Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial.

BACKGROUND: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. PURPOSE: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. RESULTS: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. CONCLUSION: Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. REGISTRATION: NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

[A man with a painful hand after punching a wall]. / Een man met een pijnlijke hand na een vuistslag.

A 23-year-old man had a painful right hand after punching a wall. The base of the second metacarpal was swollen and painful. The base of the second metacarpal is difficult to assess radiologically, due to overlying structures. After a trauma, additional slight oblique X-rays may help to make a diagnosis.

Internal fixation for coronal shear fracture of the capitellum with polylactide resorbable fixation.

A 24-year-old woman with pain in the right elbow after a fall demonstrated a coronal shear fracture on radiographic studies. Perioperative a coronal shear fracture was seen and treated successfully with a polylactide Rigid fix resorbable pin. The operative correction resulted in normal function at 6 months follow-up. We state that a capitellum shear fracture can be fixated with a single resorbable pin, leading to successful fusion.

Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow.

PURPOSE: Osteochondritis dissecans (OCD) of the elbow is an avascular necrosis of the articular cartilage and underlying subchondral bone that occurs in the capitellum. The purpose of this review is to evaluate the results of arthroscopic surgery, including debridement, fragment fixation, micro-fracturing, and osteochondral autografting, in athletes with OCD of the elbow. METHODS: We searched PubMed, EMBASE, and the Cochrane library using the following main terms: osteochondritis dissecans, elbow, and surgical intervention. The 9 selected articles were criticized by use of a quality assessment tool derived from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. RESULTS: The included studies had low methodologic quality and showed satisfactory results regarding pain, return to sports, and elbow function. CONCLUSIONS: This review suggests that surgical treatment must be contemplated after a period of unsuccessful conservative therapy for athletes with OCD. Nevertheless, larger studies with enhanced methodologic quality and longer follow-up should be performed to support this conclusion. LEVEL OF EVIDENCE: Level III, systematic review of Level IV studies.

PLDLA mesh and 60/40 biphasic calcium phosphate in iliac crest regeneration in the goat.

Although morbidity of the iliac crest after grafting has been reported to occur frequently, it is the most widely used donor site. A proper regeneration of the defect could decrease morbidity. The purpose of this study was to evaluate the efficacy of two types of reconstruction of standardized critical size defects of the iliac crest after 3, 6, and 12 months. Standardized critical defects in iliac crests were bilaterally reconstructed in 28 goats randomly with (1) no reconstruction (group A); (2) a bioresorbable polylactide mesh (group B); or (3) 60/40 biphasic calcium phosphate (BCP) granules placed within a bioresorbable mesh (group C). At follow up, the iliac crests were harvested for histologic, histomorphometric, and radiologic analyses. The defects treated with "mesh-BCP" (group C) showed a significantly (p = 0.03) larger area with diffuse bone formation, while only a small area of high density trabecular bone ingrowth was observed in the "no reconstruction" (group A) and "mesh group" (group B). However, no difference in the total volume of bone was observed; in group C, the bone was more diffusely spread over the defect. Substitution of the BCP granules by trabecular bone did not start before 6 months. At the 12 months time point, extensive resorption of BCP was found because of phagocytic activity of numerous multinucleated giant cells. We confirm the positive influence of BCP on bone formation but due to a slow rate of resorption of BCP, regeneration takes a relatively long period of time.

Lumbar body fusion with a bioresorbable cage in a goat model is delayed by the use of a carboxymethylcellulose-stabilized collagenous rhOP-1 device.

The purpose of this study was to evaluate the efficacy of recombinant human osteogenic protein-1 (rhOP-1) with a carboxymethylcellulose-stabilized collagenous carrier as a bone graft substitute for instrumented lumbar spinal fusion in an established goat model. Twenty goats received a resorbable poly-L-lactic acid (PLLA) interbody cage packed with either rhOP-1 and its carrier or autologous bone graft. The carrier material was bovine collagen type-1 stabilized with carboxymethylcellulose. The fusion segments were retrieved at 3 or 6 months postimplantation and evaluated by radiographic and histologic analyses. The rhOP-1 graft substitute, used in combination with the resorbable PLLA cage, showed inferior results as compared to autologous bone graft in the goat lumbar fusion model. Whereas four out of five segments from the autograft group were fused after 6 months, none of the four segments receiving the rhOP-1 graft substitute were fused at this time point. Bone ingrowth into the cage was delayed or absent in the experimental group, whereas all autograft specimens showed advanced bone ingrowth (3 months) or fusion (6 months). We suggest that the fusion process was inhibited, because cells were unable to penetrate the rhOP-1 graft material. This led to delayed bone formation and in some cases inadequate tissue formation.

Primary spinal segment stability with a stand-alone cage: in vitro evaluation of a successful goat model.

BACKGROUND: Interbody cages have been developed to restore disk height and to increase stability of the spinal segment, and thereby enhance fusion. However, they often prove inadequate as a stand-alone device. It is unknown how much primary stability is required to facilitate fusion. In various goat studies, we have obtained spinal fusion routinely with a stand-alone cage device. However, data covering the mechanical conditions under which these fusions have been obtained are lacking. In this study, we addressed the issue of primary stability. METHODS: We used an established goat model for spinal fusion in vitro. 48 native lumbar spine segments were mechanically tested in flexion/extension, axial torsion (left/right), anterior/posterior shear, and left/right lateral bending. Then all segments were provided with a titanium cage using the exact surgical procedure of our earlier in vivo studies, and the mechanical tests were repeated. Under shear force and axial torsion, a significant loss of stiffness was seen in the operated segments as compared to nonoperated controls. No increase in stiffness was found in any of the loading directions. INTERPRETATION: Cage implantation in a lumbar spinal segment does not increase immediate postoperative stability as compared to the native segment in this goat model. This is attributable to both the annular damage during cage implantation and the subsequent loss of segment height. Yet previous in vivo studies using this goat model have generally shown fusion. This implies that high primary segment stability is not required for fusion or, alternatively, that the tested range of motion of the spinal segment in vitro does not occur at these magnitudes in vivo.

Does bioresorbable cage material influence segment stability in spinal interbody fusion?

To reduce long term complications associated with nonresorbable interbody fusion cages, bioresorbable cages are being developed. We investigated the influence of bioresorbable cage material on segment stability, intervertebral disc height and fusion in vivo using radiostereometric analysis comparing 70/30 poly(L-lactide-co-D,L-lactide) (PLDLLA) cages with titanium cages. Twenty-eight goats were randomized to receive PLDLLA (n = 21) or a titanium control (n = 7) cage at L3-L4. Range of motion for flexion and extension and change in intervertebral disc height were measured before and after surgery and at followup (3, 6, and 12 months). Fusion was graded with a validated radiographic score. Although the PLDLLA cage could not provide the optimal environment for a successful high fusion rate, the range of motion of the PLDLLA segments gradually decreased in time and was similar to the titanium control group at 12 months. In addition the decrease of intervertebral disc height was similar for both PLDLLA (1.4 +/- 0.8 mm) and titanium (1.3 +/- 1.0 mm) specimens. Both results showed a bioresorbable cage does not lead to less decrease of motion or more loss of intervertebral disc height in time compared to titanium. This study therefore supports further development of a bioresorbable cage concept.

Radiographic, histologic, and chemical evaluation of bioresorbable 70/30 poly-L-lactide-CO-D, L-lactide interbody fusion cages in a goat model.

STUDY DESIGN: A study of lumbar interbody fusion using polylactic acid-based bioresorbable fusion cages in a goat model. OBJECTIVE: To evaluate the effect of polylactic acid polymer composition, and internal stabilization on the rate and quality of interbody fusion. SUMMARY OF BACKGROUND DATA: A spinal cage should provide an appropriate biomechanical environment to facilitate interbody fusion. Previous studies have shown that bioresorbable polylactic acid-based cages can provide adequate stability for spinal fusion. However, at present and to our knowledge, the best bioresorbable materials, optimal cage stiffness, and desired period over which the cage should biodegrade are unknown. METHODS: Interbody fusions were performed at L3-L4 level in 35 skeletally mature Dutch milk goats. Titanium and poly-L-lactide-CO-D,L-lactide (PLDLLA) cages were implanted at random as stand-alone cages. In addition, PLDLLA cages were implanted with anterior fixation. The goats were euthanized at 3, 6, or 12 months. Radiographic, magnetic resonance imaging, histologic, and histomorphometric analyses were performed on retrieved segments. Chemical analysis was used to assess degradation of the retrieved PLDLLA cages. Beforehand, chemical and mechanical degradation of the PLDLLA cages were assessed in vitro. RESULTS: At 3 months, bone graft was almost completely remodeled. Endochondral bone formation was observed in all specimens. At 6 months, 50% of the PLDLLA stand-alone cages and 83% of the PLDLLA anterior fixation cages were fused. At 12 months, 38% of the PLDLLA stand-alone and 83% of the titanium cages realized fusion. A very mild and dispersed foreign body reaction was seen in all PLDLLA specimens. E-beam sterilized PLDLLA cages degraded more rapidly in vivo as compared to both, PLDLLA cages in vitro, and ethylene oxide sterilized poly-L-lactic acid cages in vivo. CONCLUSIONS: Within the 3-6-month period, PLDLLA stand-alone cages provided insufficient mechanical stability, which manifested as cracking and deformation of the cages and lower fusion rates. This result implies that within this time, additional stabilization is required; supplemental internal fixation proved sufficient to obtain successful fusion. In all cases, only a mild host response was seen, indicating good biocompatibility.

Mycoplasma hominis deep wound infection after neuromuscular scoliosis surgery: the use of real-time polymerase chain reaction (PCR).

Mycoplasma hominis is a commensal of the genitourinary tract. It mostly causes infections to associated structures of this system; however, occasionally it is a pathogen in nongenitourinary tract infections. Since, M. hominis strains require special growth conditions and cannot be Gram stained, they may be missed or delay diagnosis. This report describes a deep wound infection caused by M. hominis after neuromuscular scoliosis surgery; M. hominis was recovered by real-time polymerase chain reaction (PCR). An awareness of the role of M. hominis as an extragenital pathogen in musculoskeletal infections, especially in neuromuscular scoliosis, being a high-risk group for postoperative wound infection, it is necessary to identify this pathogen. Real-time PCR for postoperative deep wound infection, in patients with a history of genitourinary infections, decreases the delay in diagnosis and treatment. In these cases rapid real-time PCR on deep cultures should be considered.

Emergency hemipelvectomy as a result of uncontrolled infection after total hip arthroplasty: two case reports.

Described are 2 patients with sepsis caused by an infection of a total hip arthroplasty. In both cases, the infection involved spread to the ipsilateral retroperitonial and proximal femur soft tissues, and substantial parts of the osseous hemipelvis and proximal femur. Furthermore, the infection could not be controlled despite repeated surgical interventions. Progression of the infection of soft tissue and bone resulted in severe bone stock loss, contractures of hip and knee, and severe neurologic deficit of the involved limb. Hemipelvectomy was indicated as a life-saving procedure. Reluctance to perform vigorous debridement, including removal of the components, can lead to a local spread of the infection, resulting in an uncontrollable process leading to a life-threatening situation.

The use of high-resolution magnetic resonance imaging for monitoring interbody fusion and bioabsorbable cages: an ex vivo pilot study.

OBJECT: Interbody fusion is a gradual process of graft resorption and tissue formation, ideally resulting in a bone bridge between two adjacent vertebral bodies. Initially, fibrous tissue and cartilage are formed, which subsequently are replaced by bone through the process of endochondral ossification. When cages and/or their contents are made of resorbable polymers like lactic or glycolic acids, there is a simultaneous process of implant degradation, which is eventually accompanied by reactions in the surrounding tissues. The purpose of this study was to explore the use of highresolution magnetic resonance (MR) imaging for monitoring tissue differentiation, spinal fusion, cage degradation, and eventually tissue reactions as a function of time. METHODS: Lumbar vertebral segments obtained in 14 goats with 3, 6, and 12 months of follow up (three, four, and seven animals, respectively) were available from a study of the feasibility of poly(L,D-lactic acid) cages for spinal fusion. Plain x-ray films, MR images, and histological sections were used to evaluate spinal fusion and cage resorption. The first follow-up tests revealed that MR imaging noninvasively provided three-dimensional information on cage placement, cage degradation and bone formation, and that it has potential to differentiate between the various soft tissues. CONCLUSIONS: Although the magnetic field strength and thus the resolution used were higher than normal in clinical practice, MR imaging appears to be a promising modality for the noninvasive clinical follow up of patients who undergo fusion with resorbable cages. Tissue reactions were not encountered in this study, and thus could not be evaluated.

Arthroscopic treatment of osteochondritis dissecans of the capitellum: Report of 5 female athletes.

The management of osteochondritis dissecans of the capitellum of the adolescent elbow is still controversial. We report on 5 cases of female high-level athletes aged from 10 to 19 years (4 gymnasts, 1 waterpolo player). All these athletes had a symptomatic osteochondritis dissecans of the capitellum, which was treated arthroscopically in all cases. Follow-up time averaged 5 months (1 to 6.5 months). During the arthroscopy, loose osteochondral fragments of the capitellum and radial head were removed, and the defect was debrided. Thorough evaluation of the anterior and posterior joint including the olecranon fossa was performed. One of the 5 patients had a loose body requiring arthroscopic removal. Within 6 months after surgery, all except 1 elbow, the elbow with a loose body, regained maximum range of motion. Two patients returned to a high level of gymnastics and 1 was considering return. The short-term results of this treatment suggest that arthroscopic debridement of the loose osteochondral fragments provides a good result.