Arthroscopic treatment of localized and diffuse pigmented villonodular synovitis of the knee

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial disorder of uncertain etiology. Two forms of this disorder, a localized (LPVNS) and diffuse (DPVNS) form, are well differentiated. The therapy of choice for LPVNS is arthroscopic partial synovectomy with excision of the lesion. Total synovectomy, whether done arthroscopically or through an open arthrotomy, is the recommended treatment for DPVNS. During an eight-year period 13 patients, six male and seven female, average age 28 years (range, 16 to 60 years) were treated for PVNS of the knee with arthroscopic synovectomy. Average follow-up was 84 months (range, 28 to 127 months). Four patients were affected by localized PVNS and were subjected to partial arthroscopic synovectomy (two to three portals) with a complete lesion excision. The remaining nine patients presented with the diffuse form of PVNS and all of them underwent total arthroscopic synovectomy (five portals). The diagnosis was confirmed by synovial biopsy. Each patient was evaluated before treatment and at final follow-up. Results were assessed clinically, radiographically and subjectively and were rated as excellent, good, fair, or poor. No complications or recurrences were noted in the LPVNS group, and all four patients were rated as excellent. In the DPVNS group, eight patients were rated as excellent and one patient was rated as fair and it was the patient who suffered the only recurrence in our case series. No relevant complications were encountered. No cases of infection, joint stiffness or neurovascular lesions were seen. Arthroscopy has become the golden standard in treatment of LPVNS, and can undoubtedly give results that are as good as with open synovectomy when treating DPVNS, if performed by an experienced arthroscopic surgeon.     

关节镜下滑膜大部分切除治疗早期类风湿性关节炎临床疗效观察

目的:探讨关节镜滑膜大部分切除治疗早期类风湿性关节炎(rheumatoid arthritis,RA)长期临床疗效.方法:1998年9月至2006年5月.对19例膝关节滑膜炎患者行关节镜下滑膜大部分切除术,随访3-11年,平均随访6.5年,手术前后按Ishikawa标准评分评定膝关节功能.结果:术后3周:优良率为89.5%;术后半年:优良率为79.0%;术后6.3年:优良率为42.1%.结论:关节镜下滑膜大部分切除治疗膝关节RA,近期疗效满意,远期疗效较差.关节镜下滑膜全部切除是提高手术疗效的关键.     

Correlates of knee extensor training load used in rehabilitation after knee surgery

Resistance training is one of the major components of rehabilitation after musculoskeletal injury and surgery. Despite the importance of resistance training and the frequency of its use in rehabilitation, little is known about factors that are related to training load that might be useful in devising and monitoring training in a patient and comparing training intensities between individuals and groups. We hypothesized that the following would show a statistically significant relationship to training load: injury chronicity, self-assessed knee function (Hughston Clinic questionnaire), knee swelling (injured-uninjured midpatellar knee girth), uninjured knee girth, and body mass. The purpose of this study was to evaluate whether factors such as body mass are related to the load used in training the knee extensors in rehabilitation after knee surgery. Thirty-six individuals undergoing early-phase rehabilitation after knee arthroscopic meniscectomy surgery participated in this study. Subjects were tested 5 days after surgery, just prior to commencing a 6-week outpatient rehabilitation program, and again soon after the end of this rehabilitation program. The independent variables evaluated were age, gender, body mass, meniscus injured, injury chronicity, knee function self-assessment, knee swelling (injured-uninjured midpatellar girth), uninjured knee girth, and knee flexion and extension passive range of motion (difference between injured and uninjured side). The dependent variable was the load used for training the knee extensors on the knee extension machine in the final training session prior to the posttest. The only variable exhibiting a statistically significant (p = 0.001) relationship to knee extensor final training was age (r = -0.529). This finding, that age was the only variable to have a significant relationship with training load, suggests that clinicians' expectation of training intensity should decrease with an increase in the patient's age in the range studied (20-58 years) for patients recovering from knee arthroscopic meniscectomy.     

Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis

Background:

Arthroscopic surgery for degenerative meniscal tears is a commonly performed procedure, yet the role of conservative treatment for these patients is unclear. This systematic review and meta-analysis evaluates the efficacy of arthroscopic meniscal débridement in patients with knee pain in the setting of mild or no concurrent osteoarthritis of the knee in comparison with nonoperative or sham treatments.

Methods:

We searched MEDLINE, Embase and the Cochrane databases for randomized controlled trials (RCTs) published from 1946 to Jan. 20, 2014. Two reviewers independently screened all titles and abstracts for eligibility. We assessed risk of bias for all included studies and pooled outcomes using a random-effects model. Outcomes (i.e., function and pain relief) were dichotomized to short-term (< 6 mo) and long-term (< 2 yr) data.

Results:

Seven RCTs (n = 805 patients) were included in this review. The pooled treatment effect of arthroscopic surgery did not show a significant or minimally important difference (MID) between treatment arms for long-term functional outcomes (standardized mean difference [SMD] 0.07, 95% confidence interval [CI] −0.10 to 0.23). Short-term functional outcomes between groups were significant but did not exceed the threshold for MID (SMD 0.25, 95% CI 0.02 to 0.48). Arthroscopic surgery did not result in a significant improvement in pain scores in the short term (mean difference [MD] 0.20, 95% CI −0.67 to 0.26) or in the long term (MD −0.06, 95% CI −0.28 to 0.15). Statistical heterogeneity was low to moderate for the outcomes.

Interpretation:

There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal débridement for degenerative meniscal tears in comparison with nonoperative or sham treatments in middle-aged patients with mild or no concomitant osteoarthritis. A trial of nonoperative management should be the first-line treatment for such patients.Arthroscopic meniscal débridement is one of the most commonly performed procedures in orthopedic surgery. More than 700 000 such procedures are performed each year in the United States, and more than 4 million are performed each year worldwide, with substantial economic and social burdens.^1–6 Many patients who undergo arthroscopic meniscal débridement have concurrent osteoarthritis, and orthopedic surgeons are often challenged to determine the true cause of patients’ symptoms: the meniscal tear, osteoarthritis or a combination of both.⁷Although 2 well-designed randomized controlled trials (RCTs)^8,9 have shown a lack of efficacy for arthroscopic surgery in patients with severe and advanced knee arthritis, many patients present with degenerative meniscal tears and mild or minimal concurrent osteoarthritis.¹⁰ Patients with degenerative meniscal tears in the setting of mild osteoarthritis may experience functional improvement or pain relief with arthroscopic surgery,^11–14 but the role of conservative treatment is unclear.^15–17 Arthroscopic surgery involves the potential for complications, which must be weighed against the prognosis for relief from presenting symptoms.^6,18The objective of this systematic review and meta-analysis was to evaluate the efficacy of arthroscopic meniscal débridement in comparison with nonoperative or sham treatments in patients with degenerative meniscal tears and knee pain with regard to function and pain relief in the short term (< 6 mo) and long term (< 2 yr).     

Intra-articular patient-controlled analgesia improves early rehabilitation after knee surgery

The influence of patient-controlled intra-articular analgesia with ropivacaine, morphine and ketorolac (RMK) on postoperative pain relief and early rehabilitation after anterior cruciate ligament reconstruction was studied. Twenty six patients, randomized into two groups, were enrolled in a placebo-controlled, double-blind study. At the end of surgery a catheter was placed intra-articularly and connected to a patient-controlled pump, programmed to deliver 10 mL bolus and 60 min lockout interval. RMK group received 0.25% ropivacaine, morphine 0.2 mg/mL and ketorolac 1 mg/mL; P group saline. Pain was measured with 10 cm visual analog scale. At pain scores > 3 cm, all patients were instructed to self-administer morphine intravenously using a patient-controlled pump. Daily rescue morphine consumption was noted and 48 h rehabilitation programme was evaluated. Daily morphine consumption was significantly lower in the RMK group (p < 0.001). At 24h after surgery, the patients in the RMK group experienced significantly less pain (p < 0.05). The patients in the RMK group achieved higher maximum degree of knee flexion in supine (p < 0.001) and in prone position (p < 0.05) compared to placebo group and better pain free flexion with assistance on day 1 (p < 0.05) and 2 (p > 0.05). The results show that patient-controlled intra-articular analgesia with RMK combination provides effective pain relief following anterior cruciate ligament reconstruction and improves early physical rehabilitation.     

Mechanisms of improved knee flexion after rectus femoris transfer surgery

Rectus femoris transfer is frequently performed to treat stiff-knee gait in subjects with cerebral palsy. In this surgery, the distal tendon is released from the patella and re-attached to one of several sites, such as the sartorius or the iliotibial band. Surgical outcomes vary, and the mechanisms by which the surgery improves knee motion are unclear. The purpose of this study was to clarify the mechanism by which the transferred muscle improves knee flexion by examining three types of transfers. Muscle-actuated dynamic simulations were created of ten children diagnosed with cerebral palsy and stiff-knee gait. These simulations were altered to represent surgical transfers of the rectus femoris to the sartorius and the iliotibial band. Rectus femoris transfers in which the muscle remained attached to the underlying vasti through scar tissue were also simulated by reducing but not eliminating the muscle's knee extension moment. Simulated transfer to the sartorius, which converted the rectus femoris’ knee extension moment to a flexion moment, produced 32±8° improvement in peak knee flexion on average. Simulated transfer to the iliotibial band, which completely eliminated the muscle's knee extension moment, predicted only slightly less improvement in peak knee flexion (28±8°). Scarred transfer simulations, which reduced the muscle's knee extension moment, predicted significantly less (p<0.001) improvement in peak knee flexion (14±5°). Simulations revealed that improved knee flexion following rectus femoris transfer is achieved primarily by reduction of the muscle's knee extension moment. Reduction of scarring of the rectus femoris to underlying muscles has the potential to enhance knee flexion.     

Total knee replacement surgery is followed by transitory endothelial dysfunction

Acute coronary syndrome (ACS) presents today the leading group of post-operative cardiovascular complications, while endothelial dysfunction (ED) is one of the key elements in its development. The chronic ED represents thus the basis for the gradual development of atherosclerotic changes, while its sudden aggravation leads to ACS. The persistent ED occurs due to the effects of chronic cardiovascular risk factors, while according to the available studies it can also develop or aggravate under the impact of different acute events. We have directed this study to the investigation of the dynamic of endothelial function before and after a major orthopaedic surgical intervention. This randomised prospective study included 19 patients that underwent the intervention of total knee replacement and 20 healthy examinees of the adequate age and gender High-resolution ultrasound test based on the flow mediated dilatation of the brachial artery is what at we carried out at the beginning of the research, respectively 12, 24, 48 and 72 hours, as well as 7 days after the surgical intervention. The starting values of the FMD test were within the normal range in both groups, although the ability of dilatation upon stimulus was significantly lower in the investigated group. The FMD percentage change in the total sample was negatively connected with the body weight, not having shown additional connections with other cardiovascular risk factors. During the early post-operative period, a significant transitory lowering of the FMD percentage change was recorded, having reached the lowest value 24 hours after the surgery. During the seven-day prospective surveillance, no significant cardiovascular complications were recorded. Further research is necessary in order to confirm these results as well as the testing of the possible connection of the described post-operative transitory endothelial dysfunction with the development of cardiovascular complications and the adverse event.     

High-resolution optical coherence tomographic imaging of osteoarthritic cartilage during open knee surgery

This study demonstrates the first real-time imaging in vivo of human cartilage in normal and osteoarthritic knee joints at a resolution of micrometers, using optical coherence tomography (OCT). This recently developed high-resolution imaging technology is analogous to B-mode ultrasound except that it uses infrared light rather than sound. Real-time imaging with 11-μm resolution at four frames per second was performed on six patients using a portable OCT system with a handheld imaging probe during open knee surgery. Tissue registration was achieved by marking sites before imaging, and then histologic processing was performed. Structural changes including cartilage thinning, fissures, and fibrillations were observed at a resolution substantially higher than is achieved with any current clinical imaging technology. The structural features detected with OCT were evident in the corresponding histology. In addition to changes in architectural morphology, changes in the birefringent or the polarization properties of the articular cartilage were observed with OCT, suggesting collagen disorganization, an early indicator of osteoarthritis. Furthermore, this study supports the hypothesis that polarization-sensitive OCT may allow osteoarthritis to be diagnosed before cartilage thinning. This study illustrates that OCT, which can eventually be developed for use in offices or through an arthroscope, has considerable potential for assessing early osteoarthritic cartilage and monitoring therapeutic effects for cartilage repair with resolution in real time on a scale of micrometers.     

A preliminary evaluation of limb salvage surgery for osteosarcoma around knee joint

Objective

To evaluate the effectiveness and drawbacks of diversified procedures of limb salvage surgery (LSS), providing a reference of rational surgical criterion of LSS.

Methods

Fifty eight patients with stage IIB extremity osteosarcoma around knee joint area between 1992 and 2002 were studied retrospectively. Among them, 43 patients were treated by LSS followed by reconstruction. Reconstruction approaches included re-implantation of irradiation-devitalized tumor bone (n = 12), autoclaving-devitalized tumor bone (n = 8), prosthetic replacement (n = 11), allograft transplantation (n = 8) and vascularized fibula autograft implantation (n = 4). Amputations were performed in 15 patients. Patients were followed up for 6–16 years.

Results

There were no significant difference between LSS and amputation groups regarding disease free survival and local recurrence rates. The actuarial 5-year continuous disease free survival and local recurrence rate were 30.0% and 25.0% in patients of devitalized LSS group, whereas those were 56.5% and 8.7% in patients of non-devitalized reconstruction group. The complication rate was significantly higher in LSS group compared to amputation group (P = 0.003).

Conclusion

LSS with non-devitalized procedures is the optimal treatment for osteosarcoma around knee joint area. Prosthesis implantation is the preferred option for bone reconstruction following LSS. Prevention and treatment of post-operative complications should be paid more attention to get good long-term outcomes of surgery.