The effect of nonsteroidal anti-inflammatory drug use on soft tissue and bone healing in the knee: a systematic review.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to mitigate pain and inflammation associated with musculoskeletal conditions; however, there is conflicting data on the adverse effects of these drugs on tissue and bone healing. The objective of this study was to investigate the effect of NSAIDs on the healing of knee, soft tissue, and bone. Methods: A systematic literature search was conducted across PubMed/MEDLINE, Excerpta Medical Database (Embase)/Ovid, and the Cochrane Central Register of Controlled Trials databases. Clinical, animal, and in vitro studies on the effect of NSAIDs on knee healing were included. Risk of bias assessment was performed using the Cochrane bias assessment tool and Methodological Index for Non-Randomized Studies scoring system for included clinical studies, and the Systematic Review Center for Laboratory Animal Experimentation assessment tool for all included animal studies. General study population characteristics, interventions used, NSAIDs utilized, outcome measures, and study results were analyzed using descriptive statistics. Results: Fifteen articles met the inclusion criteria. Of the 15 studies, there were three clinical, ten animal, and two in vitro studies. In clinical studies, nonselective cyclooxygenase (COX) inhibitors and selective COX-2 inhibitors did not cause a significant increase in failure of anterior cruciate ligament (ACL) reconstructions or meniscal repairs with NSAID administration pre-, peri-, or post-operatively in comparison to placebo or no NSAID administration. Among animal studies assessing COX-2 inhibitor effects on soft tissue, healing was impaired (2/4), delayed but unaffected (1/4), or unaffected (1/4). In animal studies assessing COX-1 inhibitors, ligament healing was either increased (1/4), unaffected (2/4), or impaired (1/4). Meanwhile, administration of non-selective COX inhibitors in animals did not affect soft tissue (3/3) and cartilage (1/1) healing. Two in vitro studies identified a negative outcome on patellar tendon and ACL cell proliferation or viability after non-selective COX inhibition and variable results after selective COX-2 inhibition. Conclusions: Animal studies on postoperative NSAID use after knee surgery suggest that administration of selective and nonselective COX-2 inhibitors may impair healing of soft tissue, bone and tendon-to-bone; however, further clinical studies are needed to better characterize dose and duration dependent risks of NSAIDs.

No difference in clinical outcome after rotator cuff repair performed within or later than 3 months after trauma: a retrospective cohort study.

PURPOSE: Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years. METHODS: In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma. RESULTS: Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups. CONCLUSION: In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic. LEVEL OF EVIDENCE: III.

Allo- and autografts show comparable outcomes in chronic acromioclavicular joint reconstruction: a systematic review.

PURPOSE: The aim of this review was to compare clinical and radiological outcome of acromio-clavicular joint reconstruction with allografts versus autografts. METHODS: The PubMed, MEDLINE, The Cochrane Library and WEB OF SCIENCE databases were searched in accordance with the PRISMA guidelines until February 2020 using the terms: 'coracoclavicular' OR 'coraco-clavicular' OR 'acromioclavicular' OR 'acromio-clavicular joint', AND 'reconstruction'. All studies reporting on clinical and radiological outcome as well as complications after ACJ reconstruction using allo- and/or autografts were included. RESULTS: A total of 29 articles, including 2 prospective and 27 retrospective studies, involving 622 patients, reconstructed with either allo- (n = 360) or auto-grafts (n = 262), for acromio-clavicular joint instability were identified and included in this review. The majority of studies had low sample sizes (66.7% below n = 20), were retrospective (93.3%), with short-term follow-ups (average 26.2 ± 12.6 months; range 6-186). The study with the largest sample size (n = 128) did not report clinical outcome. A comparison between allo- and auto-graft showed no significant differences regarding age, gender, and follow-up times. Clinical outcome was comparable in both groups, loss of reduction (LOR) and complication rates were higher in the allograft group. Overall a reduction of LOR was shown if additional horizontal stabilization was performed. Also a higher LOR and revision rate was documented in allografts without suture or suture-tape augmentation. The use of more clavicular drill-holes correlated with a higher frequency of fracture. CONCLUSIONS: A systematic review of the available peer-reviewed literature addressing allograft and autograft reconstruction of unstable coracoclavicular ligaments shows that the published studies are generally of low quality with low levels of evidence. The published literature shows no significant difference in clinical outcomes between the use of autografts or allografts in ACJ reconstruction surgery. Surgical techniques utilizing additional horizontal stabilization may contribute to lower rates of LOR. In cases where allograft tissue is used for ACJ reconstruction the use of suture/tape augmentation may reduce LOR rates as well as revision rates. LEVEL OF EVIDENCE: III.

Better functional results of opening wedge HTO for varus knees with medial osteoarthritis than opening wedge LFO for valgus knees with lateral osteoarthritis.

AIMS: To compare time dependent functional improvement for patients with medial, respectively lateral knee osteoarthritis (OA) after treatment with opening wedge osteotomy relieving the pressure on the osteoarthritic part of the knee. METHODS: In all, 49 patients (52 knees) with a mean age of 47 years (31 to 64) underwent high tibial osteotomies (HTO), and 24 patients with a mean age of 48 years (31 to 62) low femoral osteotomies (LFO) with opening wedge technique due to medial, respectively lateral knee OA with malalignment. All osteotomies were stabilized with a Puddu plate and bone grafting performed in the same time period (2000 to 2008). The patients were evaluated by the Knee Injury and Osteoarthritis Outcome Score (KOOS) pre-operatively and at six months, and at one, two, five, and ten years postoperatively. The knee OA was graded according to the Ahlbäck and Kellgren-Lawrence radiological scoring systems. RESULTS: The mean angular corrections were 8.0° (4° to 12°) for the HTO and 9.6° (4° to 20°) for the LFO. Both the pre-operative KOOS and the osteoarthritic gradings were similar for the two patient groups. The five subscores of KOOS increased significantly during the postoperative period (p < 0.001 to 0.029) levelling out after one year in both groups. The KOOS subscore symptoms was significantly higher for patients with HTO than those with LFO at all follow-up times, for sport and recreation in the period one to five years, and for pain and quality of life at two to five years (p < 0.001 to 0.009). Eight HTOs (15%) and five LFOs (21%) were converted to total knee arthroplasty after mean 6.7 years (2.0 to 9.8) and 5.4 years (4.0 to 8.0) respectively. The ten-year osteotomy survival rates were 88% for the HTO and 79% for the LFO (p = 0.745). CONCLUSION: Patients with unicompartmental knee OA improved after a corrective opening wedge osteotomy, but four of the five subscores of KOOS were significantly higher for those with medial than those with lateral OA in most of the ten-year follow-up period.Cite this article: Bone Joint Open 2020;1-7:346-354.

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction.

PURPOSE: Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions. METHODS: A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified. RESULTS: The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue. CONCLUSION: The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue. LEVEL OF EVIDENCE: IV.

Prognostic Factors for Functional Outcome After Rotator Cuff Repair: A Prospective Cohort Study With 2-Year Follow-up.

BACKGROUND: Although shoulder function is reported to be generally good after rotator cuff repair, limited knowledge exists regarding which prognostic factors predict functional outcomes. PURPOSE: To identify pre- and perioperative predictors of functional outcomes after arthroscopic rotator cuff repair. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A cohort of 733 consecutive patients treated with rotator cuff repair between 2010 and 2014 in a single orthopaedics unit was included. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariable linear regression analyses were used to predict shoulder function at 2-year follow-up, as measured by the Western Ontario Rotator Cuff Index (WORC). RESULTS: In total, 647 (88%) patients were followed for 25 ± 5 months (mean ± SD; range, 17-66 months). In the multivariable regression model, the adjusted R2 was 0.360, indicating that 36% of the variation in the WORC at final follow-up could be explained by this statistical model. The multivariable linear regression analysis revealed that the strongest positive independent predictors of shoulder function at 2 years were preoperative WORC and Constant-Murley score in the contralateral shoulder. The model also indicated that activities of daily living, age, subacromial decompression, and biceps surgery had independent positive associations with better shoulder function at 2 years. In addition, previous surgery in the ipsilateral or contralateral shoulder, smoking, partial rotator cuff repair, preoperative pain, and atrophy in the infraspinatus were all independent factors negatively associated with shoulder function after 2 years. The overall healing rate of complete repairs per magnetic resonance imaging was 80%. CONCLUSION: The most important finding of the present study was that the strongest prognostic factors for better WORC at 2-year follow-up were better preoperative WORC and Constant-Murley score in the contralateral shoulder. Although not all the prognostic factors identified in this study are modifiable, they can still be useful for guiding patients in shared decision making with the surgeon. This cohort study shows that if selection of patients is performed properly, it is possible to obtain a successful outcome.

No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial.

PURPOSE: The aim of this study was to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff (RC) repair in a prospective randomized controlled non-inferiority trial. METHODS: One hundred twenty patients were included after RC surgery for a small- to medium-sized tear of supraspinatus and upper infraspinatus tendons. Group A was immobilized in a simple sling for 3 weeks, and group B had a brace with a small abduction pillow with the arm in neutral position for 6 weeks. All patients started active range of motion when they removed the sling/brace. One hundred eighteen (98%) patients were assessed at 1-year follow-up. They underwent magnetic resonance imaging (MRI) of the shoulder, filled out the Western Ontario Rotator Cuff (WORC) index, and were evaluated with a Constant Murley (CM) score. RESULTS: Statistical non-inferiority was demonstrated for the 2 groups on the basis of the WORC index, the primary endpoint at 1 year. The objective for the non-inferiority test was to determine whether the expected mean WORC index for group A was at most 13% worse than standard treatment (Group B). The WORC index at 1 year was similar in both groups, with mean percent scores of 83% in group A and 87% in group B (mean difference = -4; 95% one-sided CI -9, -4). Age-adjusted CM scores were also similar, with means of 86 in group A and 90 in group B (mean difference = -4; 95% CI -13, 5; P = .37). MRI after 1 year showed 50 (89%) patients in each group with healed RC repair. Four patients in group A had complications: 1 acute postoperative infection, 2 cases of postoperative capsulitis treated with corticosteroid injections, and 1 repeat operation because of a loose anchor and subacromial pain. No patients in group B had complications. CONCLUSION: RC repair resulted in improved postoperative shoulder function, regardless of whether the shoulder was immobilized for 3 or 6 weeks. Three weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace with regard to the WORC index at 12 months' follow-up. MRI indicated similar degrees of healing between the groups. Based on these findings, it is safe to immobilize patients in a simple sling for 3 to 6 weeks after repair of small to medium RC tears. LEVEL OF EVIDENCE: Level I, high-quality randomized controlled trial with statistically significant differences.

Negative effect of zoledronic acid on tendon-to-bone healing.

Background and purpose - Outcome after ligament reconstruction or tendon repair depends on secure tendon-to-bone healing. Increased osteoclastic activity resulting in local bone loss may contribute to delayed healing of the tendon-bone interface. The objective of this study was to evaluate the effect of the bisphosphonate zoledronic acid (ZA) on tendon-to-bone healing. Methods - Wistar rats (n = 92) had their right Achilles tendon cut proximally, pulled through a bone tunnel in the distal tibia and sutured anteriorly. After 1 week animals were randomized to receive a single dose of ZA (0.1 mg/kg IV) or control. Healing was evaluated at 3 and 6 weeks by mechanical testing, dual-energy X-ray absorptiometry and histology including immunohistochemical staining of osteoclasts. Results - ZA treatment resulted in 19% (95% CI 5-33%) lower pullout strength and 43% (95% CI 14-72%) lower stiffness of the tendon-bone interface, compared with control (2-way ANOVA; p = 0.009, p = 0.007). Administration of ZA did not affect bone mineral density (BMD) or bone mineral content (BMC). Histological analyses did not reveal differences in callus formation or osteoclasts between the study groups. Interpretation - ZA reduced pullout strength and stiffness of the tendon-bone interface. The study does not provide support for ZA as adjuvant treatment in tendon-to-bone healing.

Targeted intervention of acute postoperative infection after rotator cuff repair results in good functional outcomes.

PURPOSE: The primary goal of this retrospective review of a prospective database was to document the functional results after acute postoperative deep infection following rotator cuff repair in a single orthopaedic unit over a period of 5 years. Secondary goals were to document the effect of infection on healing of the cuff repair and to describe its incidence, diagnostic challenges, pathogens and management. METHODS: Patients undergoing arthroscopic rotator cuff repair were prospectively registered from 2010 to 2014. Eleven out of 1072 repairs developed an acute postoperative infection. The patients were examined with an MRI scan, Constant-Murley (CM) score and the Western Ontario Rotator Cuff Index (WORC) at final follow-up (median of 22 months). RESULTS: All 11 patients who developed acute postoperative deep infections were males. Median age was 56 years (range 41-68). All patients underwent arthroscopic debridement and biopsies were collected at a median of 26 days (range 14-50) after primary surgery. In ten patients, Propionibacterium acnes was cultured, six of these patients also had positive cultures for coagulase-negative staphylococci. In the remaining patient, only coagulase-negative staphylococcus was cultured. Five patients were treated with one arthroscopic debridement, five had two arthroscopic debridements and one required arthroscopic debridement four times before the infection was eradicated. Two patients had their implants removed due to loosening of the suture anchors. All patients were treated with parenteral antibiotics for 1-4 weeks, followed by oral treatment for 1-5 weeks. At median 22 months (range 11-28) follow-up the median CM score was 84 and median WORC index was 81%. Ten patients had a postoperative MRI scan after a median of 23 months (range 3-49), with eight presenting a healed cuff repair. CONCLUSION: The findings of this study support the rapid, targeted intervention of acute postoperative infection after RC repair with immediate arthroscopic debridement, irrigation and biopsies for bacteriological diagnostics followed by parenteral antibiotics. Furthermore, repeated arthroscopic debridement and irrigation are recommended if signs of infection persist. Removal of the implant is rarely needed. Despite the postoperative acute infection, these patients presented good functional results at final follow-up. LEVEL OF EVIDENCE: Level III.

Good functional results following high tibial opening-wedge osteotomy of knees with medial osteoarthritis: A prospective study with a mean of 8.3years of follow-up.

BACKGROUND: To report time dependent functional improvement and predictive risk factors for failure when the load in varus knees with medial osteoarthritis is shifted from the medial to the lateral knee compartment. METHODS: Forty-nine consecutive patients (52 knees), mean age 47 (31-64) years, underwent a high tibial opening-wedge valgus osteotomy stabilized with a Puddu plate and bone grafting. The patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at three and six months, one, two, five and 10years postoperatively with a mean follow-up time of 8.3years (2.0-10.6). RESULTS: Mean angular correction was 8.0° (four to 12). The five subscores of KOOS increased significantly during the first year by 40-131% from preoperative values, the good results remaining throughout the 10-year follow-up for those with a surviving osteotomy. The outcome was related to the grade of preoperative osteoarthritis. Seven knees were converted to total knee arthroplasty (TKA) mean 6.2years (two to nine) post-operatively, and had a lower KOOS preoperatively than those of surviving osteotomies. The osteotomy survival rate at five years was 94% and at 10years 83%. Patients with KOOS subscore quality of life (QoL) <44 at the two-year follow-up had a 11.7 times higher risk for later TKA than those with QoL ≥44 (P=0.017). CONCLUSION: High tibial opening-wedge osteotomy for medial knee osteoarthritis resulted in good functional recovery after one year and favorable mid-term results. It may be a good treatment option for middle-aged patients with varus knees and medial osteoarthritis in order to prevent or postpone TKA.

The Effect of Limited Perioperative Nonsteroidal Anti-inflammatory Drugs on Patients Undergoing Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to patients undergoing anterior cruciate ligament reconstruction (ACLR) is controversial because it may impair tissue healing and clinical outcomes. PURPOSE: To assess the effect of NSAID administration on patients undergoing ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included patients were aged >15 years and were registered in the Norwegian Knee Ligament Registry from 2008 until 2013 after the primary ACLR. Patients with insufficient data regarding administration of NSAIDs and those with associated knee ligament injuries requiring surgical treatment were excluded from this study. Graft survival was estimated using Kaplan-Meier survival curves, and hazard ratios (HRs) for revision were evaluated using Cox regression analysis. Logistic regression analysis was used to calculate the odds ratio (OR) for a Knee Injury and Osteoarthritis Outcome Score (KOOS)-quality of life (QOL) subscale score <44 at 2-year follow-up. RESULTS: A total of 7822 patients were included in the analysis for graft survival and assessment for risk of revision. Of these, 4144 patients were administered NSAIDs postoperatively. The mean duration of follow-up was 2.8 years (range, 0-5.9 years). Administration of NSAIDs did not influence graft survival (P = .568). Adjusted Cox regression analyses demonstrated the same finding regarding risk of revision (HR, 1.0; 95% CI, 0.8-1.3). ACLR using a bone-patellar tendon-bone autograft showed a reduced risk of revision (HR, 0.3; 95% CI, 0.1-0.8) among patients administered NSAIDs. In subgroup analyses of 3144 patients, administration of NSAIDs demonstrated a beneficial effect on the risk of a KOOS-QOL score <44 at 2-year follow-up (OR, 0.8; 95% CI, 0.6-0.9). CONCLUSION: Administration of NSAIDs to patients after ACLR does not have a negative effect on graft survival, risk of revision, or risk of a KOOS-QOL score <44 at 2-year follow-up. We emphasize using caution when administering NSAIDs by keeping the duration and dosage of NSAIDs as short and low as possible to ensure sufficient pain relief while limiting unwanted exposure to any known and unknown adverse effects of these drugs.

A Trend for Increased Risk of Revision Surgery due to Deep Infection following Fast-Track Hip Arthroplasty.

Rates of revision surgery due to deep infection following total hip arthroplasty (THA) increased at a Norwegian hospital following implementation of fast-track procedures. The purpose of this study was to determine whether selected demographic (age and sex) and clinical (body mass index, American Society of Anesthesiologists (ASA) classification, surgery duration, length of hospital stay, cemented versus uncemented prosthesis, and fast-track procedures) factors were associated with higher risk of revision surgery due to deep infection following THA. In a prospective designed study 4,406 patients undergoing primary THA between January 2001 and January 2013 where included. Rates of infection-related revision surgery within 3 months of THA were higher among males and among patients who received fast-track THA. Adjusting for sex and age, the implemented fast-track elements were significantly associated with increased risk of revision surgery. Risk of infection-related revision surgery was unrelated to body mass index, physical status, surgery duration, length of hospital stay, and prosthesis type. Because local infiltration analgesia, drain cessation, and early mobilization were introduced in combination, it could not be determined which component or combination of components imposed the increased risk. The findings in this small sample raise concern about fast-track THA but require replication in other samples.

Good functional results of distal femoral opening-wedge osteotomy of knees with lateral osteoarthritis.

PURPOSE: To evaluate the time-dependent functional outcome of patients with lateral knee osteoarthritis with increased valgus treated with lateral opening-wedge osteotomy to shift the load from the lateral to the medial compartment of the knee. METHODS: Twenty-four consecutive patients with lateral knee osteoarthritis were treated with distal femoral opening-wedge varus osteotomy stabilized with the Puddu plate and bone transplantation. The mean age of the patients was 48 years (CI 40.3-55.7, range 31-62). The patients were evaluated by the Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at 3 and 6 months, 1, 2, 5 and 10 years post-operatively. The knee osteoarthritis was graded according to the Kellgren-Lawrence radiological scoring system. The mean follow-up time was 7.9 years (CI 6.8-9.0, range 4.0-10.2). RESULTS: The mean angular correction measured on pre- and post-operative radiographs was 9.6° (CI 7.7°-11.5°, range 4°-20°). All osteotomies healed. KOOS increased significantly during the first year by 28-122 % beyond the preoperative values for all the five subscores. This improvement remained at 10-year follow-up for those with surviving osteotomy. Six knees were converted to total knee arthroplasty (TKA) mean 6.4 years (CI 3.3-9.6, range 4.0-11.8) post-operatively. The osteotomy survival rate at 5 years was 88 % and at 10 years 74 %. The preoperative osteoarthritic grade did not increase significantly during the follow-up period, but was significantly correlated (r = -0.49), P = 0.019 to the KOOS subscore symptoms at the 2-year follow-up. CONCLUSION: Distal femoral opening-wedge osteotomy for lateral knee osteoarthritis resulted in good functional recovery after 1 year and favourable midterm results. It may be a good treatment option for middle-aged patients with valgus knees and lateral osteoarthritis in order to prevent or postpone TKA. LEVEL OF EVIDENCE: IV.

Tendon to bone tunnel healing--a study on the time-dependent changes in biomechanics, bone remodeling, and histology in a rat model.

Tendons and ligaments attach to bone through a transitional connective tissue with complex biomechanical properties. This unique tissue is not regenerated during healing, and surgical reattachment therefore often fails. The present study was designed to evaluate tendon healing in a bone tunnel and to evaluate the utilized rat model. Wistar rats (n = 61) were operated with the Achilles tendon through a bone tunnel in the distal tibia. Healing was evaluated at 2, 3, 4, and 12 weeks by biomechanical testing, bone mineral density and histology. After 2 weeks median (interquartile range) pull-out force was 2.2 N (1.9). The pull-out force increased chronologically, by 12 weeks fivefold to 11.2 N (11.4). Energy absorption, stiffness, and bone mineral density increased similarly. The histological analyses showed inflammation at early stages with increasing callus by time. Our data showed a slow healing response the first 4 weeks followed by an accelerated healing period, favoring that most of the gain in mechanical strength occurred later than 4 weeks postoperatively. These findings support the concern of a vulnerable tendon bone tunnel interface in the early stages of healing.

Worse patient-reported outcome after lateral approach than after anterior and posterolateral approach in primary hip arthroplasty. A cross-sectional questionnaire study of 1,476 patients 1-3 years after surgery.

BACKGROUND: The surgical approach in total hip arthroplasty (THA) is often based on surgeon preference and local traditions. The anterior muscle-sparing approach has recently gained popularity in Europe. We tested the hypothesis that patient satisfaction, pain, function, and health-related quality of life (HRQoL) after THA is not related to the surgical approach. PATIENTS: 1,476 patients identified through the Norwegian Arthroplasty Register were sent questionnaires 1-3 years after undergoing THA in the period from January 2008 to June 2010. Patient-reported outcome measures (PROMs) included the hip disability osteoarthritis outcome score (HOOS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), health-related quality of life (EQ-5D-3L), visual analog scales (VAS) addressing pain and satisfaction, and questions about complications. 1,273 patients completed the questionnaires and were included in the analysis. RESULTS: Adjusted HOOS scores for pain, other symptoms, activities of daily living (ADL), sport/recreation, and quality of life were significantly worse (p < 0.001 to p = 0.03) for the lateral approach than for the anterior approach and the posterolateral approach (mean differences: 3.2-5.0). These results were related to more patient-reported limping with the lateral approach than with the anterior and posterolateral approaches (25% vs. 12% and 13%, respectively; p < 0.001). INTERPRETATION: Patients operated with the lateral approach reported worse outcomes 1-3 years after THA surgery. Self-reported limping occurred twice as often in patients who underwent THA with a lateral approach than in those who underwent THA with an anterior or posterolateral approach. There were no significant differences in patient-reported outcomes after THA between those who underwent THA with a posterolateral approach and those who underwent THA with an anterior approach.

Negative effects of parecoxib and indomethacin on tendon healing: an experimental study in rats.

Conventional non-steroidal anti-inflammatory drugs (NSAIDs) and newer specific cyclooxygenase-2 (cox-2) inhibitors are commonly used in muscular skeletal trauma and in relation to orthopedic surgery to reduce the inflammatory response and pain. Studies have indicated that these drugs can have a negative effect on tendon healing in the early proliferative phase, but might be beneficial in the remodeling phase when inflammation might impede healing. Our study was designed to investigate if short-term administration of cox inhibitors after injury or postoperatively might have negative effects on the tendon healing. The right Achilles tendon of 60 rats was cut transversely, a 3 mm long segment of the tendon was removed and left unrepaired. The animals were then given parecoxib, indomethacin or saline intraperitoneally twice daily for 7 days. After 14 days, the animals were euthanized. The transverse and sagittal diameters in the healing area were measured and mechanical testing of the tensile strength of the tendons was performed. We found a significantly lower tensile strength in rats given both parecoxib and indomethacin compared to the control group. Stiffness in the healing tendons was significantly lower in the parecoxib group compared to both the placebo and the indomethacin groups. The transverse and sagittal diameters of the tendons were reduced in both the parecoxib and indomethacin groups. Both parecoxib and indomethacin impaired tendon healing; the negative effect was most pronounced with parecoxib.

Parecoxib and indomethacin delay early fracture healing: a study in rats.

Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce inflammatory response and pain. These drugs have been reported to impair bone metabolism. Parecoxib, a specific COX-2 inhibitor, exerts an inhibitory effect on the mineralization of fracture callus after a tibial fracture in rats. Decreased bone mineral density (BMD) at a fracture site may indicate impairment of early healing, casting doubt on the safety of using COX-2 inhibitors during the early treatment of diaphyseal fractures. Forty-two female Wistar rats were randomly allocated to three groups. They were given parecoxib, indomethacin, or saline intraperitoneally for 7 days after being subjected to a closed tibial fracture stabilized with an intramedullary nail. Two and 3 weeks after surgery, the bone density at the fracture site was measured using dual energy xray absorptiometry (DEXA). Three weeks after the operation the rats were euthanized and the healing fractures were mechanically tested in three-point cantilever bending. Parecoxib decreased BMD at the fracture site for 3 weeks after fracture, indomethacin for 2 weeks. Both parecoxib and indomethacin reduced the ultimate bending moment and the bending stiffness of the healing fractures after 3 weeks. These results suggest COX inhibitors should be avoided in the early phase after fractures.

Long-term outcome of shoulder arthrodesis performed with plate fixation: 18 patients examined after 3-15 years.

BACKGROUND AND PURPOSE: There have been few reports on the long-term function after shoulder arthrodesis. We report the outcome after shoulder arthrodesis with plate fixation in 18 patients who were followed for 3-15 years. METHODS: 25 patients with a median age of 64 (19-75) years were operated with a shoulder arthrodesis between 1982 and 2003. Standard AO surgical technique with plating was used in all patients. 18 of the patients were examined retrospectively after a mean of 8 (3-15) years. 6 of the other patients had died and 1 refused examination. RESULTS: Radiologically, all but two arthrodeses fused completely. The remaining two were partially fused, within the glenohumeral joint or between humerus and acromion. The mean Oxford shoulder score was 32 and the mean ASES shoulder index was 59. Nine patients had intermittent or continuous pain; their mean pain score on a visual analog scale was 3. One patient had been re-operated after 4 months because of severe pain and 1 was operated due to a humeral shaft fracture after 8 months. 1 patient suffered from a complex regional pain syndrome. No infections occurred. INTERPRETATION: In this patient series there were few complications after shoulder arthrodesis, and the longterm functional results were acceptable.

Long-term serotonin administration leads to higher bone mineral density, affects bone architecture, and leads to higher femoral bone stiffness in rats.

New evidence suggests a control of bone mass by the central nervous system. We have previously shown that functional serotonin receptors are present in bone cells and that serotonin stimulates proliferation of osteoblast precursor cells in vitro. In the present study we investigated the effects of serotonin on bone tissue in vivo. Ten, 2-month-old female Sprague-Dawley rats were injected with serotonin subcutaneously (s.c.) (5 mg/kg) once daily for 3 months, controls received saline. Using microdialysis and HPLC, free circulating serotonin levels were measured. DXA scans were made after 3 months of serotonin administration. Bone architecture and mechanical properties were investigated by micro-computed tomography (microCT), histomorphometry, and mechanical testing. A long-lasting hyperserotoninemia with a >10-fold increase in serotonin appeared. Total body BMD was significantly higher (0.1976+/-0.0015 vs. 0.1913+/-0.0012 g/cm2) in rats receiving serotonin. Cortical thickness (Ct.Th) measured by microCT analysis was also higher, whereas trabecular bone volume (BV) was lower. Interestingly, the perimeter and cross-sectional moment of inertia (MOI), a proxy for geometrical bone strength, were the same in both groups. These data suggest that serotonin reduces resorption or/and increases apposition of endosteal bone. Mechanical testing showed that femoral stiffness was higher in serotonin-dosed animals. The energy absorption also seemed slightly, but not significantly higher. In conclusion, hyperserotoninemia led to a higher BMD, altered bone architecture and higher femural bone stiffness in growing rats, demonstrating that serotonin may have important effects on bone in vivo.