Higher healing rate after meniscal repair with concomitant ACL reconstruction for tears located in vascular zone 1 compared to zone 2: a systematic review and meta-analysis.

PURPOSE: The purpose of this study was to determine and compare the percentage of completely healed meniscal tears after arthroscopic repair combined with anterior cruciate ligament reconstruction (ACLR) for the different vascular zones of the meniscus. METHODS: PubMed, Embase, Web of Science, Cochrane library and Emcare were searched on 19 May 2020 for articles reporting healing rates after arthroscopic meniscal repair with concomitant ACLR for the different meniscal vascular zones as assessed by second-look arthroscopy. Data on meniscal tears were extracted as located in zones 1, 2 or 3, according to the Cooper classification. Studies were graded in quality using a modified Newcastle-Ottawa Scale. Pooled analyses were performed utilizing a random-effects model. Meta-analyses were performed using R version 3.6.2 and SPSS statistical software version 25.0. The study was registered with PROSPERO (ID:CRD42020176175). RESULTS: Ten observational cohort studies met the inclusion criteria, accounting for 758 meniscal tear repairs in total. The pooled overall proportion of healing was 78% (95% CI 72-84%). The mean weighted proportion of healing was 83% (95% CI 76-90%) for studies (n = 10) reporting zone 1 tears and 69% (95% CI 59-79%) for studies (n = 9) reporting zone 2 tears. No study reported healing rates for zone 3 tears. The pooled overall odds ratio was 2.5 (95% CI 1.00-6.02), indicating zone 1 tears as 2.5 times more likely to heal than zone 2 tears. CONCLUSION: This study demonstrates that meniscal tears localized in vascular zone 1 were more likely to heal than those in zone 2. LEVEL OF EVIDENCE: IV.

Knee shape might predict clinical outcome after an anterior cruciate ligament rupture.

We have investigated whether shape of the knee can predict the clinical outcome of patients after an anterior cruciate ligament rupture. We used statistical shape modelling to measure the shape of the knee joint of 182 prospectively followed patients on lateral and Rosenberg view radiographs of the knee after a rupture of the anterior cruciate ligament. Subsequently, we associated knee shape with the International Knee Documentation Committee subjective score at two years follow-up. The mean age of patients was 31 years (21 to 51), the majority were male (n = 121) and treated operatively (n = 135). We found two modes (shape variations) that were significantly associated with the subjective score at two years: one for the operatively treated group (p = 0.002) and one for the non-operatively treated group (p = 0.003). Operatively treated patients who had higher subjective scores had a smaller intercondylar notch and a smaller width of the intercondylar eminence. Non-operatively treated patients who scored higher on the subjective score had a more pyramidal intercondylar notch as opposed to one that was more dome-shaped. We conclude that the shape of the femoral notch and the intercondylar eminence is predictive of clinical outcome two years after a rupture of the anterior cruciate ligament.

Bone mineral density changes in the knee following anterior cruciate ligament rupture.

OBJECTIVE: The pathophysiology of anterior cruciate ligament (ACL) rupture leading to knee osteoarthritis (OA) remains largely unknown. It seems that bone loss occurs after ACL rupture. The purpose of our study was to determine bone mineral density (BMD) changes in the knee after ACL rupture during 2-year follow-up period and to compare BMD changes between the injured and healthy contralateral knee. DESIGN: Patients were included in an observational prospective follow-up study within 6 months after ACL trauma and evaluated for 2 years. Patients were treated operatively or non-operatively. At baseline and at the one- and 2-year follow-ups, BMD was measured in six regions of the tibia and femur for both knees (medial, central, lateral) using a Dual-energy X-ray Absorptiometry (DXA) scanner. RESULTS: One hundred forty-one patients were included, with the following characteristics: 66% were male, median age at baseline was 25.3 (inter-quartile range 11.3) years, and 63% were treated operatively. After 1 year, BMD was significantly lower in all regions of the injured knee of the operatively treated patients compared to baseline. After 2 years, BMD was significantly increased, but remained lower than the baseline levels. In all regions for all measurements, the mean BMD was significantly lower in the injured knee than in the healthy contralateral knee. CONCLUSIONS: During a 2-year follow-up period after ACL rupture, the BMD level in the injured knee was found to be lower than in the healthy contralateral knee. In operatively treated patients, the BMD decreased in the first year and increased in the second follow-up year.

Pathologic deltoid activation in rotator cuff tear patients: normalization after cuff repair?

Rotator cuff (RC) tears have a high prevalence, and RC repair surgery is frequently performed. Evaluation of deltoid activation has been reported as an easy to measure proxy for RC functionality. Our goal was to test the success of RC repair in restoring muscle function, by assessing deltoid activation with varying arm abduction moment loading tasks in controls and in RC tear patients before and 1 year after RC repair. Averaged rectified electromyography recordings (rEMG) of the deltoid during 2-s isometric arm abduction tasks were assessed in 22 controls and 33 patients before and after RC repair. Changes in deltoid activation as a response to increased arm abduction moment loading (large vs. small moment), without changing task force magnitude, were expressed as: R = (rEMGLarge - rEMGSmall)/(rEMGLarge + rEMGSmall), where R > 0 indicates an increase in muscle activation with larger moment loading. In controls, a significant increase in deltoid activation was observed with large abduction moment loading: R = 0.11 (95 % CI 0.06-0.16). In patients, R was larger: 0.20 (95 % CI 0.13-0.27) preoperatively and 0.16 (95 % CI 0.09-0.22) postoperatively. Increased compensatory deltoid activation was found in pre-operative RC tear patients. The post-operative decrease in compensatory deltoid activation, although not significant, could indicate (partially) restored RC function in at least some patients.

Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study.

In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up. At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder.

Autologous interleukin-1 receptor antagonist improves function and symptoms in osteoarthritis when compared to placebo in a prospective randomized controlled trial.

INTRODUCTION: Incubation of blood with CrSO(4)-coated glass beads stimulates the synthesis of anti-inflammatory cytokines, such as interleukin-1 receptor antagonist (IL-1ra), IL-4, IL-10, and IL-13. As IL-1beta is thought to play a key role in the development of osteoarthritis (OA), this product, also known as Orthokin, might be a viable treatment for symptomatic knee OA. The aim of the current study was to evaluate the efficacy of Orthokin for treatment of symptomatic knee OA in a randomized, multicentre, double-blind, placebo-controlled trial. PATIENTS AND METHODS: One hundred and sixty-seven patients received six intra-articular injections either with Orthokin or physiological saline. The primary efficacy objective consisted of 30% superiority on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 3, 6, 9, and 12 months post-treatment. Additionally, the patients completed the visual analogue scale for pain, the Knee injury and Osteoarthritis Outcome Score (KOOS) and Knee Society Clinical Rating System. RESULTS: Orthokin and placebo treatment resulted in similar improvements on the WOMAC (16.8% vs 16.5%, respectively; n.s.). Orthokin resulted in significantly more improvement for KOOS symptom (P = 0.002) and KOOS sport (P = 0.042) parameters as compared to placebo treatment. For most other outcome parameters, Orthokin-treated patients consistently showed higher improvement compared to placebo-treated patients, although none of these differences were statistically significant. Two serious adverse events were observed in the Orthokin group: one patient with repeated severe inflammatory reactions of the knee joint within hours after the injection and one patient with septic arthritis which was attributed to the injection procedure rather than the product. CONCLUSION: The statistically significant improvement of KOOS symptom and sport parameters together with the consistently higher, though non-statistically significant, improvement of most other parameters demonstrates that Orthokin clearly induces a biological response different from placebo treatment and warrant future investigations into the possible chondroprotective effect of Orthokin. However, in the current study the primary efficacy objective was not met and, therefore, the use of Orthokin currently cannot yet be recommended for the treatment of OA.

[Habitual anterior shoulder instability caused by humeral avulsion of the inferior glenohumeral ligament]. / Habituele anterieure schouderinstabiliteit als gevolg van een humerale avulsie van het inferieure glenohumerale ligament.

Two patients, a 20-year-old male and a 33-year-old female, were referred to our orthopaedic outpatient clinic and presented with habitual anterior (sub)luxation of the shoulder as a result of humeral avulsion of the inferior glenohumeral ligament (HAGL lesion). Both patients underwent an open surgical procedure in which the ruptured ligament was restored and fixed to its anatomical point of insertion. Six months after the operation both patients had regained normal function in the glenohumeral joint without instability. The HAGL lesion is a relatively uncommon cause of anterior shoulder instability and requires surgical intervention. Recognition during physical examination, additional examination and arthroscopy are essential for a good outcome.

[Meniscus transplantation as an option in case of painful arthrosis following meniscectomy]. / Meniscustransplantatie als optie bij pijnlijke artrose na meniscectomie.

The menisci play a role as shock absorbers and distribute the pressure uniformly over the joint cartilage. Other functions are: the nutrition of the joint cartilage, secondary stability and proprioception. In case of a torn meniscus, one should first attempt to suture the meniscus, followed by arthroscopic partial meniscectomy if suturing is impossible. In a large proportion of patients, arthrosis with pain and loss of function of the knee develops several years after the meniscectomy. In order to alleviate the symptoms of such arthrosis, a trial of meniscus transplantation was undertaken. In two long-term studies without a control group, the results of meniscus transplantation were reasonable. The results of medial meniscus transplantation are dependent upon the presence of an intact anterior cruciate ligament. The accepted indication for meniscus transplantation after meniscectomy is: disabling pain following (sub)total meniscectomy in a patient younger than 45-50 years of age with a normal alignment and a stable knee joint.

Survival analysis of human meniscal transplantations.

We describe a prospective survival analysis of 63 consecutive meniscal allografts transplanted into 57 patients. The lateral meniscus was transplanted in 34, the medial meniscus in 17, and both menisci (combined) in the same knee in six. For survival analysis we used persistent pain or mechanical damage as clinical criteria of failure. A total of 13 allografts failed (5 lateral, 7 medial, 1 medial and lateral). A significant negative correlation (p = 0.003) was found between rupture of the anterior cruciate ligament (ACL) and successful meniscal transplantation. A significant difference (p = 0.004) in the clinical results was found between lateral and medial meniscal transplants. The cumulative survival rate of the lateral, medial and combined allografts in the same knee, based on the life-table method and the Kaplan-Meier calculation, was 76%, 50% and 67%, respectively. The survival of medial meniscal allografts may improve when reconstruction of the ACL is carried out at the same time as meniscal transplantation in an ACL-deficient knee.

Meniscal allografts: evaluation with magnetic resonance imaging and correlation with arthroscopy.

PURPOSE: To correlate clinical results to magnetic resonance imaging (MRI) and arthroscopy after cryopreserved nontissue-antigen-matched meniscal transplantations. TYPE OF STUDY: Blinded; the observers were blinded for each others' assessment. MATERIALS AND METHODS: Sixteen consecutive patients were included in the protocol. First, clinical evaluation and MRI were performed. Second, within 24 hours, arthroscopy was performed. RESULTS: The clinical results showed better correlation between clinical results and arthroscopy than between clinical results and MRI. In the present study, MRI was not beneficial in evaluating meniscal transplants. CONCLUSIONS: Using more sophisticated MRI techniques, the correlation between clinical results, arthroscopy, and MRI could probably be improved.

Human leukocyte antigen sensitization after cryopreserved human meniscal transplantations.

The presence of antibodies against human leukocyte antigens (HLA) in recipients of cryopreserved, non-tissue-antigen-matched human meniscal allografts was evaluated. Serological HLA typing was performed for both class I and class II antigens. The results showed that 11 of 18 recipients became sensitized.

Human meniscal transplantation. Preliminary results at 2 to 5-year follow-up.

In a prospective study, we evaluated the clinical results of 23 patients with a cryopreserved non-tissue-antigen-matched meniscal transplant at a follow-up of from two to five years. These early results were satisfactory in 20 patients. Three transplantations failed and the allografts were removed after 12, 20 and 24 months. Post-transplantation arthroscopy showed that most meniscal transplants had healed to the knee capsule. Histological examination showed revascularisation of the transplant and evidence of viable meniscal chondrocytes. The failures were probably caused by malalignment, resulting in impaired revascularisation of the graft.

Human meniscus transplantation.

The short term results of 15 cryopreserved non-tissue-antigen matched meniscus transplantations are described. The clinical outcome is satisfactory. Histological and histochemical studies showed that meniscuschondrocytes can survive cryopreservation and transplantation.

[Arthroscopic suturing of the meniscus]. / Artroscopische meniscushechting.

A retrospective study (n = 12) was made of the results of arthroscopical suturing of menisci. Suturing is indicated in peripheral longitudinal meniscal tears in young, active people. Recurrent locking symptoms were found in one patient and quadriceps atrophy in another. The mean follow-up period was 8.2 (6-12) months. There were no complications. Our findings show that the method is feasible; the results were comparable with those reported in the literature and are encouraging for meniscus-sparing therapy.

[The physician at wit's end; a bezoar]. / De dokter met de handen in het haar; een bezoar.

The case is described of a three-year-old Moroccan girl with iron deficiency anaemia and a bezoar resulting from trichotillomania and trichophagy leading to a slowly developed obstruction ileus. Causes, symptoms and treatment of the various forms of bezoar are discussed.