Meniscal Suture Influence on Driving Ability 6 Weeks after Anterior Cruciate Ligament Reconstruction with Hamstring Autograft.

The purpose of this study was to determine if driving ability 6 weeks after anterior cruciate ligament (ACL) reconstruction is affected by the addition of a meniscal suture. It was also hypothesized that no differences in the driving performance would be found between right or left knee surgery subgroups. A total of 82 people participated in this prospective cohort study: 36 healthy controls, 26 patients undergoing isolated ACL (iACL) reconstruction with hamstring autograft, and 20 patients undergoing ACL and meniscal suture (ACL-MS) reconstruction. ACL-MS group followed a weight-bearing and movement restriction protocol during the first 2 postoperative weeks, whereas patients undergoing iACL could start range-of-motion exercises and full weight-bearing ambulation on the first postoperative day. A driving simulator that reproduced real-life driving conditions was used to evaluate driving ability. The software analyzed multiple driving and braking variables. Driving performance in the sixth postoperative week was compared with that of a healthy control group. Subgroup analysis considering additional procedures (iACL, ACL-MS) and the side of the operated knee (right, left) was also performed. No statistically significant differences were found in the demographic characteristics nor in the driving performance (collisions, p = 0.897; sidewalk invasions, p = 0.749; pedestrian impact, p = 0.983) between iACL, ACL-MS, and control groups. No statistically significant differences were found in right-left subgroup analysis. The results of the present study show that patients in their sixth postoperative week after right or left ACL reconstruction showed similar driving performance as compared with a healthy control group, regardless of associating or not a meniscal suture, suggesting it is safe to resume driving 6 weeks after the mentioned surgeries.

Cemented Dual Mobility Cup for Primary Total Hip Arthroplasty in Elder Patients with High-Risk Instability.

Several studies have shown that double mobility (DM) cups reduce postoperative dislocations. Does the cemented dual mobility cup reduce dislocations in a specific cohort of elder patients with a high dislocation risk? Our hypothesis is that this implant is optimal for elder patients because it reduces early dislocation. We have retrospectively reviewed elder patients who underwent total hip arthroplasty (THA) with cemented double mobility cup between March 2009 and January 2018. The inclusion criteria were patients (>75 years) who were operated on for primary THA (osteoarthritis or necrosis) with a cemented dual mobility cup and a high-risk instability (at least two patient-dependent risk factors for instability). The exclusion criteria were revision surgeries or hip fracture. In all the cases, the same surgical approach was performed with a Watson Jones modified approach in supine position. We have collected demographic data, instability risk factors. Patients were classified using the Devane's score, Merle d'Aubigné score and the patient's likelihood of falling with the Morse Fall Scale. Surgical and follow-up complications were collected from their medical history. Sixty-eight arthroplasties (68 patients) were included in the study. The median age was 81.7 years (SD 6.4), and the American Society of Anesthesiologists (ASA) score showed a distribution: II 27.94%, III 63.24% and IV 8.82%. Devane's score was less than five in all of the cases. At least two patient-dependent risk factors for instability (87% had three or more) were present in each case. The median follow-up time was 49.04 months (SD 22.6). Complications observed were two cases of infection and one case of aseptic loosening at 15 months which required revision surgery. We did not observe any prosthetic dislocation. The cemented dual mobility cup is an excellent surgical option on primary total hip arthroplasties for elder patients with high-risk instability.

Do we really improve life quality after total knee arthroplasty in patients with Parkinson's disease?

INTRODUCTION: The knee in Parkinson's disease (PD) patients is a problematic joint due to pain, stiffness and gait instability. The aim of this study is to evaluate the functional outcome and degree of pain relief achieved after total knee arthroplasty (TKA) in PD patients. MATERIALS AND METHODS: This is a retrospective review of 26 PD patients (32 knees) with osteoarthritis who underwent a TKA between 1994 and 2013. Comorbidities, anesthetic procedures and complications were recorded. Patient functional status was assessed with the Knee Society Function Score (KFS) and the Knee Society Score (KSS). PD stage was classified with the Hoehn and Yahr Scale. RESULTS: The mean follow-up was 3.5 years (range 2-9). The mean age was 71 years (range 61-83) with a mean time since PD diagnosis of 11.8 years (range 4-24). PD severity on the Hoehn and Yahr Scale was 1.5 points before surgery and 2 points postoperatively. Pain on the visual analogic scale improved from 8 points preoperatively to 5 points at 1-year follow-up; function improved from 32 (range 20-45) to 71 (range 50-81) and from 34 (range 28-52) to 59 (range 25-76) on the KSS and KFS, respectively. The mean postoperative hospital stay was 9.8 days (range 5-21). Confusion and flexion contracture were the most frequent perioperative complications. CONCLUSION: TKA successfully provided pain relief in PD patients. However, the functional outcome is related to disease progression and, therefore, variable. Perioperative complications are difficult to avoid and manage.

Total Hip Arthroplasty Digital Templating: Size Predicting Ability and Interobserver Variability.

BACKGROUND: During the last century, total hip arthroplasties have become more popular. They have had a huge impact on the quality of life, pain, range of motion, social interaction, and psychological well-being. A number of studies have emphasized the importance of using templates to choose the appropriate implant size when planning the surgery. Our aim is to use MediCad® software to analyze the ability of the digital template system MediCad® to predict the size of the implant needed in total hip arthroplasties. MATERIALS AND METHODS: An arthroplasty preoperative plan was created according to the MediCad® software guidelines, on anteroposterior hip X-ray by one junior resident, one senior resident, and three experienced hip surgeons. RESULTS: The median size accuracy was 0.7 (range: 0.27-0.87) for the cup, 0.73 (range: 0.36-0.83) for the stem, and 0.28 (range: -0.14-0.69) for the neck. Interobserver reliability was good (kappa > 0.4) and stronger when measuring the stem than when doing so with the cup. Conclusion: Digital preoperative total hip arthroplasty planning is a good method for predicting component size, restoring hip anatomy (vertical offset and horizontal offset), with good interobserver reliability.

Phase II multicenter randomized controlled clinical trial on the efficacy of intra-articular injection of autologous bone marrow mesenchymal stem cells with platelet rich plasma for the treatment of knee osteoarthritis.

BACKGROUND: Mesenchymal stromal cells are a safe and promising option to treat knee osteoarthritis as previously demonstrated in different clinical trials. However, their efficacy, optimal dose and addition of adjuvants must be determined. Here, we evaluated the clinical effects of a dose of 100 × 106 bone marrow mesenchymal stromal cells (BM-MSCs) in combination with Platelet Rich Plasma (PRGF®) as adjuvant in a randomized clinical trial. METHODS: A phase II, multicenter, randomized clinical trial with active control was conducted. Sixty patients diagnosed with knee OA were randomly assigned to 3 weekly doses of PRGF® or intraarticular administration of 100 × 106 cultured autologous BM-MSCs plus PRGF®. Patients were followed up for 12 months, and pain and function were assessed using VAS and WOMAC and by measuring the knee range of motion range. X-ray and magnetic resonance imaging analyses were performed to analyze joint damage. RESULTS: No adverse effects were reported after BM-MSC administration or during follow-up. According to VAS, the mean value (SD) for PRGF® and BM-MSC with PRGF® went from 5 (1.8) to 4.5 (2.2) (p = 0.389) and from 5.3 (1.9) to 3.5 (2.5) (p = 0.01), respectively at 12 months. In WOMAC, the mean (SD) baseline and 12-month overall WOMAC scores in patients treated with PRGF® was 31.9 (16.2) and 22.3 (15.8) respectively (p = 0.002) while that for patients treated with BM-MSC plus PRGF® was 33.4 (18.7) and 23.0 (16.6) (p = 0.053). Although statistical significances between groups have been not detected, only patients being treated with BM-MSC plus PRGF® could be considered as a OA treatment responders following OARSI criteria. X-ray and MRI (WORMS protocol) revealed no changes in knee joint space width or joint damage. CONCLUSIONS: Treatment with BM-MSC associated with PRGF® was shown to be a viable therapeutic option for osteoarthritis of the knee, with clinical improvement at the end of follow-up. Further phase III clinical trials would be necessary to confirm the efficacy. Trial registration Clinical Trials.gov identifier NCT02365142. Nº EudraCT: 2011-006036-23.

Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: long-term follow up of a multicenter randomized controlled clinical trial (phase I/II).

BACKGROUND: Mesenchymal stromal cells (MSCs) are a promising option to treat knee osteoarthritis (OA). Their safety and usefulness have been reported in several short-term clinical trials but less information is available on the long-term effects of MSC in patients with osteoarthritis. We have evaluated patients included in our previous randomized clinical trial (CMM-ART, NCT02123368) to determine their long-term clinical effect. MATERIALS: A phase I/II multicenter randomized clinical trial with active control was conducted between 2012 and 2014. Thirty patients diagnosed with knee OA were randomly assigned to Control group, intraarticularly administered hyaluronic acid alone, or to two treatment groups, hyaluronic acid together with 10 × 106 or 100 × 106 cultured autologous bone marrow-derived MSCs (BM-MSCs), and followed up for 12 months. After a follow up of 4 years adverse effects and clinical evolution, assessed using VAS and WOMAC scorings are reported. RESULTS: No adverse effects were reported after BM-MSCs administration or during the follow-up. BM-MSCs-administered patients improved according to VAS, median value (IQR) for Control, Low-dose and High-dose groups changed from 5 (3, 7), 7 (5, 8) and 6 (4, 8) to 7 (6, 7), 2 (2, 5) and 3 (3, 4), respectively at the end of follow up (Low-dose vs Control group, p = 0.01; High-dose vs Control group, p = 0.004). Patients receiving BM-MSCs also improved clinically according to WOMAC. Control group showed an increase median value of 4 points (- 11;10) while Low-dose and High-dose groups exhibited values of - 18 (- 28;- 9) and - 10 (- 21;- 3) points, respectively (Low-dose vs Control group p = 0.043). No clinical differences between the BM-MSCs receiving groups were found. CONCLUSIONS: Single intraarticular injection of in vitro expanded autologous BM-MSCs is a safe and feasible procedure that results in long-term clinical and functional improvement of knee OA.

Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: multicenter randomized controlled clinical trial (phase I/II).

BACKGROUND: Mesenchymal stromal cells are a promising option to treat knee osteoarthritis. Their safety and usefulness must be confirmed and the optimal dose established. We tested increasing doses of bone marrow mesenchymal stromal cells (BM-MSCs) in combination with hyaluronic acid in a randomized clinical trial. MATERIALS: A phase I/II multicenter randomized clinical trial with active control was conducted. Thirty patients diagnosed with knee OA were randomly assigned to intraarticularly administered hyaluronic acid alone (control), or together with 10 × 10(6) or 100 × 10(6) cultured autologous BM-MSCs, and followed up for 12 months. Pain and function were assessed using VAS and WOMAC and by measuring the knee motion range. X-ray and magnetic resonance imaging analyses were performed to analyze joint damage. RESULTS: No adverse effects were reported after BM-MSC administration or during follow-up. BM-MSC-administered patients improved according to VAS during all follow-up evaluations and median value (IQR) for control, low-dose and high-dose groups change from 5 (3, 7), 7 (5, 8) and 6 (4, 8) to 4 (3, 5), 2 (1, 3) and 2 (0,4) respectively at 12 months (low-dose vs control group p = 0.005 and high-dose vs control group p < 0.009). BM-MSC-administered patients were also superior according to WOMAC, although improvement in control and low-dose patients could not be significantly sustained beyond 6 months. On the other hand, the BM-MSC high-dose group exhibited an improvement of 16.5 (12, 19) points at 12 months (p < 0.01). Consistent with WOMAC and VAS values, motion ranges remained unaltered in the control group but improved at 12 months with BM-MSCs. X-ray revealed a reduction of the knee joint space width in the control group that was not seen in BM-MSCs high-dose group. MRI (WORMS protocol) showed that joint damage decreased only in the BM-MSC high-dose group, albeit slightly. CONCLUSIONS: The single intraarticular injection of in vitro expanded autologous BM-MSCs together with HA is a safe and feasible procedure that results in a clinical and functional improvement of knee OA, especially when 100 × 10(6) cells are administered. These results pave the way for a future phase III clinical trial. CLINICAL TRIALS: gov identifier NCT02123368. Nº EudraCT: 2009-017624-72.

Comparison between two different platelet-rich plasma preparations and control applied during anterior cruciate ligament reconstruction. Is there any evidence to support their use?

INTRODUCTION: To compare the clinical, analytical and graft maturation effects of two different platelet-rich plasma (PRP) preparations applied during anterior cruciate ligament (ACL) reconstruction. MATERIALS AND METHODS: A total of 150 patients with ACL disruption were included in the study. Arthroscopic ACL reconstruction with patellar tendon allograft was conducted on all knees using the same protocol. One hundred patients were prospectively randomised to either a group to receive double-spinning platelet-enriched gel (PRP) with leukocytes (n=50) or to a non-gel group (n=50). Finally, we included 50 patients treated with a platelet-rich preparation from a single-spinning procedure (PRGF Endoret(®) Technology) without leukocytes. Inflammatory parameters, including C-reactive protein (CRP) and knee perimeters (PER), were measured 24 hours and 10 days after surgery. Postoperative pain score (visual analogue score [VAS]) was recorded the day after surgery. Follow-up visits occurred postoperatively at 3, 6, and 12 months. The International Knee Documentation Committee scale (IKDC) was included to compare functional state, and MRI was conducted 6 months after surgery. RESULTS: The PRGF group showed a statistically significant improvement in swelling and inflammatory parameters compared with the other two groups at 24 hours after surgery (p<0.05). The results did not show any significant differences between groups for MRI and clinical scores. CONCLUSIONS: PRGF used in ACL allograft reconstruction was associated with reduced swelling; however, the intensity and uniformity of the graft on MRI were similar in the three groups, and there was no clinical or pain improvement compared with the control group. LEVEL OF EVIDENCE: II.

Dolor inguinal tras herniorrafia causado por atrapamiento femoroacetabular anterior / Inguinal pain after herniorrhaphy caused by anterior femoroacetabular impingement

No disponible

Resultados a largo plazo de la tenodesis de castaing en la inestabilidad cronica de tobillo / The long-term results of castaing tenodesis for chronic ankle instability

Existen distintas opciones quirúrgicas cuando el tratamiento conservador de las inestabilidades crónicas de tobillo es insuficiente, desde la reparación directa hasta diversos tipos de ligamentoplastias de refuerzo externo. Uno de los inconvenientes que se les atribuye es que con el tiempo puedan provocar una artrosis tibio-astragalina y subastragalina. Para valorar el resultado del tratamiento quirúrgico de estas lesiones y su repercusión a largo plazo, mostramos nuestra experiencia con la plastia de Castaing en un grupo de pacientes con un seguimiento mínimo de 10 años. Hemos revisado 16 tobillos (14 pacientes) intervenidos mediante plastia de Castaing con un seguimiento medio de 15,5 años (rango: 10 - 22), 9 mujeres y 5 hombres con una edad media de 22,3 años (rango: 15 - 59). Los resultados se han evaluado según la escala de la Sociedad Ortopédica Americana del Tobillo y Pie mostrando una media de 92,5 puntos (rango: 79 - 97) y según la escala de Good et al. siendo: once excelentes (grado 1), 2 buenos (grado 2), dos regulares (grado 3) y uno malo (grado 3). En el estudio radiológico ninguno de los tobillos presentaba cambios significativos sugerentes de artrosis tibio-astragalina o subastragalina. Concluimos que cuando el tratamiento conservador de la inestabilidad crónica del tobillo es insuficiente, la tenodesis de Castaing es un tratamiento adecuado ya que los resultados a largo plazo son satisfactorios y no parece que provoque una sobrecarga articular que predisponga a una artrosis precoz (AU)

Tratamiento quirúrgico de la seudoartrosis diafisaria de húmero: resultados de un estudio multicéntrico

Se realizó un estudio multicéntrico retrospectivo sobre 69 pacientes que habían desarrollado seudoartrosis aséptica de húmero, y se analizaron los resultados del tratamiento quirúrgico. Los pacientes fueron evaluados entre los años 1971 y 1995. La edad media era de 48 años, 36 eran mujeres y 33 hombres. El tipo más frecuente de fractura fue A3 de la clasificación AO. Diez pacientes tenían fracturas expuestas, 17 presentaban lesiones nerviosas asociadas y 15 teníanotras fracturas asociadas. El tratamiento inicial de la fractura fue conservador en 34 pacientes y quirúrgico en 35. El tiempo medio de latencia entre el trauma inicial y el tratamiento quirúrgico de la fractura fue de 7,2 días. El tipo de callo formado fue atrófico en 52 seudoartosis e hipertrófico en 17. El tratamiento quirúrgico inicial de la seudoartrosis consistió en: placa y tornillos en 36 pacientes, enclavado endomedular en 15, fijación externa en 11, haz de Hackethal en 6 y sólo tornillos en 1. Se utilizó autoinjerto de esponjosa en 36 pacientes, injerto vascularizado de peroné en 1 y aloinjerto en 4. Se logró consolidación de la seudoartrosis en 64 de los 69 pacientes. El número medio de tratamientos quirúrgicos efectuados para lograr la consolidación fue de 1,5 por paciente con un rango de 1 a 4. Cuando utilizamos placa y tornillos se logró consolidación después del primer procedimiento en el 80 por ciento de los casos contra el 63 por ciento de los tratados con clavos endomedulares. No encontramos diferencia significativa en el tiempo medio de consolidación entre la seudoartosis atrófica e hipertrófica. La media de tiempo transcurrido entre el último procedimiento quirúrgico y la consolidación radiológica fue de 4,1 meses. Como conclusión creemos que el tratamiento óptimo de la seudoartrosis de la diáfisis del húmero es la fijación interna con placa a compresión más aporte de injerto óseo

Tratamiento quirúrgico de la seudoartrosis diafisaria de húmero: resultados de un estudio multicéntrico

Se realizó un estudio multicéntrico retrospectivo sobre 69 pacientes que habían desarrollado seudoartrosis aséptica de húmero, y se analizaron los resultados del tratamiento quirúrgico. Los pacientes fueron evaluados entre los años 1971 y 1995. La edad media era de 48 años, 36 eran mujeres y 33 hombres. El tipo más frecuente de fractura fue A3 de la clasificación AO. Diez pacientes tenían fracturas expuestas, 17 presentaban lesiones nerviosas asociadas y 15 teníanotras fracturas asociadas. El tratamiento inicial de la fractura fue conservador en 34 pacientes y quirúrgico en 35. El tiempo medio de latencia entre el trauma inicial y el tratamiento quirúrgico de la fractura fue de 7,2 días. El tipo de callo formado fue atrófico en 52 seudoartosis e hipertrófico en 17. El tratamiento quirúrgico inicial de la seudoartrosis consistió en: placa y tornillos en 36 pacientes, enclavado endomedular en 15, fijación externa en 11, haz de Hackethal en 6 y sólo tornillos en 1. Se utilizó autoinjerto de esponjosa en 36 pacientes, injerto vascularizado de peroné en 1 y aloinjerto en 4. Se logró consolidación de la seudoartrosis en 64 de los 69 pacientes. El número medio de tratamientos quirúrgicos efectuados para lograr la consolidación fue de 1,5 por paciente con un rango de 1 a 4. Cuando utilizamos placa y tornillos se logró consolidación después del primer procedimiento en el 80 por ciento de los casos contra el 63 por ciento de los tratados con clavos endomedulares. No encontramos diferencia significativa en el tiempo medio de consolidación entre la seudoartosis atrófica e hipertrófica. La media de tiempo transcurrido entre el último procedimiento quirúrgico y la consolidación radiológica fue de 4,1 meses. Como conclusión creemos que el tratamiento óptimo de la seudoartrosis de la diáfisis del húmero es la fijación interna con placa a compresión más aporte de injerto óseo