Comparison of clinical outcomes between knotted and knotless double-row arthroscopic rotator cuff repairs: a meta-analysis.

BACKGROUND: The ideal rotator cuff repair technique should allow for a quick and simple arthroscopic application which provides both adequate biomechanical stability and an appropriate biological state with the intention of promoting eventual healing of tendon to bone. While the biomechanical superiority of double-row repairs including higher repair strength, reduced gap formation, and wider footprint restoration have been proven, controversy remains regarding the clinical benefits of knotless compared with knot tying techniques. Our study aims to review the available evidence in the literature comparing the clinical outcomes between knotted and knotless transosseous double-row rotator cuff repair techniques. METHODS: A systematic literature search via PubMed, Embase, and Scopus was conducted by 2 independent reviewers. Studies reporting clinical outcomes of arthroscopic rotator cuff repair using the double-row knotted and knotless surgical techniques were identified. Data were analyzed with Review Manager 5.3, using Mantel-Haenszel statistics with both fixed and random effect models. RESULTS: A total of 1144 studies were identified from our initial search. Based on our inclusion and exclusion criteria, 8 studies were eventually selected for our review. The selected studies were published between 2012 and 2018. Of the 8 studies, 3 reported level 2 evidence and 5 reported level 3 evidence. There were a total of 589 subjects. Our meta-analysis revealed that there were no significant differences in functional outcomes postoperatively when comparing Constant score (mean difference = -1.85, 95% confidence interval: -4.42 to 0.73), University of California at Los Angeles score (mean differences = -0.14, 95% confidence interval: -0.90 to 0.62), and American Shoulder and Elbow Surgeons score (mean differences = -2.19, 95% confidence interval: -5.55 to 1.17) between patients who underwent knotted and knotless rotator cuff repairs. DISCUSSIONS AND CONCLUSION: Our review revealed no statistically significant difference in functional outcomes between knotted and knotless transosseous double-row techniques for arthroscopic rotator cuff repairs. To our knowledge, this is the first meta-analysis related to this topic. However, no level 1 studies were available for this review. Further studies related to this topic should focus on reporting level 1 evidence comparing the clinical outcomes of knotless and knotted techniques for double-row repairs.

Autologous collagen-induced chondrogenesis versus microfracture for chondral defects of the knee: Surgical technique and 2-year comparison outcome study.

OBJECTIVE: Osteochondral lesions of the knee affect patients from all age groups with arthroscopic microfracture being the current gold standard of treatment of such lesions. Autologous collagen-induced chondrogenesis (ACIC) is a novel procedure that has recently been gaining popularity. This study aims to compare the 6 and 24 month post-operative outcomes between patients undergoing microfracture only and microfracture with ACIC. METHODS: Patients from both groups were assessed pre-operatively, at 6 and 24 months post-operatively for functional outcomes using SF-36 and IKDC scoring (International Knee Documentation Committee Subjective Knee Form). RESULTS: Both groups showed improved SF-36 and IKDC scores at 6 and 24 months, however patients who underwent ACIC showed better SF-36 mental component and IKDC scores 24 months after surgery. CONCLUSION: This demonstrates that ACIC is an effective, single-stage, joint-preserving procedure which is comparable, if not better, in treating chondral defects.

Predictive value of common serum glycaemic markers on periprosthetic joint infection following Total Joint Arthroplasty: A review of the literature.

It is well established that diabetes mellitus and osteoarthritis commonly exist together and among various treatment modalities for osteoarthritis, Total Joint Arthroplasty (TJA) has been effective. Prosthetic Joint Infection (PJI) is a serious complication of TJA with high costs and morbidity associated with it. The aim of this study is to provide background information and relevance of diabetes on PJI, and to conduct a review on existing literature, to find out if common serum glycaemic markers in diabetes could be used as predictors for PJI after TJA. These markers include measuring pre-operative glucose levels with glycated haemoglobin (HbA1c) or capillary blood glucose, peri-operative or post-operative blood glucose levels. We have found that existing literature studying these markers as predictors of PJI after TJA has been largely contentious. Despite not being used widely in clinical practice, serum fructosamine has been shown to be more reliable and accurate than the above-mentioned markers. Future studies should be carried out to confirm and better understand this association.

Which Patients Require a Contralateral Total Knee Arthroplasty Within 5 Years of Index Surgery?

Osteoarthritis (OA) of the knee often presents bilaterally. However, not all patients with severe bilateral knee OA require bilateral total knee arthroplasty (TKA). This study aims to identify predictive factors for contralateral TKA in patients presenting with severe bilateral knee OA undergoing unilateral TKA. We prospectively collected perioperative data from 209 consecutive patients of a single surgeon who had severe bilateral OA knees at presentation. All patients underwent unilateral TKA on the more symptomatic knee. Patients were then stratified by their need for a contralateral TKA within the next 5 years. Using regression analysis, we compared patients who underwent contralateral knee surgery within 5 years (n = 115) against patients who did not (n = 94), so as to create a predictive model. Significant factors identified by the multiple regression models were incorporated into a decision tree using classification and regression tree analysis. Body mass index (BMI), degree of varus angulation, and Oxford knee scores were identified as significant predictive factors. The generated decision tree model was able to stratify patients according to their BMI and Oxford scores into four subgroups, the highest with more than 90% odds of contralateral surgery and the lowest with less than 40% odds of contralateral surgery. BMI, degree of varus angulation, and preoperative Oxford knee scores seem to predict the need for contralateral TKA in patients with severe bilateral OA knees undergoing unilateral TKA. These patients should be counseled on their requirement for the second TKA based on these factors.

Patterns of Weight Change and Their Effects on Clinical Outcomes Following Total Knee Arthroplasty in an Asian Population.

BACKGROUND: This prospective cohort study was designed to evaluate weight change patterns and their effects on clinical outcomes following total knee arthroplasty (TKA) in the Asian population. We hypothesized that Asian patients will have a different pattern of weight change following TKA compared to Western patients and that weight loss following TKA will be associated with better clinical outcomes. METHODS: A cohort of consecutive patients who underwent TKA from 2004 to 2015 was included. All patients received a conventional posterior-stabilized TKA implant and underwent a standard perioperative care pathway. Assessments were done preoperatively, at 6 months, and 2 years after surgery. The range of motion, Knee Society Score, Oxford Knee Score, and the Short-Form 36 questionnaire were used to assess outcomes. Height and weight of patients were recorded for body mass index (BMI) calculation. Patterns of weight loss following TKA in this cohort were charted. Clinical outcomes were then analyzed against the change in BMI. RESULTS: A total of 602 patients (602 knees) were reviewed. Mean age was 66.39 ± 7.27 years. Mean BMI was 27.75 ± 4.51 kg/m2. Overall, 63.12% of all our patients gained weight following TKA. Moreover, weight loss did not influence patients' odds for better clinical outcomes. Furthermore, patients who were in the preoperative BMI category of obese class I were more likely to gain weight as compared to those in the normal category (odds ratio 0.35, 95% confidence interval 0.2-0.61, P < .001). Moreover, older people were more likely to gain more weight compared to younger people. We also showed that the mean 2-year Knee Society Knee Score was significantly higher in the patients who gained weight while the patients who lost weight had the highest mean 2-year Oxford Knee Score and the lowest mean 2-year Knee Society Function Score. CONCLUSION: Asians tend to gain weight following TKA. However, this weight change following TKA does not affect clinical outcomes, which remain good across all BMI groups. LEVEL OF EVIDENCE: Therapeutic Level III.

Achieving Minimum Clinically Important Difference in Oxford Knee Score and Short Form-36 Physical Component Summary Is Less Likely with Single-Radius Compared with Multiradius Total Knee Arthroplasty in Asians.

Single-radius (SR) and multiradius (MR) total knee arthroplasties (TKAs) have produced similar outcomes, albeit most studies originate from Western nations. There are known knee kinematic differences between Western and Asian patients after TKA. The aim of this study is to compare the short-term patient-reported outcome measures (PROMs) of SR-TKA versus MR-TKA in Asians. Registry data of 133 SR-TKA versus 363 MR-TKA by a single surgeon were analyzed. Preoperative and 2-year postoperative range of motion (ROM) and PROMs were compared with Student's t-test and Mann-Whitney U-test. Logistic regression model was used to evaluate the odds of SR-TKA or MR-TKA achieving the minimum clinically important difference (MCID) of studied outcomes. Patients in both groups had similar age (65.7 ± 7.6 vs. 65.8 ± 8.2 years; p = 0.317), gender proportion (71% females vs. 79% females; p = 0.119), and ethnic distribution (80% Chinese vs. 84% Chinese; p = 0.258). Preoperatively, there were no statistically significant differences between both groups for ROM, Knee Society Score (KSS), Oxford Knee Score (OKS), and Short Form (SF)-36 scores. At 2 years, all outcomes were statistically similar or failed to achieve a difference of MCID. Controlling for all preoperative variables, SR-TKA has significantly lower odds of achieving MCID for OKS (odds ratio [OR]: 0.275, 95% confidence interval [CI]: 0.114-0.663; p = 0.004) and SF-36 Physical Component Summary (PCS) (OR: 0.547; 95% CI: 0.316-0.946; p = 0.031) compared with MR-TKA. In conclusion, there are no significant differences in the absolute PROMs between SR-TKA and MR-TKA at 2 years following TKA in Asians. However, SR-TKA has significantly lower odds of achieving the MCID for OKS and SF-36 PCS.

Obesity is associated with poorer range of motion and Tegner scores following hamstring autograft anterior cruciate ligament reconstruction in Asians.

BACKGROUND: Current literature reporting on the impact of BMI on outcomes of orthopaedic surgical procedures is varied and inconsistent. The purpose of our study was to evaluate if body mass index (BMI) affects outcomes of primary anterior cruciate ligament reconstruction (ACLR) in an Asian population. METHODS: We retrospectively reviewed prospectively collected data of 141 consecutive patients who underwent primary ACLR by a single surgeon, the senior author of this study. Flexion range, International Knee Documentation Committee (IKDC) score, KT-1000 translation, Tegner activity level scale, Lysholm score and satisfaction were assessed preoperatively and at 2 years postoperatively. The patients were then stratified into two groups: normal-BMI and high-BMI in accordance with WHO classification. Outcomes were then compared between the two groups. All statistical analysis were performed on IBM SPSS Statistics 20. RESULTS: There were 81 patients in the normal-BMI group (BMI, 18.5 to 24.9) and 60 patients in the high-BMI group (BMI ≥25). Preoperatively, the only differences were in the gender proportions as well as the pre-injury Tegner score. 2-years postoperatively, patients in the normal-BMI group had better flexion (139° vs. 130°; P=0.0001), Tegner scores (5.7 vs. 4.8; P=0.005) and satisfaction rate (99% vs. 90%; P=0.041). There were no differences in graft failure or complication rates. CONCLUSIONS: Obese patients had poorer range of motion and Tegner scores as compared to their nonobese counterparts following primary ACLR.

Prevalence of Venous Thromboembolic Events Is Low in Asians After Total Knee Arthroplasty Without Chemoprophylaxis.

BACKGROUND: This retrospective cohort study was designed to establish the prevalence of clinically significant venous thromboembolic events (VTE) in our patients undergoing total knee arthroplasty (TKA) without chemoprophylaxis. METHODS: A single-surgeon cohort of patients who underwent TKA from 2006 to 2014 were included. All patients had a pneumatic tourniquet applied and a drain inserted postoperatively. Tranexamic acid was not used perioperatively. All patients were under a standardized postoperative protocol with routine mechanical prophylaxis against VTE. None of the patients received prophylactic anticoagulation. All patients ambulated on the second postoperative day. Only symptomatic patients were referred for radiological examination to exclude VTE. We evaluated the patient demographics and calculated the prevalence of VTE in our cohort. RESULTS: A total of 966 patients were reviewed. Mean age was 66.1 ± 7.8 years. Mean body mass index was 28.2 ± 4.7 kg/m2. Mean tourniquet time was 53 ± 23 minutes. Patients stayed in hospital for a mean of 5.4 ± 3.1 days. There was 100% compliance to mechanical prophylaxis. And 11.1% of our patients were on concomitant antiplatelet or anticoagulant use. There were 8 patients with clinically significant VTE. This translates to a prevalence of 0.82%. Seven patients developed deep vein thrombosis and 1 patient died from massive pulmonary embolism. CONCLUSION: The prevalence of clinically significant VTE in our patients who underwent TKA without routine chemoprophylaxis is 0.82%. With proper patient selection, risk stratification, and stringent perioperative protocols, routine chemoprophylaxis may not be necessary in Asians undergoing TKA.

Injury patterns in patients presenting with a recurrent anterior cruciate ligament tear following primary reconstruction.

BACKGROUND: An anterior cruciate ligament (ACL) graft rupture or a primary ACL injury in the contralateral knee is one of the greatest concerns of patients following primary anterior cruciate ligament reconstruction (ACLR). Our study describes the epidemiology and presence of concomitant meniscal injuries of patients with a graft rupture following primary ACLR or a primary rupture of the contralateral ACL following primary ACLR of the ipsilateral knee. METHODS: We reviewed the medical records of 42 patients who underwent a second ACLR. ACLR was performed using the ipsilateral semitendinosus and gracilis autograft. Variables extracted included the presence of concomitant MM and LM injuries intra-operatively, the patients' level of intensity of sport (light, moderate, strenuous), duration of rehabilitation and mechanism of injury (contact, non-contact). RESULTS: Twenty-four (57.1%) patients had graft rupture of a previously reconstructed ACL of which 20 (83.3%) were male and 18 (42.9%) patients had a primary ACL tear of the contralateral knee following ACLR of the ipsilateral knee of which 18 (100%) were male. Patient who sustained a graft rupture were younger (29.5 vs. 31.9 years), had a higher body mass index (BMI) (26.42 vs. 25.10 kg/m(2)) and had a longer time before re-injury (6.18 vs. 4.94 years). Concomitant meniscal injury rates were comparable in both groups and the medial meniscus was injured more often. CONCLUSIONS: This study describes the demographics of 2(nd) ACL injuries in the Asian population. Additional studies that investigate the differences in knee anatomy of Asians and Caucasians and their impact on ACL injuries should be performed.

Routine pre-operative group cross-matching in total knee arthroplasty: A review of this practice in an Asian population.

BACKGROUND: Routine pre-operative group cross-match (GXM) and post-operative haemoglobin level measurements are performed for all total knee arthroplasty (TKA) patients in many institutions. We aimed to determine whether this practice is justified, and to identify predictors for post-operative transfusion. MATERIALS AND METHODS: A retrospective review was performed on 226 TKA procedures performed between Jan. 2011 and Dec. 2013. Patients' demographics and clinical details including co-morbidities, pre-operative laboratory results, type of anaesthesia, surgery duration, post-operative haemoglobin level and transfusion requirement were reviewed. RESULTS: Overall transfusion rate was 10.6% (n=24). Cross-match to transfusion ratio was 6.5. The cross-match to transfusion ratio (C:T ratio) was measured as the ratio of number of units of blood cross-matched to units of blood transfused. In females, relative risk of transfusion between patients with pre-operative haemoglobin below 12.0 and those above or equal to 12.0 was significant at 4.53 (Confidence interval (CI) 2.16 to 9.53). The relative risk of transfusion between patients above 65 years of age compared to those below 65 years of age was 1.13 (CI 1.03 to 1.23). Multivariate analysis revealed advancing age (p=0.044) and lower preoperative haemoglobin (p<0.001) as significant variables associated with post-operative transfusion. CONCLUSION: Post-operative transfusion rates are low and excessive pre-operative GXM and post-operative haemoglobin checks are contributing to unnecessary medical costs. Predictors of blood transfusion risk in unilateral TKA in our cohort of Asian population were advancing age and lower pre-operative haemoglobin level. Type and screen tests should be performed for all other patients. LEVEL OF SCIENTIFIC EVIDENCE: 3.

Diagnosis of ligamentous and meniscal pathologies in patients with anterior cruciate ligament injury: comparison of magnetic resonance imaging and arthroscopic findings.

BACKGROUND: Magnetic resonance imaging (MRI) is routinely used to diagnose or support clinical diagnoses for meniscal or ligamentous injuries prior to offering patients arthroscopic treatment. However, the sensitivity of MRI for the detection of meniscal injury is not yet 100%. Sportsmen have occasionally returned to play with undiagnosed meniscal lesions on the basis of a normal MRI examination. This study was designed to assess the diagnostic parameters of MRI in patients with acute anterior cruciate ligament (ACL) injury. METHODS: MRI and arthroscopic findings of 320 patients with acute ACL injury were included in this retrospective review. Patients belonged to a single surgeon from a high volume tertiary healthcare institution. All patients had either a MRI or an arthroscopic diagnosis of an acute ACL injury of one knee or both. All patients underwent therapeutic arthroscopy by the senior author routinely as part of arthroscopy-aided ACL reconstruction. Arthroscopic findings were the diagnostic reference based on which the positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and concordance strength of association of MRI were calculated for ACL, posterior cruciate ligament (PCL), medial meniscus (MM) and lateral meniscus (LM) injuries. RESULTS: MRI was most accurate in diagnosing cruciate ligament injuries with a PPV approaching 100%. The PPV of MRI in diagnosing meniscal injuries was approximately 60%. MRI was almost 100% sensitive and specific in diagnosing ACL injuries and 82% sensitive and 100% specific in diagnosing PCL injuries. Conversely, MRI was 77% sensitive and 90% specific in diagnosing MM injuries; and 57% sensitive and 95% specific in diagnosing LM injuries. CONCLUSIONS: MRI remains the gold standard for diagnosing soft tissue injuries of the knee. However, there is a false positive rate ranging from 6% to 11% for meniscal tears.

Outcomes are favorable in Asian patients undergoing deltoid-on open rotator cuff repair without acromioplasty.

BACKGROUND: To evaluate if rotator cuff repair without acromioplasty would result in improvement in outcomes without the risks associated with acromioplasty in Asian patients. METHODS: 38 primary repairs of tears of the rotator cuff were performed through a deltoid-on approach. The Simple Shoulder Test (SST) and UCLA shoulder rating scale were measured preoperatively and at 2 years post-operatively. RESULTS: There was a significant improvement in the SST 2 years post-operatively (p < 0.001). UCLA scores for pain control and function (p < 0.001) also significantly improved 2 years post-operatively. CONCLUSION: Outcomes are favorable in Asians following deltoid-on open rotator cuff repair without acromioplasty. LEVEL OF EVIDENCE: III.

Irreducible dislocation of the great toe interphalangeal joint secondary to an incarcerated sesamoid.

Irreducible dorsal dislocation of the interphalangeal (IP) joint of the great toe is rare. We report a case of a 29-year-old gentleman who presented to the Orthopaedic Surgery Specialist Outpatient Clinic with an irreducible IP joint of the great toe that had been untreated for 4 weeks. The mechanism of injury is believed to be a combination of axial loading with a hyperdorsiflexion force when the patient fell foot first into a drain. As the patient did not report severe symptoms and a true lateral radiograph was not ordered, the dislocation was missed initially at the emergency department. The patient had continued to run and play field hockey prior to visiting us. Incarceration of the sesamoid became a block to manipulation and reduction at the specialist outpatient clinic 3 weeks later. The patient was treated with open surgical exploration, resection of the interposed sesamoid, and Kirschner-wire fixation of the IP joint followed by occupational therapy for mobilization exercises. The operative course was uneventful. At 6 months after surgery, the patient could walk, run, and return to sports.

Total knee arthroplasty in Asian subjects: preoperative range of motion determines postoperative range of motion?

OBJECTIVE: To evaluate whether preoperative range of motion is a key determinant of postoperative range of motion in Asian patients undergoing conventional total knee arthroplasty. METHODS: A retrospective review of 302 patients who underwent primary total knee arthroplasty performed by a single surgeon was conducted. Patients who had a fixed flexion deformity of ≥15° were excluded. Postoperative range of motion (ROM) was measured prospectively. Patients were stratified into two groups: preoperative ROM < 110° and preoperative ROM ≥ 110°. Postoperative ROM and mean change in ROM at 6 months and 2 years of follow-up were then compared using Student's t-test. RESULTS: Group of ROM < 110° had a poorer postoperative range of motion at both 6-months and 2-years of follow-up than Group of ROM ≥ 110° (P < 0.001). Postoperatively, Group of ROM < 110° had gained range of motion whereas Group of ROM ≥ 110° had lost range of motion (P < 0.001). CONCLUSIONS: Similar to the Western population, preoperative range of motion is a key determinant of postoperative range of motion in Asian patients. This should be taken into consideration by surgeons during preoperative planning and in managing patients' expectations.

Postoperative range of motion does not correlate with patient reported outcome scores in Asians after total knee arthroplasty.

Activities in Asian cultures require greater knee flexion. However, this study hypothesized that post-operative range of motion (ROM) does not correlate with patient reported outcome scores at 2years. 292 TKAs were evaluated at a public hospital in Singapore from January 2006 to May 2009. The relationship between ROM and outcome scores was examined using a multiple linear regression model with Generalized Estimating Equation (GEE) allowing adjustment for confounders and repeated TKAs within a patient. Analysis did not yield statistically significant results when patients' post-op ROM was correlated with outcome scores at 2years. Lack of post op ROM does not translate into poorer outcome scores and dissatisfaction. Doctors can now counsel patients who are concerned about a lack of ROM after TKA.

The use of pneumatic tourniquets is safe in Asians undergoing total knee arthroplasty without anticoagulation.

BACKGROUND: There has always been controversy surrounding the use of pneumatic tourniquets in total knee arthroplasty (TKA) as they have been implicated in venous thromboembolic events (VTE). We aimed to evaluate the incidence of clinically significant VTE in Asians who underwent conventional TKA under tourniquet throughout the duration of surgery, without post-operative chemical VTE prophylaxis, but using post-operative pneumatic compression devices. METHODS: Five hundred and thirty-one patients of a single surgeon who underwent elective total knee arthroplasty were retrospectively reviewed. All patients had a tourniquet applied to the operated limb. None of the patients received chemoprophylaxis against VTE. Post-operatively, only symptomatic patients were referred for ultrasonography. The patients were then stratified according to the tourniquet time: <60, 61 to 90, 91 to 120, and >120 min. The overall incidence as well as the incidence of venous thromboembolic events for each group was then calculated. RESULTS: Of the 531 patients reviewed, 3 patients suffered from deep venous thrombosis (DVT) while 1 patient developed a fatal pulmonary embolism (PE). Hence, the overall incidence of clinically significant VTE was 0.75%. The 3 patients with DVT had tourniquet time of 61 to 90 min while the patient with PE had a tourniquet time of more than 120 min. CONCLUSION: With a low overall incidence of VTE, the use of tourniquet in Asians during conventional total knee arthroplasty appears safe when post-operative pneumatic compression devices are used instead of chemical VTE prophylaxis. However, the risk of VTE seems to increase with a tourniquet time of more than 60 min. LEVEL OF EVIDENCE: Therapeutic studies, level III.