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1.
BMJ Open ; 6(12): e014381, 2016 12 21.
Article in English | MEDLINE | ID: mdl-28003302

ABSTRACT

INTRODUCTION: Recent studies show similar outcome between surgery and conservative treatment in patients with non-obstructive meniscal tears. However, surgery is still often preferred over conservative treatment. When conservative treatment is non-inferior to surgery, shifting the current standard treatment choice to conservative treatment alone could save over €30 millions of direct medical costs on an annual basis. Economic evaluation studies comparing surgery to conservative treatment are lacking. METHODS AND ANALYSIS: A multicentre randomised controlled trial (RCT) with an economic evaluation alongside was performed to assess the (cost)-effectiveness of surgery and conservative treatment for meniscal tears. We will include 402 participants between 45 and 70 years with an MRI-confirmed symptomatic, non-obstructive meniscal tears to prove non-inferiority of conservative treatment. Block randomisation will be web-based. The primary outcome measure is a physical function, measured by the International Knee Documentation Committee 'Subjective Knee Form'. Furthermore, we will perform a cost-effectiveness and cost-utility analysis from societal perspective and a budget impact analysis from a societal, government and insurer perspective. Secondary outcomes include general health, quality of life, activity level, knee pain, physical examination, progression of osteoarthritis and the occurrence of adverse events. ETHICS AND DISSEMINATION: This RCT will be performed in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee (number NL44188.100.13). The results of this study will be reported in peer-reviewed journals and at international conferences. We further aim to disseminate our results to guideline committees. TRIAL REGISTRATION NUMBER: NCT01850719.


Subject(s)
Conservative Treatment , Cost-Benefit Analysis , Fractures, Cartilage/therapy , Health Care Costs , Knee Injuries/therapy , Meniscectomy , Tibial Meniscus Injuries/therapy , Aged , Clinical Protocols , Cost Savings , Female , Fractures, Cartilage/economics , Fractures, Cartilage/rehabilitation , Fractures, Cartilage/surgery , Humans , Knee Injuries/economics , Knee Injuries/rehabilitation , Knee Injuries/surgery , Male , Menisci, Tibial/pathology , Menisci, Tibial/surgery , Middle Aged , Recovery of Function , Research Design , Tibial Meniscus Injuries/economics , Tibial Meniscus Injuries/rehabilitation , Tibial Meniscus Injuries/surgery
2.
Int Orthop ; 36(11): 2243-8, 2012 Nov.
Article in English | MEDLINE | ID: mdl-22955675

ABSTRACT

PURPOSE: The purpose of this study was to evaluate the clinical outcomes of osteochondral autograft transplantation (OAT) for juvenile osteochondritis dissecans (JOCD) lesions of the knee, especially time to return to sports. METHODS: Twelve knee JOCD lesions with OCD grade 3 and 4 categorised by magnetic resonance imaging (MRI) were treated with OAT. Nine male and two female skeletally immature patients averaging 13.7 years old were included. The OCD lesions were assessed arthroscopically and then fixed in situ using multiple osteochondral plugs harvested under fluoroscopy from the distal femoral condyle without damaging the physis. International Cartilage Repair Society (ICRS) score and Lysholm score were assessed pre- and postoperatively. RESULTS: After a mean follow-up of 26.2 ± 15.1 months, the International Knee Documentation Committee (IKDC) subjective score significantly improved (p < 0.01). According to the IKDC score, objective assessment showed that ten of 12 (83 %) had excellent results (score: A) after OAT and significantly improved (p < 0.01). Based on ICRS criteria, results were satisfactory in all patients. No patients experienced complications at the graft harvest site. All patients returned to their previous level of athletic activity at an average of 5.7 months after the surgery. CONCLUSIONS: OAT for JOCD of the knee provided satisfactory results in all patients at a mean follow-up of 26.2 months.


Subject(s)
Bone Transplantation , Cartilage, Articular/surgery , Cartilage/transplantation , Knee Joint/surgery , Osteochondritis Dissecans/surgery , Activities of Daily Living , Adolescent , Arthroscopy , Cartilage, Articular/injuries , Cartilage, Articular/pathology , Child , Female , Fractures, Cartilage/rehabilitation , Fractures, Cartilage/surgery , Health Status , Humans , Injury Severity Score , Knee Joint/pathology , Knee Joint/physiopathology , Magnetic Resonance Imaging , Male , Osteochondritis Dissecans/pathology , Osteochondritis Dissecans/physiopathology , Pain , Range of Motion, Articular , Recovery of Function , Time-to-Treatment , Transplantation, Autologous , Treatment Outcome
3.
Clin Orthop Relat Res ; 470(8): 2261-7, 2012 Aug.
Article in English | MEDLINE | ID: mdl-22422593

ABSTRACT

BACKGROUND: Many surgical techniques, including microfracture, periosteal and perichondral grafts, chondrocyte transplantation, and osteochondral grafts, have been studied in an attempt to restore damaged articular cartilage. However, there is no consensus regarding the best method to repair isolated articular cartilage defects of the knee. QUESTIONS/PURPOSES: We compared postoperative functional outcomes, followup MRI appearance, and arthroscopic examination after microfracture (MF), osteochondral autograft transplantation (OAT), or autologous chondrocyte implantation (ACI). METHODS: We prospectively investigated 30 knees with MF, 22 with OAT, and 18 with ACI. Minimum followup was 3 years (mean, 5 years; range, 3-10 years). We included only patients with isolated cartilage defects and without other knee injuries. The three procedures were compared in terms of function using the Lysholm knee evaluation scale, Tegner activity scale, and Hospital for Special Surgery (HSS) score; modified Outerbridge cartilage grades using MRI; and International Cartilage Repair Society (ICRS) repair grade using arthroscopy. RESULTS: All three procedures showed improvement in functional scores. There were no differences in functional scores and postoperative MRI grades among the groups. Arthroscopy at 1 year showed excellent or good results in 80% after MF, 82% after OAT, and 80% after ACI. Our study did not show a clear benefit of either ACI or OAT over MF. CONCLUSIONS: Owing to a lack of superiority of any one treatment, we believe MF is a reasonable option as a first-line therapy given its ease and affordability relative to ACI or OAT. LEVEL OF EVIDENCE: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


Subject(s)
Cartilage, Articular/surgery , Fractures, Cartilage/surgery , Knee Joint/surgery , Orthopedic Procedures/methods , Outcome Assessment, Health Care , Adolescent , Adult , Arthroplasty, Subchondral , Arthroscopy , Cartilage, Articular/injuries , Cartilage, Articular/pathology , Cell Transplantation , Chondrocytes/transplantation , Female , Fractures, Cartilage/rehabilitation , Humans , Knee Injuries , Magnetic Resonance Imaging/methods , Male , Orthopedic Procedures/adverse effects , Postoperative Complications , Prospective Studies , Transplantation, Autologous , Transplantation, Homologous , Treatment Outcome , Young Adult
5.
Arthroscopy ; 26(6): 750-6, 2010 Jun.
Article in English | MEDLINE | ID: mdl-20511032

ABSTRACT

PURPOSE: The purpose of this study was to investigate the indications for and outcomes of arthroscopic labral reconstruction in the hip by use of iliotibial band (ITB) autograft. METHODS: Between August 2005 and May 2008, the senior author (M.J.P.) performed 95 arthroscopic labral reconstructions using an ITB autograft in patients with advanced labral degeneration or deficiency. There were 47 patients who had undergone surgery at a minimum of 1 year previously and met the inclusion criteria. The modified Harris Hip Score (MHHS) and patient satisfaction were used to measure outcomes postoperatively. The labral autograft was harvested from the ITB through a separate incision. The graft was sutured to the intact labral remnant in the region of labral deficiency, re-establishing the suction seal of the hip joint. RESULTS: There were 32 men and 15 women. The mean age at the time of surgery was 37 years (range, 18 to 55 years). The mean time from the onset of symptoms to labral reconstruction was 36 months (range, 1 month to 12 years). Subsequent total hip arthroplasty was performed in 4 patients (9%). Follow-up was obtained in 37 of the remaining 43 patients. The mean time to follow-up was 18 months (range, 12 to 32 months). The mean MHHS improved from 62 (range, 35 to 92) preoperatively to 85 (range, 53 to 100) postoperatively (P = .001). Median patient satisfaction was 8 out of 10 (range, 1 to 10). Patients who were treated within 1 year of injury had higher MHHSs than patients who waited longer than 1 year (93 v 81, P = .03). The independent predictor of patient satisfaction with outcome after labral reconstruction was age. CONCLUSIONS: This study showed that patients who have labral deficiency or advanced labral degeneration had good outcomes and high patient satisfaction after arthroscopic intervention with acetabular labral reconstruction. Lower satisfaction was associated with joint space narrowing and increased age. Patients who waited longer than 1 year from the time of injury to surgery had lower function at follow-up than those treated in the first year. LEVEL OF EVIDENCE: Level IV, therapeutic case series.


Subject(s)
Arthroscopy , Cartilage, Articular/injuries , Fascia/transplantation , Fractures, Cartilage/surgery , Hip Joint/surgery , Plastic Surgery Procedures , Acetabulum/surgery , Adolescent , Adult , Female , Follow-Up Studies , Fractures, Cartilage/rehabilitation , Humans , Male , Middle Aged , Patient Satisfaction , Patient Selection , Prospective Studies , Severity of Illness Index , Surveys and Questionnaires , Transplantation, Autologous , Treatment Outcome , Young Adult
6.
Sports Med Arthrosc Rev ; 18(2): 76-82, 2010 Jun.
Article in English | MEDLINE | ID: mdl-20473125

ABSTRACT

The incidence of labral tears has been increasing as techniques to diagnose labral tears have improved. The most common cause of labrum tears is abnormal joint morphology. To treat labral tears, you must also correct any abnormal joint morphology, such as femoroacetabular impingement, at the same time. We describe techniques for labral repair with suture anchors for the torn labrum. When the labrum cannot be repaired owing to lack of adequate or quality tissue, we describe a technique for labral reconstruction using an iliotibial band autograft. Early outcomes for these procedures show patients regain function and are very satisfied with the outcome after surgery.


Subject(s)
Acetabulum/injuries , Acetabulum/surgery , Fractures, Cartilage/surgery , Hip Joint/surgery , Orthopedic Procedures/methods , Plastic Surgery Procedures/methods , Acetabulum/pathology , Fractures, Cartilage/pathology , Fractures, Cartilage/rehabilitation , Hip Joint/anatomy & histology , Hip Joint/pathology , Humans , Orthopedic Procedures/rehabilitation , Physical Therapy Modalities , Plastic Surgery Procedures/rehabilitation , Recovery of Function , Transplantation, Autologous/methods , Treatment Outcome
7.
Clin Sports Med ; 25(2): 337-57, x, 2006 Apr.
Article in English | MEDLINE | ID: mdl-16638496

ABSTRACT

The management of hip injuries has evolved significantly in recent years with the advancement of arthroscopic techniques. These recent surgical advances require establishment of rehabilitation protocols that follow several basic principles including (1) consideration of soft-tissue healing constraints, (2) control of swelling and pain to limit muscular inhibition and atrophy, (3) early range of motion, (4) limitations of weight bearing, (5) early initiation of muscle activity and neuromuscular control, (6) progressive lower extremity strengthening and proprioceptive retraining, (7) cardiovascular training, and (8) sport-specific training. The following protocols should not be considered a cookbook approach to rehabilitation, rather guidelines that are used to achieve consistent outcomes. These guidelines will continue to evolve as we learn more about the hip joint and surrounding musculature.


Subject(s)
Arthroscopy , Athletic Injuries/rehabilitation , Athletic Injuries/surgery , Hip Injuries/rehabilitation , Hip Injuries/surgery , Sports Medicine/methods , Braces , Cartilage, Articular/injuries , Exercise Therapy/methods , Fractures, Cartilage/rehabilitation , Fractures, Cartilage/surgery , Gait , Humans , Physical Therapy Modalities , Range of Motion, Articular , Rupture/rehabilitation , Rupture/surgery
8.
Conf Proc IEEE Eng Med Biol Soc ; 2006: 1529-32, 2006.
Article in English | MEDLINE | ID: mdl-17945652

ABSTRACT

This paper presents an orthopedic stabiliser to be used for the treatment of periarticular fractures of the knee joint. The design of the device is documented by experimental research of the knee joint kinematics. Experimental and simulation research suggest the use of a four-bar linkage mechanism. This research has also made it possible to define the range of adjustment to adapt the stabiliser kinematics to the individual properties of the patients. A sensitivity analysis points to the fact that the stabiliser must be positioned very precisely during installation. The stage of prototype construction was preceded by the design of a virtual model in CAD system. The stabiliser makes it possible to move the lower leg relative to the thigh throughout the treatment. Stabiliser tests that have been made on artificial models of knee joint have proved correctness of its working. This paper also presents results of first clinical stabiliser trials.


Subject(s)
Biomechanical Phenomena/instrumentation , Braces , Fractures, Cartilage/rehabilitation , Joint Instability/rehabilitation , Knee Injuries/rehabilitation , Models, Biological , Biomechanical Phenomena/methods , Biomedical Research/instrumentation , Biomedical Research/methods , Computer Simulation , Equipment Failure Analysis , Fractures, Cartilage/diagnosis , Fractures, Cartilage/physiopathology , Humans , Joint Instability/diagnosis , Joint Instability/physiopathology , Knee Injuries/diagnosis , Knee Injuries/physiopathology , Pilot Projects , Prosthesis Design , Treatment Outcome
9.
Arthroscopy ; 21(9): 1066-75, 2005 Sep.
Article in English | MEDLINE | ID: mdl-16171631

ABSTRACT

PURPOSE: The purpose of this study was to compare the outcomes of mosaic-type osteochondral autologous transplantation (OAT) and microfracture (MF) procedures for the treatment of the articular cartilage defects of the knee joint in young active athletes. TYPE OF STUDY: Prospective randomized clinical study. METHODS: Between 1998 and 2002, a total of 60 athletes with a mean age of 24.3 years (range, 15 to 40 years) and with a symptomatic lesion of the articular cartilage in the knee were randomized to undergo either an OAT or an MF procedure. Only those athletes playing in competitive sports at regional or national levels were included in the study. Fifty-seven athletes (95%) were available for a follow-up. There were 28 athletes in the OAT group and 29 athletes in the MF group. The mean duration of symptoms was 21.32 +/- 5.57 months and the mean follow-up was 37.1 months (range, 36 to 38 months), and none of the athletes had prior surgical interventions to the affected knee. Patients were evaluated using modified Hospital for Special Surgery (HSS) and International Cartilage Repair Society (ICRS) scores, radiograph, magnetic resonance imaging (MRI), and clinical assessment. An independent observer performed a follow-up examination after 6, 12, 24, and 36 months. At 12.4 months postoperatively, arthroscopy with biopsy for histologic evaluation was carried out. A radiologist and a pathologist, both of whom were blinded to each patient's treatment, did the radiologic and histologic evaluations. RESULTS: After 37.1 months, both groups had significant clinical improvement (P < .05). According to the modified HSS and ICRS scores, functional and objective assessment showed that 96% had excellent or good results after OAT compared with 52% for the MF procedure (P < .001). At 12, 24, and 36 months after surgery, the HSS and ICRS showed statistically significantly better results in the OAT group (P = .03; P = .006; P = .006). Younger athletes did better in both groups. No serious complications were reported. There was 1 failure in the OAT group and 9 in the MF group. The ICRS Cartilage Repair Assessment for macroscopic evaluation during arthroscopy at 12.4 months showed excellent or good repairs in 84% after OAT and in 57% after MF. Biopsy specimens were obtained from 58% of the patients and histologic evaluation of repair showed better scores (according to ICRS) for the OAT group (P < .05). MRI evaluation showed excellent or good repairs in 94% after OAT compared with 49% after MF. Twenty-six (93%) OAT patients and 15 (52%) MF patients returned to sports activities at the preinjury level at an average of 6.5 months (range, 4 to 8 months). Others showed a decline in sports activity level. CONCLUSIONS: At an average of 37.1 months (range, 36 to 38 months) follow-up, our prospective, randomized, clinical study in young active athletes under the age of 40 has shown significant superiority of OAT over MF for the repair of articular cartilage defects in the knee. We found that only 52% of MF athletes could return to sports at the preinjury level. Limitations of our study included a small number of athletes and a relatively short (3-year) follow-up. A long-term follow-up is needed to assess the durability of articular cartilage repair using these methods in young active athletes. LEVEL OF EVIDENCE: Level I, Therapeutic study, randomized controlled trial, significant difference (a).


Subject(s)
Arthroscopy , Athletic Injuries/surgery , Cartilage, Articular/transplantation , Femur/transplantation , Fractures, Cartilage/surgery , Knee Injuries/surgery , Knee Joint/surgery , Osteochondritis Dissecans/surgery , Sports , Adolescent , Adult , Athletic Injuries/rehabilitation , Bone Marrow Cells/cytology , Cartilage, Articular/injuries , Cartilage, Articular/surgery , Cell Differentiation , Female , Femur/surgery , Follow-Up Studies , Fractures, Cartilage/rehabilitation , Humans , Knee Injuries/rehabilitation , Knee Joint/diagnostic imaging , Male , Osteochondritis Dissecans/rehabilitation , Prospective Studies , Radiography , Second-Look Surgery , Transplantation, Autologous , Treatment Outcome
10.
Med Sci Sports Exerc ; 27(3): 328-33, 1995 Mar.
Article in English | MEDLINE | ID: mdl-7752858

ABSTRACT

Although the overall skin injury incidence continues to decline, knee injuries requiring surgery remain extremely common. Emphasis is placed on the history of the skier's fall in making an accurate diagnosis. This injury pattern is then assessed with the skier's age and activity level in determining the most appropriate surgical procedure. The actual surgical intervention is just a portion of the rehabilitation process in returning a skier back to sport as quickly as possible. The most common injuries requiring surgical intervention include meniscal tears, osteochondral fractures, and ligament tears. Our indications and techniques are described. Early focus on postoperative range of motion is emphasized. Strengthening begins only when full, pain-free range of motion is obtained. Utilizing these principles, our goals have been to complete the rehabilitation process coexistent with healing of the injury.


Subject(s)
Knee Injuries/surgery , Skiing/injuries , Age Factors , Anterior Cruciate Ligament/surgery , Anterior Cruciate Ligament Injuries , Fractures, Cartilage/rehabilitation , Fractures, Cartilage/surgery , Humans , Knee Injuries/diagnosis , Knee Injuries/rehabilitation , Ligaments, Articular/injuries , Ligaments, Articular/surgery , Menisci, Tibial/surgery , Motor Activity/physiology , Tibial Meniscus Injuries
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