The increase in the number of individuals with an unhealthy high body weight is particularly relevant in the United States. Obesity (body mass index ≥ 30 kg/m2) is a well-documented risk factor for ...the development of osteoarthritis. Furthermore, an increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades. The primary aim of this systematic literature review was to determine whether obesity has a negative influence on outcome after primary total knee arthroplasty.
A search of the literature was performed, and studies comparing the outcome of total knee arthroplasty in different weight groups were included. The methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling were performed. The weighted mean difference for continuous data and the weighted odds ratio for dichotomous variables were calculated. Heterogeneity was calculated with use of the I2 statistic.
After consensus was reached, twenty studies were included in the data analysis. The presence of any infection was reported in fourteen studies including 15,276 patients (I2, 26%). Overall, infection occurred more often in obese patients, with an odds ratio of 1.90 (95% confidence interval CI, 1.46 to 2.47). Deep infection requiring surgical debridement was reported in nine studies including 5061 patients (I2, 0%). Deep infection occurred more often in obese patients, with an odds ratio of 2.38 (95% CI, 1.28 to 4.55). Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, was documented in eleven studies including 12,101 patients (I2, 25%). Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30 (95% CI, 1.02 to 1.67).
Obesity had a negative influence on outcome after total knee arthroplasty.
Approximately 3.4% of adults have ankle (tibiotalar) osteoarthritis and, among younger patients, ankle osteoarthritis is more common than knee and hip osteoarthritis. Few effective nonsurgical ...interventions exist, but platelet-rich plasma (PRP) injections are widely used, with some evidence of efficacy in knee osteoarthritis.
To determine the effect of PRP injections on symptoms and function in patients with ankle osteoarthritis.
A multicenter, block-randomized, double-blinded, placebo-controlled clinical trial performed at 6 sites in the Netherlands that included 100 patients with pain greater than 40 on a visual analog scale (range, 0-100) and tibiotalar joint space narrowing. Enrollment began on August 24, 2018, and follow-up was completed on December 3, 2020.
Patients were randomly assigned (1:1) to receive 2 ultrasonography-guided intra-articular injections of either PRP (n = 48) or placebo (saline; n = 52).
The primary outcome was the validated American Orthopaedic Foot and Ankle Society score (range, 0-100; higher scores indicate less pain and better function; minimal clinically important difference, 12 points) over 26 weeks.
Among 100 randomized patients (mean age, 56 years; 45 45% women), no patients were lost to follow-up for the primary outcome. Compared with baseline values, the mean American Orthopaedic Foot and Ankle Society score improved by 10 points in the PRP group (from 63 to 73 points 95% CI, 6-14; P < .001) and 11 points in the placebo group (from 64 to 75 points 95% CI, 7-15; P < .001). The adjusted between-group difference over 26 weeks was -1 (95% CI, -6 to 3; P = .56). One serious adverse event was reported in the placebo group, which was unrelated to the intervention; there were 13 other adverse events in the PRP group and 8 in the placebo group.
Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis.
Netherlands Trial Register: NTR7261.
Management of acute lateral ankle ligament injury in the athlete van den Bekerom, Michel P. J.; Kerkhoffs, Gino M. M. J.; McCollum, Graham A. ...
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA,
06/2013, Letnik:
21, Številka:
6
Journal Article
Recenzirano
Purpose
Inversion injuries involve about 25 % of all injuries of the musculoskeletal system and about 50 % of these injuries are sport-related. This article reviews the acute lateral ankle injuries ...with special emphasis on a rationale for treatment of these injuries in athletes.
Methods
A narrative review was performed using Pubmed/Medline, Ovid and Embase using key words: ankle ligaments, injury, lateral ligament, ankle sprain and athlete. Articles related to the topic were included and reviewed.
Results
It is estimated that one inversion injury of the ankle occurs for every 10,000 people each day. Ankle sprains constitute 7–10 % of all admissions to hospital emergency departments. Inversion injuries involve about 25 % of all injuries of the musculoskeletal system, and about 50 % of these injuries are sport-related. The lateral ankle ligament complex consists of three ligaments: the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. The most common trauma mechanism is supination and adduction (inversion) of the plantar-flexed foot.
Conclusion
Delayed physical examination provides a more accurate diagnosis. Ultrasound and MRI can be useful in diagnosing associated injury and are routine investigations in professional athletes. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures. RICE therapy is the treatment of choice for the first 4–5 days to reduce pain and swelling. Initially, 10–14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.
Level of evidence
IV.
Objectives
To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior ...tibiofibular ligament (AITFL).
Methods
All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard.
Results
Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74–95%) sensitivity and 69% (CI 53–82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10–56%) sensitivity and 92% (CI 83–97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74–100%) sensitivity and 100% (CI 95–100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm).
Conclusions
Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.
Key Points
• Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL).
• Ultrasound can be used to screen for injury of the ATFL and AITFL.
• Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.
High incidence of (osteo)chondral lesions in ankle fractures Martijn, Hugo A.; Lambers, Kaj T. A.; Dahmen, Jari ...
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA,
05/2021, Letnik:
29, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Purpose
To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to ...50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL).
Methods
A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis–Weber and/or Lauge–Hansen classification) was calculated and pooled. Two-sided
p
values of less than 0.05 were considered statistically significant.
Results
Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% (
n
= 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge–Hansen categories (
p
= 0.049). Post hoc pairwise comparisons between Lauge–Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.).
Conclusion
OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery.
Level of evidence
IV.
Background
People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially ...in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse.
Objectives
Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes.
Methods
PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) ‘arthroplasty’, ‘sports’ and ‘recovery of function’, the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators.
Results
Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89 % after TKA and from 75 to >100 % after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1–4.6 after UKA and 0.2–1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases.
Conclusions
Low- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.
With the worldwide rising obesity epidemic and the aging population, it is essential to deliver (cost-)effective care that results in enhanced societal participation among knee arthroplasty patients. ...The purpose of this study is to describe the development, content, and protocol of our (cost-)effectiveness study that assesses a perioperative integrated care program, including a personalized eHealth app, for knee arthroplasty patients aimed to enhance societal participation post-surgery compared to care as usual.
The intervention will be tested in a multicentre randomized controlled trial with eleven participating Dutch medical centers (i.e., hospitals and clinics). Working patients on the waiting-list for a total- or unicompartmental knee arthroplasty with the intention to return to work after surgery will be included. After pre-stratification on medical centre with or without eHealth as usual care, operation procedure (total- or unicompartmental knee arthroplasty) and recovery expectations regarding return to work, randomization will take place at the patient-level. A minimum of 138 patients will be included in both the intervention and control group, 276 in total. The control group will receive usual care. On top of care as usual, patients in the intervention group will receive an intervention consisting of three components: 1) a personalized eHealth intervention called ikHerstel ('I Recover') including an activity tracker, 2) goal setting using goal attainment scaling to improve rehabilitation and 3) a referral to a case-manager. Our main outcome is quality of life, based on patient-reported physical functioning (using PROMIS-PF). (Cost-)effectiveness will be assessed from a healthcare and societal perspective. Data collection has been started in 2020 and is expected to finish in 2024.
Improving societal participation for knee arthroplasty is relevant for patients, health care providers, employers and society. This multicentre randomized controlled trial will evaluate the (cost-)effectiveness of a personalized integrated care program for knee arthroplasty patients, consisting of effective intervention components based on previous studies, compared to care as usual.
Trialsearch.who.int; reference no. NL8525, reference date version 1: 14-04-2020.
Purpose
The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.
Methods
A literature search was performed ...to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle–Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.
Results
Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% CI 78–86%. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% CI 66–85%.
Conclusions
For primary talar osteochondral defects, none of the treatment options showed any superiority over others.
Level of evidence
IV.
Preliminary experience suggests that deep learning algorithms are nearly as good as humans in detecting common, displaced, and relatively obvious fractures (such as, distal radius or hip fractures). ...However, it is not known whether this also is true for subtle or relatively nondisplaced fractures that are often difficult to see on radiographs, such as scaphoid fractures.
(1) What is the diagnostic accuracy, sensitivity, and specificity of a deep learning algorithm in detecting radiographically visible and occult scaphoid fractures using four radiographic imaging views? (2) Does adding patient demographic (age and sex) information improve the diagnostic performance of the deep learning algorithm? (3) Are orthopaedic surgeons better at diagnostic accuracy, sensitivity, and specificity compared with deep learning? (4) What is the interobserver reliability among five human observers and between human consensus and deep learning algorithm?
We retrospectively searched the picture archiving and communication system (PACS) to identify 300 patients with a radiographic scaphoid series, until we had 150 fractures (127 visible on radiographs and 23 only visible on MRI) and 150 non-fractures with a corresponding CT or MRI as the reference standard for fracture diagnosis. At our institution, MRIs are usually ordered for patients with scaphoid tenderness and normal radiographs, and a CT with radiographically visible scaphoid fracture. We used a deep learning algorithm (a convolutional neural network CNN) for automated fracture detection on radiographs. Deep learning, an advanced subset of artificial intelligence, combines artificial neuronal layers to resemble a neuron cell. CNNs-essentially deep learning algorithms resembling interconnected neurons in the human brain-are most commonly used for image analysis. Area under the receiver operating characteristic curve (AUC) was used to evaluate the algorithm's diagnostic performance. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate that a prediction is no better than a flip of a coin. The probability of a scaphoid fracture generated by the CNN, sex, and age were included in a multivariable logistic regression to determine whether this would improve the algorithm's diagnostic performance. Diagnostic performance characteristics (accuracy, sensitivity, and specificity) and reliability (kappa statistic) were calculated for the CNN and for the five orthopaedic surgeon observers in our study.
The algorithm had an AUC of 0.77 (95% CI 0.66 to 0.85), 72% accuracy (95% CI 60% to 84%), 84% sensitivity (95% CI 0.74 to 0.94), and 60% specificity (95% CI 0.46 to 0.74). Adding age and sex did not improve diagnostic performance (AUC 0.81 95% CI 0.73 to 0.89). Orthopaedic surgeons had better specificity (0.93 95% CI 0.93 to 0.99; p < 0.01), while accuracy (84% 95% CI 81% to 88%) and sensitivity (0.76 95% CI 0.70 to 0.82; p = 0.29) did not differ between the algorithm and human observers. Although the CNN was less specific in diagnosing relatively obvious fractures, it detected five of six occult scaphoid fractures that were missed by all human observers. The interobserver reliability among the five surgeons was substantial (Fleiss' kappa = 0.74 95% CI 0.66 to 0.83), but the reliability between the algorithm and human observers was only fair (Cohen's kappa = 0.34 95% CI 0.17 to 0.50).
Initial experience with our deep learning algorithm suggests that it has trouble identifying scaphoid fractures that are obvious to human observers. Thirteen false positive suggestions were made by the CNN, which were correctly detected by the five surgeons. Research with larger datasets-preferably also including information from physical examination-or further algorithm refinement is merited.
Level III, diagnostic study.
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