthetic joint infection by facilitating bacterial translocation from these sites to the bloodstream or by impairing local or systemic immune responses. Although the processes tying the gut microbiome to infection susceptibility are still unknown, new research suggests that the presurgical gut microbiota-a previously unconsidered component-may influence the patient's ability to resist infection. Exploring the potential impact of the microbiome on periprosthetic joint infections may therefore bring new insights into the pathogenesis and therapy of these disorders. For a successful therapy, a proper surgical procedure in conjunction with an antibacterial concept is essential. As per the surgical approach, different treatment strategies include surgical irrigation, debridement, antibiotic therapy, and implant retention with or without polyethylene exchange. Other alternatives could be one-stage or two-stage revisions surgery. Interventions that either directly target gut microbes as well as interventions that modify the composition and/or function of the commensal microbes represent an innovative and potentially successful field to be explored. In recent times, innovative therapeutic methods have arisen in the realm of microbiome restoration and the management of gut-related ailments. These progressive approaches offer fresh perspectives on tackling intricate microbial imbalances in the gastrointestinal tract. These emerging therapies signify a shift towards more precise and individualized approaches to microbiome restoration and the management of gut-related disorders. Once a more advanced knowledge of the pathways linking the gut microbiota to musculoskeletal tissues is gained, relevant microbiome-based therapies can be developed. If dysbiosis is proven to be a significant contributor, developing treatments for dysbiosis may represent a new frontier in the prevention of periprosthetic joint infections.

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review.

PURPOSE: Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI. METHODS: This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported. RESULTS: The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%). CONCLUSION: Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

PCL retained is safe in medial pivot TKA-a prospective randomized trial.

PURPOSE: Medial pivot (MP) designs resemble native knee kinematics and restore the "natural" kinematics of a knee after total knee arthroplasty (TKA). However, whether to preserve or resect the posterior cruciate ligament (PCL) is still under debate. We inquired whether sacrificing the PCL would improve range of motion, functional outcomes, and limb alignment compared to preserving the PCL in TKA using medial pivot implants (MP-TKA). METHODS: This prospective, double-blinded, randomized controlled trial consisted of 33 patients (66 knees) undergoing bilateral simultaneous MP-TKA. In one knee, a PCL preservation technique was performed, and in the contralateral knee, the PCL was resected. The primary outcome was postoperative range of motion (ROM). The secondary outcomes were visual analogue scale (VAS) score for knee pain at walking, Knee Injury and Osteoarthritis Outcome Score for symptoms (KOOS-S) and quality of life (KOOS-QoL), Oxford knee score (OKS), and Forgotten Joint Score (FJS), and measurement of the mechanical femoral-tibial axis (mFTA) on X-ray images. All patients were followed up for a minimum of 2 years after surgery. RESULTS: Patients who underwent MP-TKA with PCL preservation had a similar ROM at 2 years (125.45 ± 7.00 vs. 126.21 ± 6.73, p = 0.65) as those who underwent MP-TKAs with PCL resection. There was also no difference in VAS score (1.94 ± 0.79 vs. 2.00 ± 0.71, respectively, p = 0.51), OKS (39.97 ± 2.01 vs. 39.67 ± 2.03, respectively, p = 0.52), KOOS-S (84.41 ± 3.77 vs. 84.19 ± 3.57, respectively, p = 0.92), KOOS-QoL (82.94 ± 4.76 vs. 82.75 ± 4.70, respectively, p = 0.84), or FJS (72.66 ± 8.99 vs. 72.35 ± 8.64, respectively, p = 0.76) at the 2-year follow-up. No difference in the measurement of the mFTA was found between the two groups (180.27 ± 2.25 vs. 181.30 ± 2.13, respectively, p = 0.59). CONCLUSION: This study demonstrated that both medial pivot TKA with PCL preservation and PCL resection achieved excellent results. There was no difference at the 2-year follow-up in terms of postoperative ROM, patient-reported outcomes, or radiographic evaluation. LEVEL OF EVIDENCE: Therapeutic study, Level I.

Brown Tumour in Chronic Kidney Disease: Revisiting an Old Disease with a New Perspective.

Osteitis fibrosa cystica (OFC) and Brown Tumours are two related but distinct types of bone lesions that result from the overactivity of osteoclasts and are most often associated with chronic kidney disease (CKD). Despite their potential consequences, these conditions are poorly understood because of their rare prevalence and variability in their clinical manifestation. Canonically, OFC and Brown Tumours are caused by secondary hyperparathyroidism in CKD. Recent literature showed that multiple factors, such as hyperactivation of the renin-angiotensin-aldosterone system and chronic inflammation, may also contribute to the occurrence of these diseases through osteoclast activation. Moreover, hotspot KRAS mutations were identified in these lesions, placing them in the spectrum of RAS-MAPK-driven neoplasms, which were until recently thought to be reactive lesions. Some risk factors contributed to the occurrence of OFC and Brown Tumours, such as age, gender, comorbidities, and certain medications. The diagnosis of OFC and Brown Tumours includes clinical symptoms involving chronic bone pain and laboratory findings of hyperparathyroidism. In radiological imaging, the X-ray and Computed tomography (CT) scan could show lytic or multi-lobular cystic alterations. Histologically, both lesions are characterized by clustered osteoclasts in a fibrotic hemorrhagic background. Based on the latest understanding of the mechanism of OFC, this review elaborates on the manifestation, diagnosis, and available therapies that can be leveraged to prevent the occurrence of OFC and Brown Tumours.

The use of bovine-derived hydroxyapatite xenograft for defect filling in opening-wedge high tibial osteotomy.

High tibial osteotomy is a reliable procedure for the correction of knee varus deformity. An opening-wedge high tibial osteotomy (OW-HTO) is the most popular technique. The results of the bone defect after opening the wedge needed special treatment to ensure bone healing. This study aims to evaluate the use of bovine-derived hydroxyapatite graft for defect filling after OW-HTO. Methods: A retrospective study was performed on all patients who received OW-HTO at Prof. Dr R. Soeharso Orthopaedic Hospital from November 2019 to December 2022. A total of 21 patients (24 knees) were included in this study. Clinical dan radiological evaluation was performed on all patients preoperative and postoperatively. The mean of the follow-up period was 12.6 months with a minimum of 4 months follow-up. Results: Primary medial uni-compartment knee osteoarthritis was the most common diagnosis, with 17 of 24 cases (70.8%). Mechanical axis deviation was changed from 31 mm medial deviation (range: 8-52 mm) to 0.45 mm medial deviation (range: 13 - (-8) mm). The anatomic tibiofemoral angle was corrected from a preoperative mean of 4.7° of varus to a mean of 5.8° of valgus postoperatively. Bone defect height was mean 15.9 mm with a range of 10-23 mm. Bone defect width was mean 46.7 mm (range: 34-60 mm). Hydroxyapatite graft integration with the host bone was found in all patients during the final follow-up period. Conclusions: Bovine-derived hydroxyapatite graft is a safe and effective material for bone defect filling in OW-HTO procedures with a high bone union rate.

The role of genetic polymorphisms of interleukin-1 (IL-1R1 and IL-1RN) in primary knee osteoarthritis in Indonesia.

This study aimed to evaluate the association of SNPs of the IL-1 family with the clinical severity of knee OA. This case‒control study was performed among 100 healthy knees and 130 osteoarthritis (OA) knees of people aged ≥ 50 years with a BMI ≥ 25 kg/m2. The possible correlations among clinical findings, radiographic evaluations, serum levels of IL-1R1 and IL-1Ra, and genotype analyses were evaluated. Three SNPs of IL-1R1, rs871659, rs3771202, and rs3917238, were associated with primary knee OA. Females with IL-1R1 SNP rs871659 allele A had a higher prevalence of primary knee OA. No correlation was found between SNPs of IL-1R1 and IL-1RN and clinical or radiologic severity or serum concentrations of IL-1R1 and IL-1Ra (p > 0.05). BMI and IL-1R1 rs3917238 genotype C/C were correlated with moderate-severe VAS scores. A correlation was also found between the EQ-5D-3L self-care dimension and obesity and between the EQ-5D-3L pain and usual activity dimensions and age ≥ 60 and obesity (p < 0.05). Radiologic severity was only associated with age ≥ 60 years (p < 0.05). We found the IL-1R1 SNPs rs871659, rs3771202, and rs3917238 to be predisposing factors for primary knee osteoarthritis. The clinical findings, radiographic severity, and serum concentrations of IL-1R1 and IL-1Ra were not correlated with these gene polymorphisms.

Prospect of Exosome in Ligament Healing: A Systematical Review.

Aim: The relationship between ligaments and bone is a complex and heterogeneous junction involving bone, mineralized fibro cartilage, non-mineralized fibro cartilage and ligaments. Mesenchymal stem cells (MSC) can be used in vivo to control inflammation and aid in tissue repair, according to studies. This review focused on using exosomes as an alternative to MSC, as a cell-free therapy for modulating the remodelling process. Methods: To conduct a systematic review of the literature, the phrases "exosome" and "ligament" or "tendon" and "extracellular vesicle" and "stem cells" were used as the search keywords in PubMed (MEDLINE), OVID, the Cochrane Library, and Science Direct. From the literature, 73 studies in all were found. Six studies were included in this systematic review after full-text evaluation. Results: Six included studies covered a range of MSC types, isolation techniques, animal models, and interventions. Biomechanical results consistently indicated the beneficial impact of conditioned media, vesicles, and exosomes on treating tendons and ligaments. Noteworthy findings were the reduction of inflammation by iMSC-IEVs, chondrocyte protection by iPSC-EVs (extracellular vesicles generated by inflammation-primed adipose-derived stem cells), osteolysis treatment using DPSC-sEVs (small extracellular vesicles derived from dental pulp stem cells), and the contribution of exosome-educated macrophages to ligament injury wound healing. Conclusion: Exosomes may serve as a cell-free therapeutic substitute for modulating the remodelling process, particularly in ligament healing.

Adductor canal block in outpatient clinic for pain control after knee arthroplasty: A randomized controlled, clinical trial.

BACKGROUND: Successful total knee replacement surgery is influenced by surgery and rehabilitation program. We hypothesized the adductor canal block (ACB) in the outpatient clinic is safe, effective for pain relief and decreases analgesic consumption compared with controls. METHODS: a paired, randomized controlled trial. The intervention group received ACB with 15 mL mixture of ropivacaine 0.2% with isotonic saline and steroids on post-operative day 14 (POD-14) at the outpatient clinic, the control group received daily consumption of analgesic. We evaluated Visual Analog Score (VAS) pain score, and analgesic consumption. RESULTS: 35 subjects for each group. In the ACB group, mean of age was 66.42 years old, mean of BMI was 25.87. The control group, mean of age was 64.11 years old, mean of BMI was 25.95. There were significantly different mean VAS scores of both groups and analgesic consumption of both groups on POD 15th, 17th and 19th (p = 0.00, 0.000 and 0.001, respectively). Two patients complained about hematoma in their thigh (insertion needle) and recovered. CONCLUSIONS: Single-shot ACB in the outpatient clinic is safe, significantly decreased pain and analgesic consumption and may enhance the rehabilitation program.

Prosthetic joint infection of the hip and knee due to Mycobacterium species: A systematic review.

BACKGROUND: Mycobacterium species (Mycobacterium sp) is an emerging cause of hip and knee prosthetic joint infection (PJI), and different species of this organism may be responsible for the same. AIM: To evaluate the profile of hip and knee Mycobacterium PJI cases as published in the past 30 years. METHODS: A literature search was performed in PubMed using the MeSH terms "Prosthesis joint infection" AND "Mycobacterium" for studies with publication dates from January 1, 1990, to May 30, 2021. To avoid missing any study, another search was performed with the terms "Arthroplasty infection" AND "Mycobacterium" in the same period as the previous search. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart was used to evaluate the included studies for further review. In total, 51 studies were included for further evaluation of the cases, type of pathogen, and treatment of PJI caused by Mycobacterium sp. RESULTS: Seventeen identified Mycobacterium sp were reportedly responsible for hip/knee PJI in 115 hip/knee PJI cases, whereas in two cases there was no mention of any specific Mycobacterium sp. Mycobacterium tuberculosis (M. tuberculosis) was detected in 50/115 (43.3%) of the cases. Nontuberculous mycobacteria (NTM) included M. fortuitum (26/115, 22.6%), M. abscessus (10/115, 8.6%), M. chelonae (8/115, 6.9%), and M. bovis (8/115, 6.9%). Majority of the cases (82/114, 71.9%) had an onset of infection > 3 mo after the index surgery, while in 24.6% (28/114) the disease had an onset in ≤ 3 mo. Incidental intraoperative PJI diagnosis was made in 4 cases (3.5%). Overall, prosthesis removal was needed in 77.8% (84/108) of the cases to treat the infection. Overall infection rate was controlled in 88/102 (86.3%) patients with Mycobacterium PJI. Persistent infection occurred in 10/108 (9.8%) patients, while 4/108 (3.9%) patients died due to the infection. CONCLUSION: At least 17 Mycobacterium sp can be responsible for hip/knee PJI. Although M. tuberculosis is the most common causal pathogen, NTM should be considered as an emerging cause of hip/knee PJI.

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Interleukin-1 genetic polymorphisms in knee osteoarthritis: What do we know? A meta-analysis and systematic review.

PURPOSE: Interleukin-1 is the main proinflammatory cytokine in osteoarthritis (OA). Several single-nucleotide polymorphisms (SNPs) within the IL-1 gene cluster (IL-1ß, IL-1R1, and IL-1RN) have been determined, but their associations with knee OA remain poorly understood. The present study aimed to identify the associations between IL-1 SNPs and knee osteoarthritis. METHODS: This meta-analysis and systematic review included all comparative studies published in the MEDLINE/PubMed, Embase, Google Scholar, and Cochrane Library databases. We performed a systematic search to identify relevant studies on the evaluation of the correlation between the IL-1 gene and knee OA published up to February 2020 that met the eligibility criteria. Nine studies on a total of 2256 knees with OA and 3527 healthy knees met the eligibility criteria. Results associated with IL-1A, IL-1B, IL-1R1, and IL-1RN SNPs were extracted and compared between knees with OA and healthy knees. Methodological quality was assessed using the Newcastle-Ottawa scale (NOS). All studies with fair or good quality were included. RESULTS: The meta-analysis showed that the risk of knee OA is decreased by the IL-1RN*1 and IL-1RN*1/*1 genotypes and increased by the IL-1RN*2 and I-L1RN*1/*2 genotypes. The systematic review revealed only two studies associating the IL-1RN allele, none associating the IL-1B polymorphism, and only one study associating IL-1A and IL-1R1 polymorphisms with knee OA. CONCLUSIONS: Several IL-1RN alleles and genotypes play a role in knee OA but other genetic variations in the IL-1 region were still conflicting in its association with knee OA.

Case Report: Asymptomatic COVID-19 patient with a subtle hypercoagulable state and fluctuating D-dimer level.

Background: COVID-19 can infect an asymptomatic person silently without any overt symptoms despite diffuse blood clots throughout the body. Clot formation is induced by COVID-19 associated coagulopathy that can cause a high mortality rate. D-dimer, a fairly decisive marker for the coagulopathy event, is physiologically a marker of the fibrinolysis process. The increase of D-dimers in COVID-19 cases must be followed up because it relates to the initiation of a cytokine storm. Case presentation: We report an asymptomatic patient with sudden D-dimer elevation who received anticoagulant therapy. After three days of heparin administration, D-dimer results became normal and anticoagulant therapy was stopped. However, on the 12th day, the D-dimer level rebounded back and was followed by an increase of hs-C-reactive protein, erythrocyte sedimentation rate, IL-6, although SARS-CoV-2 PCR result became negative. A hyperglycaemic reaction and a sudden increase of HbA1C was observed in the patient. After three weeks D-dimer had returned to normal levels, and so did the other markers. The patient recovered fully and still no symptoms were obvious. Conclusion: COVID-19 patients without symptoms may be at risk of an asymptomatic coagulopathy process. The decreasing level of D-dimer erroneously cannot ensure that the coagulopathy process stops.

Mismatched knee implants in Indonesian and Dutch patients: a need for increasing the size.

PURPOSE: The aim of this study was to evaluate the anthropometric differences between knees of Indonesian Asians and Dutch Caucasians and the fit of nine different knee implant systems. METHODS: A total of 268 anteroposterior (AP) and lateral knee preoperative radiographs from 134 consecutive patients scheduled for total knee arthroplasty at two different centres in Jakarta and Leiden were included. Both patient groups were matched according to age and sex and included 67 Asians and 67 Caucasians. We assessed the radiographic differences between the Asian and Caucasian anthropometric data. The dimensions of the nine knee implant designs (Vanguard, Genesis II, Persona Standard, Persona Narrow, GK Sphere, Gemini, Attune Standard, Attune Narrow, and Sigma PFC) were compared with the patients' anthropometric (distal femur and proximal tibia) measurements. RESULTS: The Dutch Caucasian patients had larger mediolateral (ML) and AP femoral and tibial dimensions than the Indonesian Asians. The aspect ratios of the distal femur and tibia were larger in Asians than in Caucasians. The AP and ML dimensions were mismatched between the tibial components of the nine knee systems and the Asian anthropometric data. Both groups had larger ML distal femoral dimensions than the knee systems. CONCLUSION: Absolute and relative differences in knee dimensions exist not only between Asian and Caucasian knees but also within both groups. Not all TKA systems had a good fit with the Asian and Caucasian knee phenotypes. An increase in the range of available knee component sizes would be beneficial, although TKA remains an adequate compromise. LEVEL OF EVIDENCE: III.

Posterior cruciate ligament reconstruction with peroneus longus tendon versus hamstring tendon: a comparison of functional outcome and donor site morbidity.

PURPOSE: This study aimed to evaluate the differences in clinical outcome and donor site morbidity between the Peroneus Longus Tendon (PLT) and Hamstring Tendon (HT) in single-bundle Posterior Cruciate Ligament (PCL) reconstruction. METHODS: Patients with an isolated PCL injury underwent single-bundle PCL reconstruction using consecutive sampling. Patients were allocated into two groups (PLT and HT) and prospectively observed. The tendon graft diameter was measured intraoperatively. Functional scores (IKDC, Lysholm, and modified Cincinnati scores) were recorded preoperatively and 2 years postoperatively. The thigh circumference and functional score according to the Foot and Ankle Disability Index (FADI) and American Orthopedic Foot and Ankle Society (AOFAS) were recorded to evaluate the morbidities in the ankle. RESULTS: Fifty-five patients (hamstring n = 27, peroneus n = 28) met the inclusion criteria. The diameter of the PLT graft (8.2 ± 0.6 mm) was comparable to that of the HT graft (8.3 ± 0.5 mm). Both groups had excellent postoperative knee functional outcome scores. The mean AOFAS and FADI scores were excellent, with no difference in thigh circumference between the groups. CONCLUSION: PLT is a good choice as a graft in PCL reconstruction at the 2-year follow-up, with minimal donor site morbidity. LEVEL OF EVIDENCE: II.

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations.

PURPOSE: To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections. METHOD: A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations. RESULTS: Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves. CONCLUSIONS: The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.

Does Circumferential Patellar Denervation Result in Decreased Knee Pain and Improved Patient-reported Outcomes in Patients Undergoing Nonresurfaced, Simultaneous Bilateral TKA?

BACKGROUND: Anterior knee pain, which has a prevalence of 4% to 49% after TKA, may be a cause of patient dissatisfaction after TKA. To limit the occurrence of anterior knee pain, patellar denervation with electrocautery has been proposed. However, studies have disagreed as to the efficacy of this procedure.Questions/purposes We evaluated patients undergoing bilateral, simultaneous TKA procedures without patellar resurfacing to ask: (1) Does circumferential patellar cauterization decrease anterior knee pain (Kujala score) postoperatively compared with non-cauterization of the patella? (2) Does circumferential patellar cauterization result in better functional outcomes based on patient report (VAS score, Oxford knee score, and Knee Injury and Osteoarthritis Outcome Score) than non-cauterization of the patella? (3) Is there any difference in the complication rate (infection, patellar maltracking, fracture, venous thromboembolism, or reoperation rate) between cauterized patellae and non-cauterized patellae? METHODS: Seventy-eight patients (156 knees) were included in this prospective, quasi-randomized study, with each patient serving as his or her own control. Patellar cauterization was always performed on the right knee during simultaneous, bilateral TKA. Five patients (6%) were lost to follow-up before the 2-year minimum follow-up interval. A single surgeon performed all TKAs using the same type of implant, and osteophyte excision was performed in all patellae, which were left unresurfaced. Patellar cauterization was performed at 2 mm to 3 mm deep and approximately 5 mm circumferentially away from the patellar rim. The preoperative femorotibial angle and degree of osteoarthritis (according to the Kellgren-Lawrence grading system) were measured. Restoration of the patellofemoral joint was assessed using the anterior condylar ratio. Clinical outcomes, consisting of clinician-reported outcomes (ROM and Kujala score) and patient-reported outcomes (VAS pain score, Oxford knee score, and Knee Injury and Osteoarthritis Outcome Score), were evaluated preoperatively and at 1 month and 2 years postoperatively. Preoperatively, the radiologic severity of osteoarthritis, based on the Kellgren-Lawrence classification, was not different between the two groups, nor were the baseline pain and knee scores. The mean femorotibial angle of the two groups was also comparable: 189° ± 4.9° and 191° ± 6.3° preoperatively (p = 0.051) and 177° ± 2.9° and 178° ± 2.1° postoperatively (p = 0.751) for cauterized and non-cauterized knees, respectively. The preoperative (0.3 ± 0.06 versus 0.3 ± 0.07; p = 0.744) and postoperative (0.3 ± 0.06 versus 0.2 ± 0.07; p = 0.192) anterior condylar ratios were also not different between the cauterized and non-cauterized groups. RESULTS: At the 2-year follow-up interval, no difference was observed in the mean Kujala score (82 ± 2.9 and 83 ± 2.6 for cauterized and non-cauterized knees, respectively; mean difference 0.3; 95% confidence interval, -0.599 to 1.202; p = 0.509). The mean VAS pain score was 3 ± 0.9 in the cauterized knee and 3 ± 0.7 in the non-cauterized knee (p = 0.920). The mean ROM was 123° ± 10.8° in the cauterized knee and 123° ± 10.2° in the non-cauterized knee (p = 0.783). There was no difference between cauterized and non-cauterized patellae in the mean Knee Injury and Osteoarthritis Outcome Score for symptoms (86 ± 4.5 versus 86 ± 3.9; p = 0.884), pain (86 ± 3.8 versus 86 ± 3.6; p = 0.905), activities (83 ± 3.2 versus 83 ± 2.8; p = 0.967), sports (42 ± 11.3 versus 43 ± 11.4; p = 0.942), and quality of life (83 ± 4.9 versus 83 ± 4.7; p = 0.916), as well as in the Oxford knee score (40 ± 2.1 versus 41 ± 1.9; p = 0.771). Complications were uncommon and there were no differences between the groups (one deep venous thromboembolism in the cauterized group and two in the control group; odds ratio 0.49, 95% CI, 0.04-5.56; p = 0.57). CONCLUSIONS: Patellar cauterization results in no difference in anterior knee pain, functional outcomes, and complication rates compared with non-cauterization of the patella in patients who undergo non-resurfaced, simultaneous, bilateral, primary TKA with a minimum of 2 years of follow-up. We do not recommend circumferential patellar cauterization in non-resurfaced patellae in patients who undergo TKA. LEVEL OF EVIDENCE: Level II, therapeutic study.