Arthroscopic Partial Meniscectomy for a Degenerative Meniscus Tear Is Not Cost Effective Compared With Placebo Surgery: An Economic Evaluation Based on the FIDELITY Trial Data.

BACKGROUND: In patients with a degenerative tear of the medial meniscus, recent meta-analyses and systematic reviews have shown no treatment benefit of arthroscopic partial meniscectomy (APM) over conservative treatment or placebo surgery. Yet, advocates of APM still argue that APM is cost effective. Giving advocates of APM their due, we note that there is evidence from the treatment of other musculoskeletal complaints to suggest that a treatment may prove cost effective even in the absence of improvements in efficacy outcomes, as it may lead to other benefits, such as diminished productivity loss and reduced costs, and so the question of cost effectiveness needs to be answered for APM. QUESTIONS/PURPOSES: (1) Does APM result in lower postoperative costs compared with placebo surgery? (2) Is APM cost-effective compared with placebo surgery? METHODS: One hundred forty-six adults aged 35 to 65 years with knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis according to the American College of Rheumatology clinical criteria were randomized to APM (n = 70) or placebo surgery (n = 76). In the APM and placebo surgery groups, mean age was 52 ± 7 years and 52 ± 7 years, and 60% (42 of 70) and 62% (47 of 76) of participants were men, respectively. There were no between-group differences in baseline characteristics. In both groups, a standard diagnostic arthroscopy was first performed. Thereafter, in the APM group, the torn meniscus was trimmed to solid meniscus tissue, whereas in the placebo surgery group, APM was carefully mimicked but no resection of meniscal tissue was performed; as such, surgical costs were the same in both arms and were not included in the analyses. All patients received identical postoperative care including a graduated home-based exercise program. At the 2-year follow-up, two patients were lost to follow-up, both in the placebo surgery group. Cost effectiveness over the 2-year trial period was computed as incremental net monetary benefit (INMB) for improvements in quality-adjusted life years (QALY), using both the societal (primary) and healthcare system (secondary) perspectives. To be able to consider APM cost effective, the CEA analysis should yield a positive INMB value. Nonparametric bootstrapping was used to assess uncertainty. Several one-way sensitivity analyses were also performed. RESULTS: APM did not deliver lower postoperative costs, nor did it convincingly improve quality of life scores when compared with placebo surgery. From a societal perspective, APM was associated with € 971 (95% CI -2013 to 4017) higher costs and 0.015 (95% CI -0.011 to 0.041) improved QALYs over 2-year follow-up compared with placebo surgery. Both differences were statistically inconclusive (a wide 95% CI that crossed the line of no difference). Using the conventional willingness to pay (WTP) threshold of € 35,000 per QALY, APM resulted in a negative INMB of € -460 (95% CI -3757 to 2698). In our analysis, APM would result in a positive INMB only when the WTP threshold rises to about € 65,000 per QALY. The wide 95% CIs suggests uncertain cost effectiveness irrespective of chosen WTP threshold. CONCLUSION: The results of this study lend further support to clinical practice guidelines recommending against the use of APM in patients with a degenerative meniscus tear. Given the robustness of existing evidence demonstrating no benefit or cost effectiveness of APM over nonsurgical treatment or placebo surgery, future research is unlikely to alter this conclusion.Level of Evidence Level III, economic analysis.

Arthroscopic Bankart versus open Latarjet as a primary operative treatment for traumatic anteroinferior instability in young males: a randomised controlled trial with 2-year follow-up.

OBJECTIVES: To compare the success rates of arthroscopic Bankart and open Latarjet procedure in the treatment of traumatic shoulder instability in young males. DESIGN: Multicentre randomised controlled trial. SETTING: Orthopaedic departments in eight public hospitals in Finland. PARTICIPANTS: 122 young males, mean age 21 years (range 16-25 years) with traumatic shoulder anteroinferior instability were randomised. INTERVENTIONS: Arthroscopic Bankart (group B) or open Latarjet (group L) procedure. MAIN OUTCOME MEASURES: The primary outcome measure was the reported recurrence of instability, that is, dislocation at 2-year follow-up. The secondary outcome measures included clinical apprehension, sports activity level, the Western Ontario Shoulder Instability Index, the pain Visual Analogue Scale, the Oxford Shoulder Instability Score, the Constant Score and the Subjective Shoulder Value scores and the progression of osteoarthritic changes in plain films and MRI. RESULTS: 91 patients were available for analyses at 2-year follow-up (drop-out rate 25%). There were 10 (21%) patients with redislocations in group B and 1 (2%) in group L, p=0.006. One (9%) patient in group B and five (56%) patients in group L returned to their previous top level of competitive sports (p=0.004) at follow-up. There was no statistically significant between group differences in any of the other secondary outcome measures. CONCLUSIONS: Arthroscopic Bankart operation carries a significant risk for short-term postoperative redislocations compared with open Latarjet operation, in the treatment of traumatic anteroinferior instability in young males. Patients should be counselled accordingly before deciding the surgical treatment. TRIAL REGISTRATION NUMBER: NCT01998048.

Long-term follow-up results of medial opening wedge high tibia osteotomy with a pre-countered non-locking steel plate.

INTRODUCTION: This retrospective study investigated the long-term follow-up results of medial opening wedge high tibial osteotomy (MOWHTO) with a pre-countered non-locking steel plate implant (Puddu plate = PP) used for medial knee osteoarthrosis (OA) treatment. MATERIALS AND METHODS: Consecutive 70 MOWHTOs (66 patients) were performed between 01.01.2004 and 31.12.2008 with the mean follow-up time of 11.4 (SD 4.5; range 1.2-16.1) years. The Kaplan-Meier survival analysis was used to evaluate the cumulative survival of the implant in terms of age (< 50 years old and ≥ 50 years old) and gender. Adverse events were studied and Cox regression analysis was used to evaluate risk factors [age, gender, body mass index (BMI), preoperative mechanical axis, severity of OA, use of bone grafting or substitution and undercorrection of mechanical axis from varus to valgus] for revisions. RESULTS: The estimates for the cumulative survival with no need for TKA after MOWHTO were 86% at 5 years, 67% at 10 years and 58% at 16.1 years (SE 0.6, CI 95% 11.1-13.5). A total of 33/70 (47%) adverse events occurred and 38/70 (54%) knees required some revision surgery during the follow-up. Cox regression did not show any statistically significant risk factors for revision. CONCLUSIONS: The PP has feasible MOWHTO results with a cumulative survival of 67% at 10 years with no need for conversion to TKA. Many adverse events occurred and revision rate due to any reason was high. Age or gender did not have statistically significant differences in terms of survival.

Characterization of hyaluronan-coated extracellular vesicles in synovial fluid of patients with osteoarthritis and rheumatoid arthritis.

BACKGROUND: Hyaluronic acid (HA) is the major extracellular matrix glycosaminoglycan with a reduced synovial fluid (SF) concentration in arthropathies. Cell-derived extracellular vesicles (EV) have also been proposed to contribute to pathogenesis in joint diseases. It has recently been shown that human SF contains HA-coated EV (HA-EV), but their concentration and function in joint pathologies remain unknown. METHODS: The aim of the present study was to develop an applicable method based on confocal laser scanning microscopy (CLSM) and image analysis for the quantification of EV, HA-particles, and HA-EV in the SF of the human knee joint. Samples were collected during total knee replacement surgery from patients with end-stage rheumatoid arthritis (RA, n = 8) and osteoarthritis (OA, n = 8), or during diagnostic/therapeutic arthroscopy unrelated to OA/RA (control, n = 7). To characterize and quantify EV, HA-particles, and HA-EV, SF was double-stained with plasma membrane and HA probes and visualized by CLSM. Comparisons between the patient groups were performed with the Kruskal-Wallis analysis of variance. RESULTS: The size distribution of EV and HA-particles was mostly similar in the study groups. Approximately 66% of EV fluorescence was co-localized with HA verifying that a significant proportion of EV carry HA. The study groups were clearly separated by the discriminant analysis based on the CLSM data. The intensities of EV and HA-particle fluorescences were lower in the RA than in the control and OA groups. CONCLUSIONS: CLSM analysis offers a useful tool to assess HA-EV in SF samples. The altered EV and HA intensities in the RA SF could have possible implications for diagnostics and therapy.

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial.

BACKGROUND: Nontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years. MATERIALS AND METHODS: One hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA). RESULTS: A total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045). CONCLUSIONS: On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.

Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial.

OBJECTIVES: To assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up. DESIGN: Multicentre, randomised, participant- and outcome assessor-blinded, placebo-surgery controlled trial. SETTING: Orthopaedic departments in five public hospitals in Finland. PARTICIPANTS: 146 adults, mean age 52 years (range 35-65 years), with knee symptoms consistent with degenerative medial meniscus tear verified by MRI scan and arthroscopically, and no clinical signs of knee osteoarthritis were randomised. INTERVENTIONS: APM or placebo surgery (diagnostic knee arthroscopy). MAIN OUTCOME MEASURES: We used two indices of radiographic knee osteoarthritis (increase in Kellgren and Lawrence grade ≥1, and increase in Osteoarthritis Research Society International (OARSI) atlas radiographic joint space narrowing and osteophyte sum score, respectively), and three validated patient-relevant measures of knee symptoms and function (Western Ontario Meniscal Evaluation Tool (WOMET), Lysholm, and knee pain after exercise using a numerical rating scale). RESULTS: There was a consistent, slightly greater risk for progression of radiographic knee osteoarthritis in the APM group as compared with the placebo surgery group (adjusted absolute risk difference in increase in Kellgren-Lawrence grade ≥1 of 13%, 95% CI -2% to 28%; adjusted absolute mean difference in OARSI sum score 0.7, 95% CI 0.1 to 1.3). There were no relevant between-group differences in the three patient-reported outcomes: adjusted absolute mean differences (APM vs placebo surgery), -1.7 (95% CI -7.7 to 4.3) in WOMET, -2.1 (95% CI -6.8 to 2.6) in Lysholm knee score, and -0.04 (95% CI -0.81 to 0.72) in knee pain after exercise, respectively. The corresponding adjusted absolute risk difference in the presence of mechanical symptoms was 18% (95% CI 5% to 31%); there were more symptoms reported in the APM group. All other secondary outcomes comparisons were similar. CONCLUSIONS: APM was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at 5 years after surgery. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01052233 and NCT00549172).

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial.

OBJECTIVE: To assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus. METHODS: In this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35-65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out. RESULTS: In the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, -4.3; 95% CI, -11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (-3.2; -8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (-0.4; -1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups. CONCLUSIONS: In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.

Regular chondrocyte spacing is a potential cause for coherent ultrasound backscatter in human articular cartilage.

The potential of quantitative ultrasound (QUS) to assess the regular cellular spacing in the superficial cartilage zones was investigated experimentally and numerically. Nine osteochondral samples, extracted from two human cadaver knee joints, were measured using a 50-MHz ultrasound scanning device and evaluated using Mankin score. Simulated backscattered power spectra from models with an idealized cell alignment exhibited a pronounced frequency peak. From the peak, cell spacing in the range between 15 and 40 µm between cell layers was detected with an average error of 0.2 µm. The mean QUS-based cell spacing was 28.3 ± 5.3 µm. Strong correlation (R2 = 0.59, p ≤ 0.001) between spacing estimates from light microscopy (LM) and QUS was found for samples with Mankin score ≤3. For higher scores, QUS-based spacing was significantly higher (p ≤ 0.05) compared to LM-based spacing. QUS-based spacing estimates together with other QUS parameters may serve as future biomarkers for detecting early signs of osteoarthrosis.

Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear.

BACKGROUND: Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking. METHODS: We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure. RESULTS: In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, -1.6 points; 95% confidence interval [CI], -7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, -2.5 points; 95% CI, -9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, -0.1; 95% CI, -0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively). CONCLUSIONS: In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.).

Increasing incidence of rotator cuff repairs--A nationwide registry study in Finland.

BACKGROUND: Rotator cuff repair incidence rates have reportedly increased in the United States and England. Here we analyzed nationwide data relating to rotator cuff repairs recorded in the Finnish National Hospital Discharge Register (NHDR). METHODS: The NHDR was reviewed to identify adult patients who underwent rotator cuff repair between 1998 and 2011. Incidence rates per 10(5) person-years were calculated using the annual adult population size. RESULTS: During the 14-year time period, 50,646 rotator cuff repairs were performed on subjects aged 18 years or older. The incidence of rotator cuff repair showed an almost linear increase of 204%, from 44 per 10(5) person-years in 1998 to 131 per 10(5) person-years in 2011. The most common concomitant procedure was acromioplasty, which was performed in approximately 40% of rotator cuff repairs in 2011. Other common concomitant procedures included tenodesis (7%) and tenotomy (6%) of the long head of the biceps tendon, and resection of the acromioclavicular joint (3%). CONCLUSIONS: This nationwide analysis revealed a remarkable increase in the incidence of rotator cuff repair from 1998 to 2011 in Finland. This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears.

Clinical Super-Resolution Computed Tomography of Bone Microstructure: Application in Musculoskeletal and Dental Imaging.

PURPOSE: Clinical cone-beam computed tomography (CBCT) devices are limited to imaging features of half a millimeter in size and cannot quantify the tissue microstructure. We demonstrate a robust deep-learning method for enhancing clinical CT images, only requiring a limited set of easy-to-acquire training data. METHODS: Knee tissue from five cadavers and six total knee replacement patients, and 14 teeth from eight patients were scanned using laboratory CT as training data for the developed super-resolution (SR) technique. The method was benchmarked against ex vivo test set, 52 osteochondral samples are imaged with clinical and laboratory CT. A quality assurance phantom was imaged with clinical CT to quantify the technical image quality. To visually assess the clinical image quality, musculoskeletal and maxillofacial CBCT studies were enhanced with SR and contrasted to interpolated images. A dental radiologist and surgeon reviewed the maxillofacial images. RESULTS: The SR models predicted the bone morphological parameters on the ex vivo test set more accurately than conventional image processing. The phantom analysis confirmed higher spatial resolution on the SR images than interpolation, but image grayscales were modified. Musculoskeletal and maxillofacial CBCT images showed more details on SR than interpolation; however, artifacts were observed near the crown of the teeth. The readers assessed mediocre overall scores for both SR and interpolation. The source code and pretrained networks are publicly available. CONCLUSION: Model training with laboratory modalities could push the resolution limit beyond state-of-the-art clinical musculoskeletal and dental CBCT. A larger maxillofacial training dataset is recommended for dental applications.

Hyaluronic Acid and Large Extracellular Vesicles (EVs) in Synovial Fluid and Plasma of Patients With End-Stage Arthritis: Positive Association of EVs to Joint Pain.

OBJECTIVE: Hyaluronic acid (HA) in synovial fluid (SF) contributes to boundary lubrication with altered levels in osteoarthritis (OA) and rheumatoid arthritis (RA). SF extracellular vesicles (EVs) may participate in arthritis by affecting inflammation and cartilage degradation. It remains unknown whether HA and EVs display joint-specific alterations in arthritic SFs. DESIGN: We investigated the numbers and characteristics of HA-particles and large EVs in SF from knees and shoulders of 8 OA and 8 RA patients and 8 trauma controls, and in plasma from 10 healthy controls and 11 knee OA patients. The plasma and SF HA concentrations were determined with a sandwich-type enzyme-linked sorbent assay, and EVs and HA-particles were characterized from plasma and unprocessed and centrifuged SFs with confocal microscopy. The data were compared according to diagnosis, location, and preanalytical processing. RESULTS: The main findings were: (1) OA and RA SFs can be distinguished from trauma joints based on the distinctive profiles of HA-particles and large EVs, (2) there are differences in the SF HA and EV characteristics between shoulder and knee joints that could reflect their dissimilar mobility, weight-bearing, and shock absorption properties, (3) EV counts in SF and plasma can positively associate with pain parameters independent of age and body adiposity, and (4) low-speed centrifugation causes alterations in the features of HA-particles and EVs, complicating their examination in the original state. CONCLUSIONS: Arthritis and anatomical location can affect the characteristics of HA-particles and large EVs that may have potential as biomarkers and effectors in joint degradation and pain.

Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.

BACKGROUND: The minimal clinically important difference (MCID) is increasingly used to evaluate treatment effectiveness. The MCID for the Constant score has not been previously reported. MATERIALS AND METHODS: A prospectively collected cohort of 802 consecutive shoulders with arthroscopically treated partial- or full-thickness rotator cuff tears was analyzed. The Constant score was measured preoperatively and at 3 months and 1 year postoperatively. At follow-up visits, the patients were asked a simple 2-stage question: Is the shoulder better or worse after the operation compared with the preoperative state? This single 2-level question was used as an indicator of patient satisfaction and as an anchor to calculate the MCID for the Constant score. RESULTS: At 1 year, 781 (97.4%) patients (474 men, 307 women) were available for follow-up. The preoperative Constant score was 53.1 (SD 17.2) in all patients, 56.2 (SD 17.4) in male patients, and 48.2 (SD 15.6) in female patients. Postoperatively at 3 months, the scores were 61.7 (SD 16.4) in all patients, 65.1 (SD 16.1) in male patients, and 56.8 (SD 15.5) in female patients. At 1 year, the scores were 75.9 (SD 15.2) in all patients, 79.0 (SD 14.9) in male patients, and 71.0 (SD 14.3) in female patients. At 3 months postoperatively, 92.2% of male patients and 87.2% of female patients were satisfied with the outcome (P = .027); at 1 year, the satisfaction was 93.2% and 89.5%, respectively (P = .067). Five different statistical approaches yielded 5 different MCID estimates (range, 2-16). The 3-month mean change estimate of MCID was 10.4 points. CONCLUSION: Our study demonstrates an MCID estimate of 10.4 points as the threshold for the Constant score in patients with rotator cuff tear. LEVEL OF EVIDENCE: Basic science study, validation of outcomes instruments/classification systems.

The effect of glenohumeral osteoarthritis on the outcome of isolated operatively treated supraspinatus tears.

BACKGROUND: Rotator cuff tear is considered to be a common source of shoulder pain and dysfunction. Osteoarthritis of the glenohumeral joint (OAG) may coexist with rotator cuff tear, especially in elderly patients. The aim of the study was to evaluate the effect of associated OAG on the treatment outcome of rotator cuff repair. METHODS: A total of 85 consecutive shoulders with an arthroscopically repaired isolated full-thickness supraspinatus tendon tear in males were included in this study. The grade of OAG was estimated preoperatively from shoulder radiographs using the Kellgren-Lawrence (K-L) classification, and peroperatively using the Outerbridge classification. Supraspinatus tendon tear was re-inserted anatomically to the native footprint in all cases. The Constant score was used as an outcome measure and was measured preoperatively and 1 year after the operation. The effect of OAG on the Constant score was analyzed statistically. RESULTS: 82 shoulders (96.5 %) were available for the 1-year follow-up. Preoperative OAG was detected in 22/82 patients (26.8 %). Any OAG above K-L grade 0 was associated with a lower Constant score preoperatively [49.9 (SD 17.6) vs. 60.1 (SD 16.7) (p = 0.0185)] and also at the 1-year follow-up [73.9 (SD 17.5) vs. 82.8 (SD 10.9) (p = 0.0074)]. 16/60 patients (26.7 %) with K-L grade 0 radiographs had peroperatively detected OAG. Furthermore, any peroperatively detected OAG was associated with a lower Constant score preoperatively [53.2 (SD 19.0) vs. 60.9 (SD 15.2) (p = 0.0445)] and at the 1-year follow-up 76.8 [(SD 14.8) vs. 83.5 (SD 11.4) (p = 0.0223)]. CONCLUSION: OAG is a relatively common finding in operated supraspinatus tear patients. Pre- and peroperatively detected OAG during rotator cuff reconstruction is predictive for lower pre- and postoperative Constant scores.

[Treatment of plantar fasciopathy]. / Jalkapohjan kalvojänteen rappeuman hoito.

Plantar fasciopathy is the most frequent reason for foot pain. It is characterized by degeneration of the insertion of the plantar fascia on the medial process of the calcaneal tuberosity. Palpation over plantar fascia insertion reproduces the pain and may reveal swelling. Conservative treatment is almost always successful. Initial treatment consists of anti-inflammatory medication, stretching exercises, night splints and shoe inserts. If these fail, steroid injections, custom made orthotics, and extra corporeal shock wave therapy may be tried. If disabling pain persists for more than one year, surgery may be indicated.

Survival and failure analysis of 167 medial opening wedge high tibial osteotomy with a locking titanium plate.

INTRODUCTION: This retrospective study investigated the survival rate and complications of medial opening wedge high tibial osteotomy (MOWHTO) with a precountered titanium locking plate. HYPOTHESIS: Advanced age (≥50years), gender, body mass index (BMI), type of osteotomy cut (monoplanar or biplanar), osteoarthritis (OA) grade, the use of bone grafting or substitution and preoperative hip-knee-ankle (HKA) have impact on MOWHTO survival. MATERIAL AND METHODS: A total of 167 knees (155 patients) were consecutively operated during the study period of 01.01.2006-31.12.2014. The primary outcome measure was survival without a need for revision to total knee arthroplasty (TKA). The secondary outcome was a major adverse event leading to revision surgery. Adverse events and complications were evaluated and radiological analyses were done. Furthermore, risk factors that affected the survival were analysed with the Cox regression model. RESULTS: The mean follow-up time was 7.7 (SD: 2.7, range: 0.9-14.5) years. The Kaplan-Meier estimates for the cumulative survival considering no need for TKA after MOWHTO was 90% at 5years, 78% at 10years and 61% at 14.5years (SE: 0.4, 95% CI: 11.2-12.9). The adverse event rate was 30% and 35% of the patients required a secondary surgery. The Cox regression model did not show that age, gender, weight, osteotomy type, the use of bone grafting or substitution, preoperative HKA angle or OA grade were not risk factors for conversion to arthroplasty. DISCUSSION: MOWHTO with locking plate provides good survival with no need for TKA in 78% of the knee medial OA patients at 10years of cumulative follow-up. However, a high adverse event rate (30%) is expected. Risk factors for conversion to TKA were not found and thereby hypothesis of this study was not proved. LEVEL OF EVIDENCE: VI; Retrospective cohort study.

Near-Infrared Spectroscopy Enables Arthroscopic Histologic Grading of Human Knee Articular Cartilage.

Purpose: To develop the means to estimate cartilage histologic grades and proteoglycan content in ex vivo arthroscopy using near-infrared spectroscopy (NIRS). Methods: In this experimental study, arthroscopic NIR spectral measurements were performed on both knees of 9 human cadavers, followed by osteochondral block extraction and in vitro measurements: reacquisition of spectra and reference measurements (proteoglycan content, and three histologic scores). A hybrid model, combining principal component analysis and linear mixed-effects model (PCA-LME), was trained for each reference to investigate its relationship with in vitro NIR spectra. The performance of the PCA-LME model was validated with ex vivo spectra before and after the exclusion of outlying spectra. Model performance was evaluated based on Spearman rank correlation (ρ) and root-mean-square error (RMSE). Results: The PCA-LME models performed well (independent test: average ρ = 0.668, RMSE = 0.892, P < .001) in the prediction of the reference measurements based on in vitro data. The performance on ex vivo arthroscopic data was poorer but improved substantially after outlier exclusion (independent test: average ρ = 0.462 to 0.614, RMSE = 1.078 to 0.950, P = .019 to .008). Conclusions: NIRS is capable of nondestructive evaluation of cartilage integrity (i.e., histologic scores and proteoglycan content) under similar conditions as in clinical arthroscopy. Clinical Relevance: There are clear clinical benefits to the accurate assessment of cartilage lesions in arthroscopy. Visual grading is the current standard of care. However, optical techniques, such as NIRS, may provide a more objective assessment of cartilage damage.

Metabolomics of Synovial Fluid and Infrapatellar Fat Pad in Patients with Osteoarthritis or Rheumatoid Arthritis.

Osteoarthritis (OA) and autoimmune-driven rheumatoid arthritis (RA) are inflammatory joint diseases with complex and insufficiently understood pathogeneses. Our objective was to characterize the metabolic fingerprints of synovial fluid (SF) and its adjacent infrapatellar fat pad (IFP) obtained during the same surgical operation from OA and RA knees. Non-targeted metabolite profiling was performed for 5 non-inflammatory trauma controls, 10 primary OA (pOA) patients, and 10 seropositive RA patients with high-resolution mass spectrometry-based techniques, and metabolites were matched with known metabolite identities. Groupwise differences in metabolic features were analyzed with the univariate Welch's t-test and the multivariate linear discriminant analysis (LDA) and principal component analysis (PCA). Significant discrimination of metabolite profiles was discovered by LDA for both SF and IFP and by PCA for SF based on diagnosis. In addition to a few drug-derived substances, there were 16 and 13 identified metabolites with significant differences between the diagnoses in SF and IFP, respectively. The pathways downregulated in RA included androgen, bile acid, amino acid, and histamine metabolism, and those upregulated included biotin metabolism in pOA and purine metabolism in RA and pOA. The RA-induced downregulation of androgen and bile acid metabolism was observed for both SF and IFP. The levels of 11 lipid metabolites, mostly glycerophospholipids and fatty acid amides, were also altered by these inflammatory conditions. The identified metabolic pathways could be utilized in the future to deepen our understanding of the pathogeneses of OA and RA and to develop not only biomarkers for their early diagnosis but also therapeutic targets.

Anterior glenohumeral instability treated with arthroscopic Bankart operation - a retrospective 5-year follow-up study.

BACKGROUND: This retrospective study investigated 5-year results of primary arthroscopic operation for anterior glenohumeral instability (AI) with special interest in patients aged<25 years and gender. HYPOTHESIS: Recurrence of AI is higher in male patients aged<25 years than older patients or females. PATIENTS AND METHODS: Primary arthroscopic Bankart repair was performed between January 2009 and December 2015 on 156 shoulders [154 patients, 104/156 (67%) males]. The mean follow-up was 5.6 (SD 2.1, range 0.4-8.9) years. Outcome measures, including re-dislocation, fear of dislocation, Western Ontario instability index, Subjective shoulder value and pain Numerical rating scale scores, the number of revision surgeries and satisfaction with the result of surgical treatment, were assessed for 130 shoulders [82/130 (63%) males]. AI recurrence was defined as a dislocation or a fear of such. RESULTS: The Kaplan-Meier analysis estimates for the cumulative survival of stable shoulders were 28% at 8.8 years for patients aged<25 years (SE 0.4, CI 95% 5.5-7.2) and 53% at 8.9 years for patients aged ≥25 years (SE 0.2, CI 95% 7.2-8.0; p=0.005). The Kaplan-Meier estimates for the cumulative survival of stable shoulders were 50% at 8.9 years for males (SE 0.3, CI 95% 6.8-7.8) and 37% at 8.6 years for females (SE 0.3, CI 95% 6.5-7.7; p=0.8). Mean time to revision was 2.4 (SD 1.7, range 0.4-5.3) years. DISCUSSION: Recurrence of AI was higher in the patients aged<25 years (p=0.005), but gender was not a risk factor. Re-operation rate due to recurrent AI was 10% in this 5-year follow-up. LEVEL OF EVIDENCE: III; case-control study.