Evidence based Orthopaedics: Similar prevalence of knee OA at 12 years following endoscopic and open ACL reconstruction ...

Abstract

BACKGROUND:

Although arthroscopic techniques are the most common procedures today when reconstructing the anterior cruciate ligament (ACL), many surgeons still prefer the open and/or 2-incision techniques.

HYPOTHESIS:

There are no differences in knee function or prevalence of knee osteoarthritis (OA) in patients who have undergone the open versus endoscopic technique for ACL reconstruction using the patellar tendon autograft.

STUDY DESIGN:

Randomized controlled trial; Level of evidence, 2.

METHODS:

Sixty-seven patients with subacute or chronic rupture of the ACL were randomly assigned to open (OPEN) (n = 33) or endoscopic (ENDO) (n = 34) reconstruction. Function was evaluated by the Cincinnati knee score, single-legged hop tests, and isokinetic muscle strength tests. The radiographs were classified according to the Kellgren and Lawrence (KL) classification system, defining grade 2 or more as the cutoff point for knee OA. The Insall-Salvati ratio and the Blackburne-Peel ratio were used to calculate the patellar position and height.

RESULTS:

Mean age at inclusion and at the 12-year follow-up evaluation was 27.9 ± 8.6 and 39.8 ± 8.6 years, respectively. At 12-year follow-up, 53 patients (79%) were eligible for evaluation. There were no significant differences between the 2 surgical procedures with respect to the pain, function, muscle strength, hop tests, patellar height, or the prevalence of OA. The prevalence of OA was high in the tibiofemoral joint on the operated side, 79% and 80% in the OPEN and ENDO groups, respectively. For the uninvolved knee, the corresponding numbers were 36% and 21%.

CONCLUSION:

This study suggests that the open procedure does not produce more functional problems or osteoarthritis compared with the endoscopic technique up to 12 years postoperatively.

http://www.ncbi.nlm.nih.gov/pubmed/22984128

Evidence based Orthopedics: Greater satisfaction in older patients with a mobile-bearing compared with fixed-bearing total knee arthroplasty....

A prospective, randomized, controlled, double-blind trial was performed to compare outcomes between 61 mobile- and 58 fixed-bearing primary TKAs in patients aged 70 years or older. At last follow-up, no difference was found for Knee Society score. The mobile-bearing group had greater knee flexion at 3 and 6 months, but this was similar at 2 years. The patient satisfaction was better in the mobile-bearing group than in fixed-bearing group, with respect to Knee Society functional score, Western Ontario MacMasters University score, Short-Form 12 score, and visual analog scale score. A multivariate analysis confirmed that the only independent factors predictive of postoperative quality of life were early postoperative flexion. We believe that better perception and satisfaction with mobile-bearing in older patients was due to the earlier regain of their knee flexion. Our results justify the use of mobile-bearing design in the older population.


J Arthroplasty. 2012 Feb;27(2):207-12. Epub 2011 Jul 12.

Evidence based Orthopedics: HXLPE acetabular liners have 40% lower wear rate compared to UHMWPE at 2 years after THA ...

HXLPE acetabular liners have 40% lower wear rate compared to UHMWPE at 2 years after THA

54 patients with primary hip osteoarthritis schedule to undergo total hip arthroplasty were randomized to receive either highly cross-linked polyethylene (HXLPE) or standard ultra high-molecular-weight polyethylene (UHMWPE) liners. HXLPE acetabular liners have 40% lower wear rate compared to UHMWPE at 2 years after THA.

J Arthroplasty. 2008 Apr;23(3):337-43.

Evidence based Orthopedics: Arthroscopic surgery for knee OA provides no additional benefit to physical and medical therapy alone ...

Arthroscopic surgery for knee OA provides no additional benefit to physical and medical therapy alone

178 patients >18 yr of age with moderate-to-severe osteoarthritis of the knee were randomly assigned to surgical lavage and arthroscopic debridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. Arthroscopic surgery for knee OA provided no additional clinical or symptomatic benefit over optimized physical and medical therapy.

N Engl J Med. 2008 Sep 11;359(11):1097-107.

Evidence based Orthopedics: Balloon kyphoplasty efective for treatment of painful vertebral body compression fractures in patients with cancer

Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial.

Berenson J, Pflugmacher R, Jarzem P, Zonder J, Schechtman K, Tillman JB, Bastian L, Ashraf T, Vrionis F; Cancer Patient Fracture Evaluation (CAFE) Investigators.

Collaborators (32)

Thomson K, Spencer A, Bron D, Body JJ, du Plessis S, Jarzem P, Asenjo JF, Smith R, Pflugmacher R, Krettek C, Bastian L, Muller C, Jakob T, Ordeberg G, Försth P, Afshar F, Villavicencio A, Smith F, Sobecks R, Mroz T, Zonder J, Fessler R, Georgy B, Burton A, Zangari M, Erdem E, Schmidt J, Woods M, Schmidt M, Trehan R, Schneider P, Vrionis F.

Abstract

BACKGROUND:Non-randomised trials have reported benefits of kyphoplasty in patients with cancer and vertebral compression fractures (VCFs). We aimed to assess the efficacy and safety of balloon kyphoplasty compared with non-surgical management for patients with cancer who have painful VCFs.

METHODS:The Cancer Patient Fracture Evaluation (CAFE) study was a randomised controlled trial at 22 sites in Europe, the USA, Canada, and Australia. We enrolled patients aged at least 21 years who had cancer and one to three painful VCFs. Patients were randomly assigned by a computer-generated minimisation randomisation algorithm to kyphoplasty or non-surgical management (control group). Investigators and patients were not masked to treatment allocation. The primary endpoint was back-specific functional status measured by the Roland-Morris disability questionnaire (RDQ) score at 1 month. Outcomes at 1 month were analysed by modified intention to treat, including all patients with data available at baseline and at 1 month follow-up. Patients in the control group were allowed to crossover to receive kyphoplasty after 1 month. This study is registered with ClinicalTrials.gov, NCT00211237.

FINDINGS:Between May 16, 2005, and March 11, 2008, 134 patients were enrolled and randomly assigned to kyphoplasty (n=70) or non-surgical management (n=64). 65 patients in the kyphoplasty group and 52 in the control group had data available at 1 month. The mean RDQ score in the kyphoplasty group changed from 17·6 at baseline to 9·1 at 1 month (mean change -8·3 points, 95% CI -6·4 to -10·2; p<0·0001). The mean score in the control group changed from 18·2 to 18·0 (mean change 0·1 points; 95% CI -0·8 to 1·0; p=0·83). At 1 month, the kyphoplasty treatment effect for RDQ was -8·4 points (95% CI -7·6 to -9·2; p<0·0001). The most common adverse events within the first month were back pain (four of 70 in the kyphoplasty group and five of 64 in the control group) and symptomatic vertebral fracture (two and three, respectively). One patient in the kyphoplasty group had an intraoperative non-Q-wave myocardial infarction, which resolved and was attributed to anaesthesia. Another patient in this group had a new VCF, which was thought to be device related.

INTERPRETATION:For painful VCFs in patients with cancer, kyphoplasty is an effective and safe treatment that rapidly reduces pain and improves function.

Evidence based Orthopedics: Is Intra-Articular Multimodal Drug Injection Effective in Pain Management After Total Knee Arthroplasty?

Is Intra-Articular Multimodal Drug Injection Effective in Pain Management After Total Knee Arthroplasty?

286 patients who were scheduled to undergo simultaneous bilateral total knee arthroplasty (TKA) were randomzied to receive injection of intra-articular multimodal drugs in one knee and normal saline solution as a placebo in the contralateral knee. The results of the study indicated that patients who received the multimodal drugs displayed similar levels of pain, satisfaction, range of motion, and blood loss in comparison to those who received placebo. Therefore, the effects of the drug were minimal.

J Arthroplasty; 2011; 26(7):1095-1099

Evidence based Orthopedics: Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial...

Vertebroplasty provides better pain relief than conservative management for osteoporotic fractures but at a greater cost

202 patients aged 50 years and above with symptomatic radiologically confirmed vertebral compression fractures (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain of less than 6 week duration and a visual analogue scale (VAS) score of >=5, were randomized to be managed with a percutaneous vertebroplasty or conservative management. At 1 year it was observed that the percutaneous vertebroplasty offered a much quicker and greater pain relief in comparison to conservative treatment, at a justifiable expense.

Lancet. 2010 Sep 25;376(9746):1085-92. Epub 2010 Aug 9.

Evidence based Orthopedics: Rivaroxaban is an adequate treatment for thromboprophylaxis after total knee arthroplasty ...

 

Rivaroxaban is an adequate treatment for thromboprophylaxis after total knee arthroplasty

3148 patients who underwent total knee arthroplasty were randomized to thromboprophylaxis using either orally administer rivaroxaban or subcutaneous injection of enoxaparin. This study assessed the efficacy of thromboprophylaxis treatment with rivaroxaban and assessed it's non-inferiority to enoxaparin. The results of this study indicate that rivaroxaban is superior in comparison to enoxaparin for the use in patients undergoing total knee arthroplasty.

Lancet. 2009 May 16;373(9676):1673-80. Epub 2009 May 4

Evidence based Orthopedics: Better clinical outcomes after acute fracture surgery with smoking cessation program

Better clinical outcomes after acute fracture surgery with smoking cessation program

 

105 smokers with acute fracture of the lower or upper extremity requiring surgical intervention and treated no more than two days prior to inclusion in the study were randomized to undergo a structured smoking cessation program for a period of 6 weeks or to continue as usual. At 6 to 12 weeks follow up the postoperative complications were significantly reduced when smoking cessation was implemented immediately after emergency fracture surgery.

J Bone Joint Surg Am. 2010 Jun;92(6):1335-42.

Evidence based Orthopedics: Intra-articular injection of tranexamic acid reduces blood loss and knee joint swelling ...

Intra-articular injection of tranexamic acid reduces blood loss and knee joint swelling

100 patients undergoing total knee arthroplasty (TKA) due to osteoarthritis were randomized to receive either an intra-articular injection of tranexamic acid (TXA) or saline (control). The post-operative results of the study indicated that the blood loss and subsequent drop in the hemoglobin levels were significantly reduced in patients that received TXA. Additionally, knee joint swelling was also significantly lesser in these patients compared to controls.
 
Int Orthop; 2011; 35(11):1639-1645

Evidence based Orthopedics: Arthroscopic Rotator Cuff Repair with and without Acromioplasty...

Arthroscopic Rotator Cuff Repair with and without Acromioplasty

86 patients with full-thickness rotator cuff tears were randomized to undergo arthroscopic repair with or without acromioplasty. The results from the 2 year study indicated that both groups displayed significant improvements in WORC and ASES scores; however, no significant difference was observed in these scores between the two groups. In addition, it was also found that a significantly higher number of revision surgeries were performed in patients randomized to arthroscopic repair alone.

Journal of Bone and Joint Surgery; 2011; 93(A): 1953-1960

Evidence based Orthopedics: Biodegradable screws create larger bone tunnels in ACL graft fixation...

Biodegradable screws create larger bone tunnels in ACL graft fixation


77 patients with a symptomatic unilateral chronic ACL rupture were randomized to reconstruction using hamstring autograft with the use of either poly-L-lactide acid (PLLA) or metal interference screw fixation. At 8 years follow up, the PLLA screw for hamstring tendon (HT) autograft fixation in ACL repair was found to have a significantly larger femoral bone tunnels compared to metal interference screws. However, these observations were not associated with any differences in the clinical outcome measurements.


Am J Sports Med. 2010 Aug;38(8):1598-605. Epub 2010 Apr 14.

Evidence based Orthopedics: Comparison of two surgical fixations for two-part proximal humeral surgical neck fractures ...

Comparison of two surgical fixations for two-part proximal humeral surgical neck fractures

51 patients with two-part proximal humeral fractures were randomized to either locking intramedullary nail or locking plate fixation groups. This study aimed to evaluate and compare longitudinal outcomes of these treatment methods. The results indicate that at one year follow up the locking nail fixation group had fewer complications (p=0.024), whereas the locking plate group had superior ASES and VAS scores (p=0.021, p=0.042 respectively). There were no differences seen at three year follow-up between groups. 

J Bone Joint Surg Am. 2011 Jan 19;93(2):159-68

Evidence based Orthopedics: Non-operative management of achilles tendon rupture equivalent to the surgical repair ....

Non-operative management of achilles tendon rupture equivalent to the surgical repair

144 patients with primary complete achilles tendon rupture were randomized to be treated with a surgical repair and accelerated functional rehabilitation or just the accelerated functional rehabilitation. Over the course of two year follow up, it was observed that achilles tendon rupture lead to clinically similar results between the two treatment groups.

J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. Epub 2010 Oct 29.

Evidence based Orthopedics: Education and physiotherapy combination effective in treating low back pain

Education and physiotherapy combination effective in treating low back pain

69 primary care physicians were randomized to one of three groups: control, education, and education and physiotherapy and asked to recruit patients suffering from low back pain (LBP). The physicians recruited 348 patients with. The aim of this study was to assess the efficacy of primary care education and physiotherapy. Results indicate at 6 months, the greatest improvements in pain and quality of life were seen in the group receiving education and physiotherapy, demonstrating the efficacy of this treatment in a primary care setting for LBP.
 
Spine (Phila Pa 1976). 2010 Mar 1;35(5):483-96.

Evidence based Orthopedics: Comparison of bipolar hemiarthroplasty with total hip arthroplasty

Comparison of bipolar hemiarthroplasty with total hip arthroplasty

120 elderly patients with acute displaced femoral neck fractures were randomized to treatment with either a bipolar hemiarthroplasty or a total hip arthroplasty. Differences in the hip function and health related quality of life were measured at 4/12/24/48 months post operation. The results from this trial indicate that patients who received total hip arthroplasty presented with better hip function at all time points and the health related quality of life was significantly improved at 48 month follow-up in these patients.
 

J Bone Joint Surg Am. 2011 Mar 2;93(5):445-50.

Evidence based Orthopedics: Hemiarthroplasty versus nonoperative treatment of displaced 4-part humeral fractures

Hemiarthroplasty versus nonoperative treatment of displaced 4-part humeral fractures


55 elderly patients with displaced 4-part fractures of the proximal humerus were randomized to receive either hemiarthroplasty (HA) or nonoperative treatment. At 2 year follow-up it was found that quality of life was significantly better in patients who received HA. Additionally, patients in the HA group had significantly better pain scores in comparison to nonoperative treatment. However, the two interventions did not differ in regards range of motion and flexion.


J Shoulder Elbow Surg; 2011; 20(7):1025-1033

Evidence based Orthopedics: Tranexamic Acid Reduces Blood Loss and Blood Transfusion after TKA

Tranexamic Acid Reduces Blood Loss and Blood Transfusion after TKA
 

100 patients with primary osteoarthritis who were scheduled to undergo unilateral cemented total knee arthroplasty were randomized to receive either placebo or intravenous tranexamic acid 10 minutes prior to surgery, 3 hours after surgery, and orally for 5 days after surgery. Patients who received tranexamic acid displayed significantly less blood loss, hemoglobin loss, and required significantly less blood transfusion in comparison to patients who received placebo. Additionally, no changes were observed in symptomatic thromboembolic events.  

Clin Orthop Relat Res; 2011; 469(10): 2874-2880