Osteoarthritis Grade Research Articles

Surgical versus conservative management of patellar re-dislocation: clinical and radiological results at a mid-term follow-up of 5 years

Background: Patellar dislocation accounts for 2–3% of all knee lesions and is the second most common cause of traumatic hemarthrosis of the knee. Proper treatment is essential to minimize long term sequelae, such as recurrent dislocation, painful subluxation, and osteoarthritis. Aim: The purposes of this perspective randomized study were: 1) to evaluate the mid-term clinical and radiological results of the Elmslie–Trillat procedure for the treatment of traumatic patellar re-dislocation; and 2) to compare the results, especially radiological osteoarthritis development, with those of non-operative management for traumatic patellar re-dislocation. Methods: From June 2013 to February 2015, 65 patients were admitted to our Emergency Department for a first patellar dislocation episode. All patients were treated non-operatively. When a second episode occurred within two years, patients were randomly assigned in two groups: Group A, patients treated surgically with Elmslie-Trillat procedure, and Group B, patients were further treated non-operatively. The Knee Society Score (KSS), Lysholm scale and Kujala questionnaire were administered immediately after the re-dislocation and at the final follow-up. Tangential patella radiographs were evaluated for patellofemoral osteoarthritis and graded according to Sperner’s classification. Results: The mean follow-up was 6.4±1.7 years (range 5-8) in Group A and 6.3±2.1 years (range 5-9) in Group B. In Group A, the KSS and Lysholm scale showed significant differences between pre- and post-operatively values (p<0.05). The mean Kujala score was significantly lower in Group B when compared with the mean value of Group A (p<0.05). At the final follow-up of more than 5 five years, the mean grade of patellofemoral osteoarthritis according to Sperner’s classification changed in Group A and Group B, with respectively 25% and 29% of patients having a grade greater than or equal to 3. Conclusion: This study confirms that Elmslie-Trillat is a safe and effective procedure in the treatment of patellar instability, relieving pain and inability, and reducing recurrence risk. However, it cannot avoid the degenerative changes occurring in the natural evolution of patellar dislocation.

Assessment of Platelet Rich Plasma (PRP) In the Treatment of Primary Osteoarthritis Knee: An Original Research

Introduction: The present therapeutic line of osteoarthritis of knee is primarily symptomatic, therefore the need to discover treatment modality which tackles the disease process in itself. This study was done with an intention to examine the efficacy of platelet rich plasma in primary osteoarthritis of knee.
 Materials and Methods: This prospective investigation was done on 100 knees in 100 individuals having early primary osteoarthritis of the knee. Three injections of platelet rich plasma were administered at four weeks interval and the outcome was analyzed by WOMAC and VAS score at pre injection, 3 weeks, 12 weeks and 24 weeks. Ahlback’s grading was done at pre-injection and at 6 months.
 Results: Most of the cases in our series were in the age category of 50-65 years with female predominance (73%), 51% cases had grade 2 disease and the remaining had grade 1 involvement. Improvement in WOMAC score parameters started after 3 weeks with continuing improvement at successive follow-ups. WOMAC score parameters (pain, stiffness, physical function and total score) at pre injection were 14.22, 5.05, 36.41and 55.8 and at 6 months follow up were 5.92, 2.07, 16.78 and 24.11 correspondingly. Similar improvement was noted in VAS score with pre injection score of 7.12 and final score of 2.96. The average WOMAC score was less for grade 1 as compared to grade 2 (43.42 vs 60.41); (43.63 vs 61.36). Improvement was reported in 86% of patients however the level varied from good to slight improvement. There was no problem associated to the treatment in our series.
 Conclusion: The initial data show that PRP is an effective therapeutic strategy in early grades of primary Osteoarthritis of knee. However, further strong evidence Research is required to check for the long-term impacts and to corroborate the conclusions of this investigation.
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Effect of hip joint mobilisations and strength training on pain, physical function and dynamic balance in patients with Knee Osteoarthritis: A randomized controlled trial.

To determine the effects of hip joint mobilisations and strengthening exercises on pain, physical function and dynamic balance in patients with knee osteoarthritis. The single-blind three-arm parallel randomised controlled trial was conducted at Sindh Institute of Physical Medicine and Rehabilitation, the outpatient department of Dow University of Health Sciences' Ojha Campus, Rabia Moon Memorial Welfare Trust and the Civil Hospital, Karachi, from January to July 2021. The sample comprised patients aged at least 50 years having knee osteoarthritis grade 1-3. The patients were randomised into 3 equal groups, with group A receiving hip mobilisations along with strengthening exercises of hip and conventional knee exercises, group B receiving strengthening exercises of hip along with conventional knee interventional exercises, and group C receiving conventional knee exercises only. Pain, physical function and dynamic balance were assessed using visual analogue scale, knee injury osteoarthritis outcome score and four-step square test, respectively, at baseline and after 18th session. Data was analysed using SPSS 21. Of the 74 subjects assessed, 66(89.2%) were included; 22(33.3%) in each of the three groups. The sample had 19(28.8%) male subjects and 47(71.2%) female. The mean age in groups A, B and C were 55.64±3.56 years, 53.64±4.65 years and 54.91±4.30 years, respectively. There was significant difference among groups post-treatment (p<0.001). Significant improvement was also found in inter-group analyses of all outcomes (p<0.001). Addition of hip joint mobilisations provided better results compared to the other two groups. https://clinicaltrials.gov/ct2/show/NCT04769531.

Improved Outcome With Knee Arthroscopy Relative to Physiotherapy for Symptomatic Unstable Meniscal Tears: 2-Year Prospective Cohort Study.

Although preservation of meniscal tissue is paramount, there are occasions when repair of a torn meniscus is not possible. The surgical option may be a partial meniscectomy, the objective being to alleviate the patient's symptoms with resection of only that portion of the meniscus that is no longer functioning but is the cause of symptoms. Previous studies have questioned the need to perform such surgery and have recommended nonoperative treatment instead. Our goal was to compare the outcome of partial meniscectomy with that of physiotherapy alone for irreparable meniscal tears. Clinical outcome following arthroscopic partial meniscectomy may differ from that following physiotherapy alone, for patients with symptomatic irreparable meniscal tears. Nonrandomized prospective cohort study. Level 2. Patients satisfying the inclusion criteria chose to undergo knee arthroscopy (group A) or physiotherapy (group B). The diagnosis of a meniscal tear was made on physical assessment and magnetic resonance imaging examination. The meniscal tear was preventing them from continuing with their regular weightbearing exercise. Outcomes of interest were the following patient-reported outcomes (PROs): the Knee Osteoarthritis Outcome Score (KOOS) and Tegner Activity Score (TAS), with minimal clinically important differences being 10 and 1, respectively. PROs were completed at baseline, and at 1-year and 2-year follow-up. Changes in scores within and between groups were compared using analysis of variance and Wilcoxon tests (P <0.05). A power analysis demanded 65 patients in each group to produce a power of 80% and a P value of 5%. Of 528 patients enrolled in the study, 10 were lost to follow-up and 8 were excluded. Data were complete for 269 in group A, and 228 in Group B. Group A and B were similar in terms of age (41.1 years, SD 7.8 vs 40 years, SD 13.3), body mass index (22.5 kg/m2, SD 3.1 vs 23.1 kg/m2, SD 2.3), radiographic grade of osteoarthritis (median grade 2, range 0-3 in both groups), gender (male:female = 134:135 vs 112:116), and duration of symptoms (44.4 days, SD 5.6 vs 46.6 days, SD 8.8), with P >0.05. At both 1-year and 2-year follow-up, Group A had higher scores in the mean total KOOS (88.8, SD 8.0 vs 72.4, SD 3.8), as well as in all subscales within the KOOS, and the TAS (median 7, range 5-9 vs median 5, range 3-6), with P <0.001 for each variable. Performing a knee arthroscopy with partial meniscectomy is associated with improved KOOS and TAS, relative to treatment with physiotherapy alone, at 2-year follow-up. Physically active patients with symptomatic irreparable meniscal tears may experience a better clinical outcome following knee arthroscopy, relative to to physiotherapy alone.

Paper 08: Long Term Survivorship and Outcomes of Patients Undergoing Capsular Repair and Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Objectives: The purpose of this study is to report minimum 10-year survivorship and patient-reported outcomes (PROs) following primary hip arthroscopy with capsular repair for FAIS and to compare outcomes of patients undergoing capsular repair to capsular release. Methods: Data were prospectively collected and retrospectively reviewed on all patients undergoing primary hip arthroscopy with capsular repair between October 2008 and February 2011. Survivorship was defined as a non-conversion to total hip arthroplasty (THA). Patients with minimum 10-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Visual Analog Scale for pain (VAS). If available, preoperative and minimum 10-year follow-up for the Hip Outcome Score—Sports Specific Subscale (HOS-SSS) were reported. Patients with ipsilateral hip surgery, worker’s compensation, Tönnis osteoarthritis grade &gt; 1, and hip dysplasia (lateral center-edge angle &lt; 25°) were excluded. Survivorship defined by non-conversion to THA, PROS, and clinical benefit (minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS)) were reported. An additional propensity-matched sub-analysis comparing patients undergoing capsular repair with patients undergoing capsular release over the age of 40 with acetabular labrum articular disruption ≥ 2 was performed. Results: 145 (130 patients) out of 180 eligible hips (165 patients) had minimum 10-year follow-up (80.6%). 126 hips (86.9%) were female, and 19 hips (13.1%) were male. The average patient age was 30.3 ± 12.9 years. The survivorship rate was 91.0% at minimum 10-year follow-up. The cohort experienced significant improvement (P &lt; 0.001) in the mHHS, NAHS, HOS-SSS, and VAS for pain. Additionally, the cohort achieved high rates of PASS for the mHHS (89.8%), and high rates of the MCID for the mHHS (82.4%) and VAS for pain (80.6%). 29 capsular repair hips were matched to 81 capsular release hips. Both groups experienced significant improvement in all PROs, but there was a higher conversion to THA rate in the release group (P &lt; 0.05). Conclusions: Patients undergoing primary hip arthroscopy with capsular repair experienced a high rate of survivorship of 91.0% at minimum 10-year follow-up. Patients that did not convert to THA saw favorable improvements in PROs and achieved high rates of clinical benefit. In the subanalysis, patients undergoing capsular repair demonstrated higher rates of survivorship.

Patients With Mild Osteoarthritis Are Less Likely to Achieve a Clinically Important Improvement in Pain or Function After Anatomic Total Shoulder Arthroplasty.

The severity of glenohumeral osteoarthritis (OA) as demonstrated by preoperative radiographs and patient-reported pain plays an important role in the indication for anatomic total shoulder arthroplasty (aTSA). In hip and knee research, data about the effect of the severity of preoperative radiographic OA on the outcome of total joint arthroplasty have been mixed. For shoulder replacement, we are unsure of the effects of radiographic severity on outcomes. This study investigated whether the preoperative radiographic severity of glenohumeral OA is associated with improvement in pain and function after aTSA. We asked, (1) does the severity of glenohumeral OA correlate with improvement in patient-reported outcomes after TSA (delta American Shoulder and Elbow Surgeons score [postoperative-preoperative], delta Single Assessment Numeric Evaluation, delta Simple Shoulder Test, and delta VAS)? (2) Is having mild osteoarthritis associated with not meeting the minimum clinically important differences in preoperative and postoperative American Shoulder and Elbow Surgeons scores? An institutional query of patients who underwent aTSA for OA was performed between January 2015 and December 2018. A total of 1035 patients were eligible; however, only patients with adequate preoperative radiographs and patient-reported outcome measures collected preoperatively and at a minimum of 2 years postoperatively were included. Patients with proximal humerus fractures, inflammatory arthropathy, cuff tear arthropathy, prior ipsilateral rotator cuff repair, brachial plexus injury or neuromuscular disorder, workers compensation, periprosthetic joint infection, or revision surgery within 2 years were excluded. Patient characteristics, comorbidities, and prior shoulder surgery were recorded. The severity of OA was classified based on the modified Samilson-Prieto and Walch classification. The association between Samilson-Prieto grade and patient-reported outcome measures (American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS score) was evaluated. Radiographic characteristics, patient demographics, comorbidities, and prior surgery were also evaluated for the potential risk of not achieving improvement in the minimum clinically important difference (16.1) with respect to the American Shoulder and Elbow Surgeons score. The American Shoulder and Elbow Surgeons score is scored 0 to 100, with higher scores representing less pain and better function. A total of 206 patients (20% of those eligible) with a mean follow-up of 2.3 years were included. Twenty-three patients had Samilson-Prieto Grade I, 38 had Grade II, 57 had Grade III, and 88 had Grade IV. There were no differences in improvements (delta) between the groups and between patient-reported outcome scores (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS). Compared with patients with more severe osteoarthritis (Samilson-Prieto Grades II, III, and IV), a higher proportion of patients with less severe osteoarthritis (Grade I) did not exceed the minimum clinical important difference for the American Shoulder and Elbow Surgeons score (22% [five of 23] versus 4% [seven of 183]; odds ratio 0.14 [95% confidence interval 0.04 to 0.520]; p = 0.006). The improvement in patient-reported outcome measure scores was similar regardless of radiographic severity after aTSA. Surgeons should use caution when recommending surgery to patients with less severe OA because a higher percentage did not improve, based on the minimum clinically important difference. Level III, therapeutic study.

Effects of Iliotibial Band Myofascial Release with/without Stretching with Iliotibial Band Tightness Secondary to Knee Osteoarthritis

Background: Knee osteoarthritis (OA), also referred to as degenerative joint disease of the knee, is brought on by wear-and-tear and the slow loss of articular cartilage. The term "iliotibial band" (IT band) also refers to the iliotibial tract or Maissiat's band. Methodology: This study was conducted using randomized clinical trial, quasi experimental research design as we need to make 2 groups and evaluate the effects of Iliotibial band myofascial release and stretching on the patients of knee OA. Study population was 36 individuals of ages 50-70 having knee osteoarthritis grade II or III characterized by Kellgren-Lawrence grades, visiting the physical therapy department of Mumtaz physiotherapy clinic. It was a randomized clinical trial with convenient sampling where participants were randomly allocated in two groups by simple random sampling, one group was experimental that received IT band myofascial release other than the stretching and baseline treatment and second group received the myofascial release and baseline treatment only. Data collection tools were Visual Analogue Scale (VAS) and Woman Osteoarthritis index. For the within group analysis of VAS, Friedman test was used and wilcoxon signed rank test was used for the within group analysis of the WOMAC. For the between group analysis of variables, Mann-whitney U test was used. Results: Both groups showed some significant improvement in all outcome measures (p&lt;0.05), but the results produced by IT band Myofascial release along with stretching group was statistically significant in terms of reduced pain and disability (p&lt;0.0005) as compared to myofascial release alone group. The iliotibial band myofascial release along with stretching has statistically significant effect in improving the pain and disability among knee osteoarthritis patients. Practical Implication: Iliotibial band tightness can potentially lead to the alterations in the mobility of patella and disturb the overall knee complex. Proper arthrokinematics of joint is necessary for ambulation. So, this study focused to draw results from combined therapy of IT band myofascial release and stretching will redound to the benefit of physiotherapy field considering that knee plays an important role in better Quality of life. Conclusions: The iliotibial band myofascial release along with stretching has statistically significant effect in improving the pain and disability among knee osteoarthritis patients. Keywords: IT Band; Myofascial Release; Stretching; WOMAC; VAS.

Histological Findings and T2 Relaxation Time in Canine Menisci of Elderly Dogs—An Ex Vivo Study in Stifle Joints

Osteoarthritis is a chronic disease that often affects the canine stifle joint. Due to their biomechanical function, the menisci in the canine stifle play an important role in osteoarthritis. They compensate for the incongruence in the joint and distribute and minimize compressive loads, protecting the hyaline articular cartilage from damage. Meniscal degeneration favors the development and progression of stifle joint osteoarthritis. Qualitative magnetic resonance imaging (MRI) is the current golden standard for detecting meniscal changes, but it has limitations in detecting early signs of meniscal degeneration. A quantitative MRI offers new options for detecting early structural changes. T2 mapping can especially visualize structural changes such as altered collagen structures and water content, as well as deviations in proteoglycan content. This study evaluated T2 mapping and performed a histological scoring of menisci in elderly dogs that had no or only low radiographic osteoarthritis grades. A total of 16 stifles from 8 older dogs of different sex and breed underwent ex vivo magnet resonance imaging, including a T2 mapping pulse sequence with multiple echoes. A histological analysis of corresponding menisci was performed using a modified scoring system. The mean T2 relaxation time was 18.2 ms and the mean histological score was 4.25. Descriptive statistics did not reveal a correlation between T2 relaxation time and histological score. Ex vivo T2 mapping of canine menisci did not demonstrate histological changes, suggesting that early meniscal degeneration can be present in the absence of radiological signs of osteoarthritis, including no significant changes in T2 relaxation time.

Analgesic Effectiveness of Physical Therapy Combining the Use of Electromagnetic Fields with Light Radiation Emitted by LEDs along with the Use of Topical Herbal Ointment in Patients with Gonarthrosis

(1) Background: The aim of the study is to evaluate the analgesic effectiveness of a physical therapy regimen that combines the use of an electromagnetic field with light radiation emitted by LEDs, along with the use of Traumeel S ointment, in patients with gonarthrosis. (2) Methods: The study included 90 patients with knee osteoarthritis (grade 2 Kellgren and Lawrence osteoarthritis). They were divided into three groups: Group I, 30 patients treated with magnetic stimulation plus LED therapy; Group II, 30 patients treated with Traumeel S ointment; and Group III, 30 patients treated with magnetic stimulation plus LED therapy with Traumeel S ointment. Pain intensity was assessed using the VAS and Laitinen scales before and after a series of treatments. (3) Results: Significant results in terms of pain reduction before and after treatment were obtained in each of the study groups, as there were significant differences in the VAS pain intensity scores before and after the procedures between the groups. In group I, with electromagnetic field and LED light treatment, the difference was 35.5; in group II, which received Traumeel S® ointment, the difference was 18.5; and in group III, with electromagnetic field and LED light treatment as well as Traumeel S ointment, the difference was 26.5. In the Laitinen scale, the differences were insignificant, although the size distribution was similar. (4) Conclusions: The therapy used in this study showed that magnetic stimulation plus LED therapy and the use of Traumeel S ointment gave positive results in terms of pain reduction in each of the study groups. The strongest analgesic factor seems to be magnetic and LED therapies used separately. Traumeel S in magnetoledophoresis does not work synergistically with the magnetic field of LED light, and even worsens the effect of the therapy used.

Aragonite-Based Scaffold Versus Microfracture and Debridement for the Treatment of Knee Chondral and Osteochondral Lesions: Results of a Multicenter Randomized Controlled Trial

Background: Lesions of the articular cartilage, with or without involvement of the subchondral bone, are a common cause of pain and dysfunction in the knee. Although several treatment options have been developed, the majority of previous clinical trials examined patients with isolated or focal midsized defects, which rarely represent the condition found in the general population. Rather, cartilage lesions are often associated with the presence of mild to moderate osteoarthritic changes. Purpose: The present multicenter randomized controlled trial compared the clinical and radiographic outcomes of an aragonite-based osteochondral implant with a control group (arthroscopic debridement/microfractures) in patients affected by joint surface lesions of the knee, including those with concurrent mild to moderate osteoarthritis. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 251 patients were enrolled in 26 medical centers according to the following criteria: age 21 to 75 years, up to 3 cartilage defects of International Cartilage Regeneration & Joint Preservation Society grade 3a or above located on the femoral condyles and/or trochlea, total treatable area from 1 to 7 cm2, bony defect depth ≤8 mm, and knee osteoarthritis grade 0 to 3 according to Kellgren-Lawrence score. Patients were randomized to the aragonite-based implant or debridement/microfracture control arm in a 2:1 ratio. Evaluation was performed at 6, 12, 18, and 24 months based on overall Knee injury and Osteoarthritis Outcome Score (KOOS) as the primary endpoint, and the KOOS subscales (Pain, Quality of Life, Activities of Daily Living), percentage of responders, and International Knee Documentation Committee (IKDC) subjective score as the secondary endpoints. Patients also underwent magnetic resonance imaging evaluation at 12 and 24 months to assess defect fill grade. Failures (ie, need for any secondary treatment) and adverse events were also recorded. Results: The implant group showed a statistically superior outcome in the primary endpoint and all secondary endpoints at each follow-up. The magnitude of improvement in the implant group was twice as large as that in the control group in terms of mean KOOS improvement at 2 years. Responder rate (defined as at least a 30-point improvement in overall KOOS) was 77.8% in the implant group as opposed to 33.6% in the control (P < .0001). Statistically superior results were seen in the IKDC score as well. At 24 months, 88.5% of the implanted group had at least 75% defect fill on magnetic resonance imaging as compared with 30.9% of controls (P < .0001). The failure rate was 7.2% for the implant group versus 21.4% for control. Conclusion: This aragonite-based scaffold was safe and effective in the treatment of chondral and osteochondral lesions in the knee, including patients with mild to moderate osteoarthritis, and provided superior outcomes as compared with the control group. Registration: NCT03299959 (ClinicalTrials.gov identifier).

Do Platelet-Rich Plasma Injections for Knee Osteoarthritis Work?

Recent evidence suggests a benefit in platelet-rich plasma injections (PRP) for the knee in the management of mild to moderate osteoarthritis (OA). There is a reported reduction in pain, stiffness, and improved function. However, there is very little level-one literature available that supports this practice and conclusively proves a benefitgained throughout the course. Three main randomized control trials (RCTs) conducted in North America are often referenced and cited to prove their efficacy. This study aimed to look at the outcomes of patients having undergone this treatment to determine if there was any benefit. This study aimed to determine if PRP injections administered in patients with knee OA over a six to eight-week time period demonstrated any benefit. The Western Ontario and McMaster Universities arthritis index (WOMAC) tool was used before each of the three PRP injections over the six to eight-week period, and six weeks after the final injection in 31 patients. Each injection was given spaced two to three weeks apart. The outcomes observed were pain, stiffness, and physical function, and the total WOMAC score was calculated. The third injection showed a reduction in total WOMAC score, pain, stiffness, and physical function by 16.36%, 16.37%, 5.12%, and 18.03%, respectively. However, all scores returned close to baseline at the sixth-weekfollow-up post treatment. Results showed a trend of reduction in the WOMAC score. However, they are overall indicative of a placebo effect from the injections. Further studies are neededto explore whether the grade of OA and patients' weight have a significant impact on the results.

Association between the degree of Osteoarthritis and pain level of patients at Baptist Hospital, Batu City

Osteoarthritis is a chronic disease characterized by the destruction of cartilage in the joints, causing stiffness, pain, and impaired movement. The condition most commonly affects the joints of the knees, hands, feet, spine, and often the shoulders and hips. Knee osteoarthritis is a major public health problem that causes chronic pain and reduces physical function and quality of life. This study determined the relationship between the degree of Osteoarthritis and the pain level in patients at Baptist Hospital, Batu City. This research used a cross-sectional study with 31 respondents. Data collection was conducted directly using the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) questionnaire, modified in Indonesian. To determine the grade of Osteoarthritis using the Kellgren-Lawrence system. The results showed that out of 31 respondents, there were nine patients (29%) who had grade 1 osteoarthritis, 12 patients (38.7%) had grade 2, and 10 patients (32.3%) had grade 3. There were 22 patients (71%) who had a mild pain level, four patients (13%) had a moderate level, and five patients (16%) had a severe pain level. The Spearman correlation test showed no significant relationship (p&gt;0.05) between the degree of Osteoarthritis and the level of pain in patients. This study concludes that there was no relationship between the increasing degree of Osteoarthritis and the level of pain.

Ankle Pain After Medial Opening-Wedge High Tibial Osteotomy in Patients With Knee Osteoarthritis and Concurrent Ankle Osteoarthritis

Background: Medial opening-wedge high tibial osteotomy (MOWHTO) in patients with varus knee osteoarthritis (OA) causes changes to ankle and hindfoot alignment. However, the compensatory ability of the ankle and hindfoot varies according to the severity of ankle OA. Purpose: To investigate whether the changes in ankle symptoms and ankle and hindfoot alignments differ after MOWHTO according to the severity of preoperative ankle OA. Study design: Case-control study; Level of evidence, 3. Methods: The data of 130 patients who were followed for ≥4 years were reviewed. Patients were classified into 2 groups according to their severity of ankle OA: group 1, modified Kellgren-Lawrence grade 0 and 1; group 2, grade ≥2. Four radiographic parameters were examined to evaluate ankle alignment: tibial plafond inclination, talar tilt, talar inclination, and tibial surface angle. The hindfoot alignment was evaluated using the varus-valgus angle (VVA) of the calcaneus. A visual analog scale (VAS) was used to evaluate ankle pain. The patient-reported outcome measure of the knee joint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Results: There were 110 patients in group 1 and 20 patients in group 2. In group 2, the change in talar inclination after MOWHTO was significantly greater and the changes in tibial plafond inclination, talar tilt, and VVA were significantly smaller compared with in group 1 (all P < .05). Ankle pain VAS scores were more severe in group 2 than in group 1 pre- and postoperatively (all P < .05), and group 2 reported that ankle pain worsened postoperatively (P < .05). In both groups, knee WOMAC scores improved, and there were no differences between groups pre- or postoperatively (all P > .05). A multivariate regression analysis demonstrated that a small VVA change (odds ratio, 0.775; P = .027) and severe OA grade of the ankle joint preoperatively (Kellgren-Lawrence grades 2-4 vs 0 and 1; odds ratio, 4.241 [P = .046]) predicted increased ankle pain VAS scores after MOWHTO. Conclusion: Although the patient-reported outcome measures for the knee joint improved irrespective of the presence of ankle OA, ankle pain worsened after MOWHTO in patients with ankle OA. Inadequate compensatory change in hindfoot alignment increased ankle pain in these patients.

The Reliability of the Tönnis Grading System in Patients Undergoing Hip Preservation

Background: The presence of pre-existing osteoarthritis (OA) has been associated with poor results after hip arthroscopic surgery. There is limited evidence validating the currently available grading systems of hip OA in patients undergoing hip preservation. Purpose/Hypothesis: Our purpose was to evaluate the interobserver and intraobserver reliabilities of 2 grading systems in a group of patients undergoing hip preservation: the Tönnis grading system and a simple 4-choice Likert scale. The hypothesis was that interobserver and intraobserver reliabilities using the Tönnis grading system would be poor among surgeons experienced in hip preservation and that a 4-choice Likert scale would be more reliable. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 100 hip radiographs were reviewed by 8 experienced hip preservation surgeons. Overall, 2 rounds of reviews were performed, at least 3 weeks apart, assessing for the presence, degree, and/or location of joint space narrowing, joint space asymmetry, subchondral cysts, osteophytes, and sclerosis. The radiographs were assigned a Tönnis grade as well as a Likert grade of OA, reported as none, mild, moderate, or severe. Statistical analysis was conducted to provide Fleiss kappa values with 95% CIs. Agreement was classified as poor for <0.00, slight for 0.00-0.20, fair for 0.21-0.40, moderate for 0.41-0.60, substantial for 0.61-0.80, and almost perfect for >0.80. Results: A total of 50 patients (28 female and 22 male) with a mean age of 42.8 ± 14.2 years (range, 19-70 years) were reviewed. The Tönnis grade demonstrated an interobserver kappa value of 0.30 (95% CI, 0.26-0.34). The Likert grade demonstrated an interobserver kappa value of 0.33 (95% CI, 0.28-0.37). All other measures demonstrated interobserver kappa values classified as slight or fair except for subchondral cysts which was moderate. Intraobserver reliabilities were statistically significantly higher than interobserver reliabilities. Intraobserver reliabilities for both the Tönnis grade (κ = 0.55 [95% CI, 0.51-0.60]) and Likert grade (κ = 0.59 [95% CI, 0.55-0.63]) demonstrated similar kappa values, consistent with moderate agreement. Subchondral cysts demonstrated the strongest interobserver (κ = 0.53) and intraobserver (κ = 0.85) reliabilities. Conclusion: Interobserver and intraobserver reliabilities were fair and moderate, respectively, for grading OA. Given the limited interobserver reliability, caution should be used when interpreting and translating studies that utilize the Tönnis grade or other rating to dictate treatment algorithms.

Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for lateral osteochondral lesions of the talus: operative technique.

To provide anatural scaffold, good quality cells, and growth factors to facilitate replacement of the complete osteochondral unit with matching talar curvature for large osteochondral lesions of the lateral talar dome. Symptomatic primary and non-primary lateral osteochondral lesions of the talus not responding to conservative treatment. The anterior-posterior or medial-lateral diameter should exceed 10 mm on computed tomography (CT) for primary lesions; for secondary lesions, there are no size limitations. Tibiotalar osteoarthritis gradeIII, malignancy, active infectious ankle joint pathology, and hemophilic or other diffuse arthropathy. Anterolateral arthrotomy is performed after which the Anterior TaloFibular Ligament (ATFL) is disinserted from the fibula. Additional exposure is achieved by placing aHintermann distractor subluxating the talus ventrally. Thereafter, the osteochondral lesion is excised in toto from the talar dome. The recipient site is micro-drilled in order to disrupt subchondral bone vessels. Thereafter, the autograft is harvested from the ipsilateral iliac crest with an oscillating saw, after which the graft is adjusted to an exactly fitting shape to match the extracted lateral osteochondral defect and the talar morphology as well as curvature. The graft is implanted with apress-fit technique after which the ATFL is re-inserted followed by potential augmentation with an InternalBrace™ (Arthrex, Naples, FL, USA). Non-weightbearing cast for 6weeks, followed by another 6weeks with awalking boot. After 12weeks, acomputed tomography (CT) scan is performed to assess consolidation of the inserted autograft. The patient is referred to aphysiotherapist.

Extrusion of the anterior segment of the medial meniscus extrusion initiates knee osteoarthritis: evaluation using magnetic resonance imaging

PurposeMeniscus extrusion contributes to the progression of knee osteoarthritis (OA). It is not clear which site of the medial meniscus (MM) extrusion (MME) is greatest. Moreover, the relationship between sites of MME and progression of OA has not yet been elucidated. The purpose of this study was to determine which sites of MME that showed the greatest extrusion and to investigate the relationship between the presence of MM tears and MME, the relationship between the progression of OA and MME.MethodsA cohort of 111 patients were studied retrospectively. The OA grade was classified using the Kellgren-Lawrence (K-L) grade. MME was measured at 13 positions from the anterior to the posterior segment using magnetic resonance imaging (MRI) with slices perpendicular to the MM (radial MRI). The relationship between the K-L grade and the site of the MME was investigated. The patients were grouped as follows: The patients over 40-years-old were grouped as follows: patients with the K-L grade ≤1 and without a MM tear (Group En (early, no meniscus tear)); patients with the K-L grade ≤1 with a MM tear (Group Ep (early, positive meniscus tear)); patients with the K-L grade ≥2 and without a MM tear (Group An (advanced, no meniscal tear)); patients over-40 years-old with the K-L grade ≥2 and with a MM tear (Group Ap (advanced, positive meniscus tear)). And patients between 15 and 39-years-old with no abnormal findings on MRI were defined as control group (Group C).ResultsIn the Groups En and Ep, MME was greatest in the anterior segment, and was greater in Group Ep than in Group En. In Groups Ap and Group C, extrusion was greatest in the middle segment.ConclusionThe results suggest that MME predominantly occurred in the anterior segment with increasing age, after that, MM extruded at the middle segment with progression of OA and MM tear.Level of evidence IV

Current Situation of Adipose-Derived Stem Cells Treatments for Knee Ostheoarthritis and Hypothesis for a New Protocol Based on Cryoconservation and Multiple Injections of Mechanically Fragmented Adipose Tissue Extracts

Osteoarthritis (OA) is a widespread degenerative joint disease. The knee arthroplasty has represented for about 40 years the main treatment option, when pain and functional decrease became unbearable for the patient. The knee arthroplasty represents a challenging surgical operation, in which, based on current data available, about 20% of the patients are left totally or partially unsatisfied with the clinical result. A recent therapeutic alternative for mild-to-moderate grade OA (Kellgren-Lawrence grade II to III) in order to delay (or ultimately avoid) the need for prosthetic surgery, is a treatment with Adipose-Derived Stem Cells (or ADSCs). The safety and efficacy in terms of functional improvement, cartilage repair and inflammation reduction were already reported for OA treatment through a single intra-articular injection of Micro-Fragmented Autologous Fat Tissue (M-FAT), which is known to be rich in ADSCs. This efficacy period appears to be ranging from several months to a few years. Research has shown that the effect of single-dose M-FAT treatment, despite being evident in most cases, is not statistically uniform among the studies now available. This is also due to different treatment protocols, that leave to every research group the ultimate choice of preparation methods, rules and exclusion criteria. It is possible, because of this, to hypothesize a new kind of treatment protocol based on a single surgical harvesting operation. The extract would then need to be cryopreserved and administered multiple times over a several-years period. We hope, thanks to the subsequent injections of purified extract, to prolong and boost the effect of the treatment. We tried to elaborate, based on our experience in the field, a new protocol for this multi-injection treatment. This protocol is going to be applied to a small number of patients and evaluated over time, to elaborate the actual benefit from a treatment like this.

Association of Body Mass Index with Kellgren–Lawrence Grading of Knee Osteoarthritis – A Cross-sectional Study

Background: Osteoarthritis is the most prevalent form of arthritis causing disability, particularly in elderly population. Aging, female sex, obesity, and possibly nutritional deficiencies trigger the pathogenesis of osteoarthritis. This study aims to identify the association of body mass index (BMI), with knee osteoarthritis grading viewed from Kellgren–Lawrence (KL) criteria in participants with osteoarthritis of the knee joint.Methods: This research is a cross-sectional study using analytical approach in 70 participants diagnosed with Knee Osteoarthritis at Vaidyaratnam Ayurveda College, Ollur, Thrissur. BMI was calculated by measuring the height and weight of participants. Grading of knee OA based on KL criteria was assessed from the antero-posterior X-ray radiograph.Results: Of 70 participants, 81.4% were female and 31.4% were in the age group of 50–55 years, 27.1% in the age group of 61–65 years. Among the total 70 participants, 45.7% belong to overweight category, 28.6% were obese. Knee OA grading based on KL criteria indicates that the most frequent grade is Grade 2 with 34.3% followed by Grade 3 30%. Spearman rank correlation showed a positive correlation between BMI and degree of joint damage, which was statistically significant at 0.01 level (r = 0.491**, P &lt; 0.001).Conclusion: The higher the BMI value, the heavier the grading of OA of the knee

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity

PurposeThe purpose of this study was to examine the relationship between preoperative Ahlbäck radiographic classification grade and the clinical outcomes of double level osteotomy (DLO) performed for osteoarthritic knees with severe varus deformity.MethodsThe study population comprised a consecutive series of 99 knees (68 patients) for which DLO was performed and follow-up results for a minimum of two years were available. The Ahlbäck radiographic classification system was used to determine the osteoarthritic grade. The following radiological parameters for alignment and bone geometry were measured: mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), joint-line convergence angle (JLCA), and mechanical tibiofemoral angle (mTFA). Clinical results were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) subjective score preoperatively and at 2 years after surgery. Difference between preoperative and postoperative measurements as well as relationship between Ahlbäck grade and radiological/clinical results were statistically assessed.ResultsThe average age of the study participants was 60.9 ± 6.2 years and the mean follow-up period was 45.4 ± 15.2 months. Each of the radiological parameters exhibited preoperative abnormal values. Knees with Ahlbäck grade 3 and 4 osteoarthritis exhibited significantly greater JLCA and mTFA than grade 1 knees. Two years post-surgery, all radiological parameter values measured within a normal range. Clinical evaluation showed significant improvement in KOOS after surgery. Analysis of the relationship between Ahlbäck grade and clinical score showed that the 2-year postoperative KOOS scores in grade 3 and 4 osteoarthritic knees were significantly lower than grade 1 knees (with the mean 2-year KOOS scores of 350.0 ± 79.9, 317.9 ± 78.3, and 420.2 ± 42.9, respectively).ConclusionsWhile DLO may produce significant radiological and clinical improvement in knees with joint space obliteration, Ahlbäck grade 3 and 4 osteoarthritic knees associated with larger JLCA and mTFA showed less satisfactory clinical results compared to grade 1 knees. Level of Evidence: IV case series.

Consequences of sagittal malalignment following reconstruction of complex tibial plateau fractures

Abstract Purpose Changes of posterior tibial slope following complex tibial plateau fractures have not been fully evaluated in the literature. Some studies indicated that arthritic changes that occur following tibial plateau fracture were more correlated to deformity and instability rather than articular surface step-off. The aim of this study was to evaluate the midterm clinical effects following changes in the posterior slope that might be associated with reconstruction of complex tibial plateau fractures. Patients and methods This retrospective cohort study was carried out on 112 patients operated by internal fixation following complex tibial plateau fracture within 4 weeks of the incident of injury. Modified Rasmussen score was used for both clinical and radiological evaluations in addition to final evaluation of the slope by computed tomography scan. The Knee Injury and Osteoarthritis Outcome Score was used for subjective evaluation of the clinical results, and Kellgren–Lawrence radiological grading was used for osteoarthritis grading. Results The mean flexion was 118.8 ± 13.0° (range, 90–140) in GI and 119.7 ± 13.5° (range, 70–140) in GII, and the mean extension deficit was 1.6 ± 2.7° (range, 0–10) in GI compared with 1.9 ± 2.9° (range, 0–10) in GII. The mean clinical Rasmussen score was 26.3 ± 2.9 (18–30) in GI and 26.1 ± 3.2 (16–30) in GII. The mean Knee Injury and Osteoarthritis Outcome Score in GI was 79.3 ± 5.1 compared with 77.7 ± 5.6 in GII. According to Kellgren–Lawrence grading system for osteoarthritis, there were 23 patients with grades 2 and 3 osteoarthritis in GI compared with 32 cases in GII. The study showed a statistically significant correlation between decreased tibial slope and limitation of extension. Otherwise, there were no statistically significances between changes of tibial slope and stability, pain, or the overall postoperative knee score. Conclusion Changes in posterior slope angle of the tibial plateau during fracture fixation is an important factor that can significantly affect range of motion, particularly extension. Osteoarthritis is higher in patients with disturbed posterior slope; however, a larger sample is needed for possible significance. Level of evidence: therapeutic level IV.