Bioabsorbable pins for treatment of osteochondral fractures of the knee after acute patella dislocation in children and young adolescents

A retrospective study was performed on the use of bioabsorbable pins in the fixation of osteochondral fractures (OCFs) after traumatic patellar dislocation in children. Eighteen children (13 females, 5 males) aged 11 to 15 years (mean age 13.1 years) with osteochondral fracture (OCF) of the knee joint were treated at the authors' institution. Followup ranged from 22 months to 5 years. Diagnosis was verified by X-ray and magnetic resonance imaging (MRI) of the knee and patella. In seven patients the osteochondral fragment was detached from the patella and in 11 it was detached from the lateral femoral condyle. All patients were subjected to open reduction and fixation of the lesion with bioabsorbable pins. Postoperatively, the knee was immobilized in a cast and all patients were mobilized applying a standardized protocol. Bone consolidation was successful in 17 of the 18 patients. Bioabsorbable pins reliably fix OCF in children and adolescents, demonstrating a high incidence of consolidation of the detached osteochondral fragment in short- and middle-term followup without requiring further operative procedures.

Doxycycline for osteoarthritis of the knee or hip

Osteoarthritis is a chronic joint disease that involves degeneration of articular cartilage. Pre-clinical data suggest that doxycycline might act as a disease-modifying agent for the treatment of osteoarthritis, with the potential to slow cartilage degeneration. This is an update of a Cochrane review first published in 2009.

Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis

Viscosupplementation, the intra-articular injection of hyaluronic acid, is widely used for symptomatic knee osteoarthritis.

Comparison of cartilage histopathology assessment systems on human knee joints at all stages of osteoarthritis development

To compare the MANKIN and OARSI cartilage histopathology assessment systems using human articular cartilage from a large number of donors across the adult age spectrum representing all levels of cartilage degradation.

No difference in anterior tibial translation with and without posterior cruciate ligament in less invasive total knee replacement

The relative advantages of cruciate retaining or cruciate resecting total knee replacement are still controversial. If the posterior cruciate ligament (PCL) is preserved, it should be properly balanced. In a previous study, it was demonstrated that increasing the flexion gap leads to an anterior translation of the tibia relative to the femur. Based on these results, we hypothesized that cutting the PCL increases the flexion gap and lessens anterior tibial translation.

Hemophilia A pseudoaneurysm in a patient with high responding inhibitors complicating total knee arthroplasty: embolization: a cost-reducing alternative to medical therapy

Joint hemorrhages are very common in patients with severe hemophilia. Inhibitors in patients with hemophilia are allo-antibodies that neutralize the activity of the clotting factor. After total knee replacement, rare intra-articular bleeding complications might occur that do not respond to clotting factor replacement. We report a 40-year-old male with severe hemophilia A and high responding inhibitors presenting with recurrent knee joint hemorrhage after bilateral knee prosthetic surgery despite adequate clotting factor treatment. There were two episodes of marked postoperative hemarthrosis requiring extensive use of substitution therapy. Eleven days postoperatively, there was further hemorrhage into the right knee. Digital subtraction angiography diagnosed a complicating pseudoaneurysm of the inferior lateral geniculate artery and embolization was successfully performed. Because clotting factor replacement therapy has proved to be excessively expensive and prolonged, especially in patients with inhibitors, we recommend the use of cost-effective early angiographic embolization.

Is restricted femoral navigation sufficient for accuracy of total knee arthroplasty?

A total knee arthroplasty performed with navigation results in more accurate component positioning with fewer outliers. It is not known whether image-based or image-free-systems are preferable and if navigation for only one component leads to equal accuracy in leg alignment than navigation of both components. We evaluated the results of total knee arthroplasties performed with femoral navigation. We studied 90 knees in 88 patients who had conventional total knee arthroplasties, image-based total knee arthroplasties, or total knee arthroplasties with image-free navigation. We compared patients' perioperative times, component alignment accuracy, and short-term outcomes. The total surgical time was longer in the image-based total knee arthroplasty group (109 +/- 7 minutes) compared with the image-free (101 +/- 17 minutes) and conventional total knee arthroplasty groups (87 +/- 20 minutes). The mechanical axis of the leg was within 3 degrees of neutral alignment, although the conventional total knee arthroplasty group showed more (10.6 degrees ) variance than the navigated groups (5.8 degrees and 6.4 degrees , respectively). We found a positive correlation between femoral component malalignment and the total mechanical axis in the conventional group. Our results suggest image-based navigation is not necessary, and image-free femoral navigation may be sufficient for accurate component alignment.

Efficacy and safety of intraarticular hylan or hyaluronic acids for osteoarthritis of the knee: a randomized controlled trial

OBJECTIVE: To compare the efficacy and safety of intraarticular hylan and 2 hyaluronic acids (HAs) in osteoarthritis (OA) of the knee. METHODS: This was a multicenter, patient-blind, randomized controlled trial in 660 patients with symptomatic knee OA. Patients were randomly assigned to receive 1 cycle of 3 intraarticular injections per knee of 1 of 3 preparations: a high molecular weight cross-linked hylan, a non-cross-linked medium molecular weight HA of avian origin, or a non-cross-linked low molecular weight HA of bacterial origin. The primary outcome measure was the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 6 months. Secondary outcome measures included local adverse events (effusions or flares) in injected knees. During months 7-12, patients were offered a second cycle of viscosupplementation. RESULTS: Pain relief was similar in all 3 groups. The difference in changes between baseline and 6 months between hylan and the combined HAs was 0.1 on the WOMAC pain score (95% confidence interval [95% CI] -0.2, 0.3). No relevant differences were observed in any of the secondary efficacy outcomes, and stratified analyses provided no evidence for differences in effects across different patient groups. There was a trend toward more local adverse events in the hylan group than in the HA groups during the first cycle (difference 2.2% [95% CI -2.4, 6.7]), and this trend became more pronounced during the second cycle (difference 6.4% [95% CI 0.6, 12.2]). CONCLUSION: We found no evidence for a difference in efficacy between hylan and HAs. In view of its higher costs and potential for more local adverse events, we see no rationale for the continued use of hylan in patients with knee OA.

Hylan versus hyaluronic acid for osteoarthritis of the knee: a systematic review and meta-analysis

OBJECTIVE: To compare the effectiveness and safety of intraarticular high-molecular hylan with standard preparations of hyaluronic acids in osteoarthritis of the knee. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials comparing hylan with a hyaluronic acid in patients with knee osteoarthritis. Trials were identified by systematic searches of Central, Medline, EMBase, Cinahl, the Food and Drug Administration, and Science Citation Index supplemented by hand searches of conference proceedings and reference lists (last update November 2006). Literature screening and data extraction were performed in duplicate. Effect sizes were calculated from differences in means of pain-related outcomes between treatment and control groups at the end of the trial, divided by the pooled standard deviation. Trials were combined using random-effects meta-analysis. RESULTS: Thirteen trials with a pooled total of 2,085 patients contributed to the meta-analysis. The pooled effect size was -0.27 (95% confidence interval [95% CI] -0.55, 0.01), favoring hylan, but between-trial heterogeneity was high (I(2) = 88%). Trials with blinded patients, adequate concealment of allocation, and an intent-to-treat analysis had pooled effect sizes near null. The meta-analyses on safety revealed an increased risk associated with hylan for any local adverse events (relative risk [RR] 1.91; 95% CI 1.04, 3.49; I(2) = 28%) and for flares (RR 2.04; 95% CI 1.18, 3.53; I(2) = 0%). CONCLUSION: Given the likely lack of a superior effectiveness of hylan over hyaluronic acids and the increased risk of local adverse events associated with hylan, we discourage the use of intraarticular hylan in patients with knee osteoarthritis in clinical research or practice.

Meta-analysis: chondroitin for osteoarthritis of the knee or hip

BACKGROUND: Previous meta-analyses described moderate to large benefits of chondroitin in patients with osteoarthritis. However, recent large-scale trials did not find evidence of an effect. PURPOSE: To determine the effects of chondroitin on pain in patients with osteoarthritis. DATA SOURCES: The authors searched the Cochrane Central Register of Controlled Trials (1970 to 2006), MEDLINE (1966 to 2006), EMBASE (1980 to 2006), CINAHL (1970 to 2006), and conference proceedings; checked reference lists; and contacted authors. The last update of searches was performed on 30 November 2006. STUDY SELECTION: Studies were included if they were randomized or quasi-randomized, controlled trials that compared chondroitin with placebo or with no treatment in patients with osteoarthritis of the knee or hip. There were no language restrictions. DATA EXTRACTION: The authors extracted data in duplicate. Effect sizes were calculated from the differences in means of pain-related outcomes between treatment and control groups at the end of the trial, divided by the pooled SD. Trials were combined by using random-effects meta-analysis. DATA SYNTHESIS: 20 trials (3846 patients) contributed to the meta-analysis, which revealed a high degree of heterogeneity among the trials (I2 = 92%). Small trials, trials with unclear concealment of allocation, and trials that were not analyzed according to the intention-to-treat principle showed larger effects in favor of chondroitin than did the remaining trials. When the authors restricted the analysis to the 3 trials with large sample sizes and an intention-to-treat analysis, 40% of patients were included. This resulted in an effect size of -0.03 (95% CI, -0.13 to 0.07; I2 = 0%) and corresponded to a difference of 0.6 mm on a 10-cm visual analogue scale. A meta-analysis of 12 trials showed a pooled relative risk of 0.99 (CI, 0.76 to 1.31) for any adverse event. LIMITATIONS: For 9 trials, the authors had to use approximations to calculate effect sizes. Trial quality was generally low, heterogeneity among the trials made initial interpretation of results difficult, and exploring sources of heterogeneity in meta-regression and stratified analyses may be unreliable. CONCLUSIONS: Large-scale, methodologically sound trials indicate that the symptomatic benefit of chondroitin is minimal or nonexistent. Use of chondroitin in routine clinical practice should therefore be discouraged.

Disseminated Tuberculosis Following Total Knee Arthroplasty in an HIV Patient

Skeletal tuberculosis is now uncommon in developed countries. In immunocompromised patients - particularly in the HIV-infected - who present with subacute or chronic joint pain refractory to conventional treatment, osteoarticular tuberculosis should still be included in the differential diagnosis. We report on a lethal case of disseminated tuberculosis in an HIV-infected subject. Dissemination may have resulted from the implantation of an articular prosthesis in a knee joint with unsuspected osteoarticular tuberculosis. The diagnosis was established months later when the patient presented with far-advanced tuberculous meningitis, miliary tuberculosis of the lungs, femoral osteomyelitis and extended cold abscesses along the femoral shaft. Failure to respond to a conventional four-drug regimen is explained by the resistance pattern of his multi-drug resistant strain of Mycobacterium tuberculosis, which was only reported after the patient's death. This case illustrates the diagnostic challenges of osteoarticular tuberculosis and the consequences of a diagnostic delay in an HIV-infected individual.

MRI monitoring of cartilage repair in the knee: a review

Various treatment options for deep cartilage defects are presently available. The efficacy of bone marrow stimulation with microfracture, of mosaicplasty and of various autologous chondrocyte implantation (ACI) techniques has been subject to numerous studies recently. Magnetic resonance imaging (MRI) has gained a major role in the assessment of cartilage repair. The introduction of high-field MRI to clinical routine makes high resolution and three-dimensional imaging readily available. New quantitative MRI techniques that directly visualize the molecular structure of cartilage may further advance our understanding of cartilage repair. The clinical evaluation of cartilage repair tissue is a complex issue, and MR imaging will become increasingly important both in research and in clinical routine. This article reviews the clinical aspects of microfracture, mosaicplasty, and ACI and reports the recent technical advances that have improved MRI of cartilage. Morphological evaluation methods are recommended for each of the respective techniques. Finally, an overview of T2 mapping and delayed gadolinium-enhanced MR imaging of cartilage in cartilage repair is provided.

Advanced morphological and biochemical magnetic resonance imaging of cartilage repair procedures in the knee joint at 3 Tesla

Morphological and biochemical magnetic resonance imaging (MRI) is due to high field MR systems, advanced coil technology, and sophisticated sequence protocols capable of visualizing articular cartilage in vivo with high resolution in clinical applicable scan time. Several conventional two-dimensional (2D) and three-dimensional (3D) approaches show changes in cartilage structure. Furthermore newer isotropic 3D sequences show great promise in improving cartilage imaging and additionally in diagnosing surrounding pathologies within the knee joint. Functional MR approaches are additionally able to provide a specific measure of the composition of cartilage. Cartilage physiology and ultra-structure can be determined, changes in cartilage macromolecules can be detected, and cartilage repair tissue can thus be assessed and potentially differentiated. In cartilage defects and following nonsurgical and surgical cartilage repair, morphological MRI provides the basis for diagnosis and follow-up evaluation, whereas biochemical MRI provides a deeper insight into the composition of cartilage and cartilage repair tissue. A combination of both, together with clinical evaluation, may represent a desirable multimodal approach in the future, also available in routine clinical use.