Establishing minimum clinically important difference values for the Patient-Reported Outcomes Measurement Information System Physical Function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis out

AIM To establish minimum clinically important difference(MCID) for measurements in an orthopaedic patient population with joint disorders.METHODS Adult patients aged 18 years and older seeking care for joint conditions at an orthopaedic clinic took the Patient-Reported Outcomes Measurement Information System Physical Function(PROMIS~? PF) computerized adaptive test(CAT), hip disability and osteoarthritis outcome score for joint reconstruction(HOOS JR), and the knee injury and osteoarthritis outcome score for joint reconstruction(KOOS JR) from February 2014 to April 2017. MCIDs were calculated using anchorbased and distribution-based methods. Patient reports of meaningful change in function since their first clinic encounter were used as an anchor.RESULTS There were 2226 patients who participated with a mean age of 61.16(SD = 12.84) years, 41.6% male, and 89.7% Caucasian. Mean change ranged from 7.29 to 8.41 for the PROMIS~? PF CAT, from 14.81 to 19.68 for the HOOS JR, and from 14.51 to 18.85 for the KOOS JR. ROC cut-offs ranged from 1.97-8.18 for the PF CAT, 6.33-43.36 for the HOOS JR, and 2.21-8.16 for the KOOS JR. Distribution-based methods estimated MCID values ranging from 2.45 to 21.55 for the PROMIS~? PF CAT; from 3.90 to 43.61 for the HOOS JR, and from 3.98 to 40.67 for the KOOS JR. The median MCID value in the range was similar to the mean change score for each measure and was 7.9 for the PF CAT, 18.0 for the HOOS JR, and 15.1 for the KOOS JR.CONCLUSION This is the first comprehensive study providing a wide range of MCIDs for the PROMIS? PF, HOOS JR, and KOOS JR in orthopaedic patients with joint ailments.

Oncogenic Osteomalacia Associated with Phosphaturic Mesenchymal Tumor of the Knee: Case Presentation and Review of the Literature

Oncogenic osteomalacia (OOM) is an uncommon metabolic and bone disease caused by fibroblast growth factor 23 (FGF23), a phosphaturic factor produced by phosphaturic mesenchymal tumors (mixed connective tissue variant, PMTMCTV) characterized by phosphate leakage from kidneys and subsequent hypophosphatemia. In this paper, we present the case of a patient, 42-year-old woman affected by left side limp and pain involving lumbar spine, pelvis and hip joints, referred to the Rheumatology Department of our Hospital for the treatment of a suspected sero-negative spondilo-arthritis. During hospitalization patient began an immuno-suppressive therapy with TNF-alpha inhibitors associated with Pamidornate, Indometacin, Esomeprazole and vitamin D3. Nevertheless pain did not decrease and a new examination found a worst hypophosphatemia (1 mg/dl) with normal Ca and PTH’s plasma values. During the same check-up a painful bulge on the anterior part of the right knee was observed and the Magnetic Resonance Imaging scan revealed an ovular solid lesion in the soft tissue closed to the upper part of the patella. Histological analysis identified the lesion as a PMTMCTV. After surgical removal patient got complete recovery. We will discuss about diagnostic evaluation, differential diagnosis and treatment.

Perioperative blood management strategies for patients undergoing total knee replacement:Where do we stand now?

Total knee replacement(TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions(ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.

Common controversies in total knee replacement surgery: Current evidence

Total knee replacement(TKR) is a widely used operation that has radically improved the quality of life of millions of people during the last few decades. However, some technical details, concerning the surgical procedure and the rehabilitation following total knee arthroplasty, are still a matter of a strong debate. In this review of the literature, we have included the best evidence available of the last decade, in an effort to shed light on some of the most controversial subjects related to TKR surgery. Posterior-stabilized or cruciate-retaining prosthesis? To use a tourniquet during operation or not? Do patients need continuous passive motion for their post-surgery rehabilitation? To resurface patella or not? These are some of the most controversial topics that until now have been persistent dilemmas for the orthopedic surgeon. Results of this systematic review of the literature are highly controversial. These conflicting results are an indication that larger and more well conducted high quality trials are needed in order to gain more secure answers. At the same time, it is becoming apparent that a meticulous operative technique, respecting the soft tissue envelope and knowing the principles of alignment and soft tissue balancing, aresome of the parameters that might contribute more to achieving the optimal results for the patients.

Loose Body in the Knee Joint: A Case Report

Background: Loose bodies (LBs) within the knee joint are commonly encountered during clinical practice and are frequently observed during knee arthroscopy. The primary treatment involves the removal of loose bodies;however, their complete eradication is often challenging and may not address underlying diseases, leading to persistent symptoms and the risk of new loose body formation. Aim: This case report aims to present the findings and surgical management of a 52-year-old male with an unusually large osseous loose body in the knee joint and associated pathologies. Case Presentation: The patient, a 52-year-old male, experienced recurrent episodes of severe, sudden, and painful locking of the knee joint, leading to difficulties moving. A plain MRI study was conducted to evaluate the condition of the knee joint, which revealed various degenerative changes and the presence of a loose body. Subsequently, an arthroscopic examination was performed under general anesthesia, uncovering the presence of an abnormally large loose body, as well as other pathologies including chondropathy, meniscal degeneration, and Baker’s cyst. Conclusion: Loose bodies (LBs) in the knee joint pose significant challenges and may lead to debilitating symptoms. Timely diagnosis and appropriate surgical intervention are crucial for symptom relief and the prevention of further joint damage as arthroscopic excision. Comprehensive imaging has a vital role in guiding treatment decisions and optimizing patient outcomes. In this case, the removal of the loose body improved patient outcomes and helped prevent potential joint complications.

Radiographic assessment of leg alignment and grading of knee osteoarthritis:A critical review

Knee osteoarthritis(OA) is a progressive joint disease hallmarked by cartilage and bone breakdown and associated with changes to all of the tissues in the joint,ultimately causing pain,stiffness,deformity and disability in many people.Radiographs are commonly used for the clinical assessment of knee OA incidence and progression,and to assess for risk factors.One risk factor for the incidence and progression of knee OA is malalignment of the lower extremities(LE).The hipknee-ankle(HKA) angle,assessed from a full-length LE radiograph,is ideally used to assess LE alignment.Careful attention to LE positioning is necessary to obtain the most accurate measurement of the HKA angle.Since full-length LE radiographs are not always available,the femoral shaft-tibial shaft(FS-TS) angle may be calculated from a knee radiograph instead.However,the FS-TS angle is more variable than the HKA angle and it should be used with caution.Knee radiographs are used to assess the severity of knee OA and its progression.There are three types of ordinal grading scales for knee OA:global,composite and individual feature scales.Each grade on a global scale describes one or more features of knee OA.The entire description must be met for a specific grade to be assigned.The KellgrenLawrence scale is the most commonly-used global scale.Composite scales grade several features of knee OA individually and sum the grades to create a total score.One example is the compartmental grading scale for knee OA.Composite scales can respond to change in a variety of presentations of knee OA.Individual feature scales assess one or more OA features individually and do not calculate a total score.They are most often used to monitor change in one OA feature,commonly joint space narrowing.The most commonly-used individual feature scale is the OA Research Society International atlas.Each type of scale has its advantages;however,composite scales may offer greater content validity.Responsiveness to change is unknown for most scales and deserves further evaluation.

Effects of Activating Blood Circulation to Resolve Blood Stasis and Glucosamine Capsules Therapy on the Expression of Matrix Metalloproteinase in Post-traumatic Knee Osteoarthritis

[Objectives] To observe the clinical effects of activating blood circulation to resolve blood stasis and glucosamine hydrochloride capsules therapy on post-traumatic knee osteoarthritis treatment,to measure the expression of matrix metalloproteinase in post-traumatic knee osteoarthritis patients before and after treatment,and to explore its relevant molecular mechanisms. [Methods]A total of 60 patients with posttraumatic knee osteoarthritis in early stage in Affiliated Hospital of Shannxi University of Chinese Medicine from January 2015 to December2017 were selected and randomly divided into the control group( n = 30) and the observation group( n = 30). The control group was given oral administration of glucosamine hydrochloride capsules for 6 courses of the treatment. The observation group was using the activating blood circulation to resolve blood stasis therapy for 6 courses of treatment. The recovery of traumatic knee osteoarthritis and the symptom of traditional Chinese medicine( TCM) in 2 groups was compared before and after treatment. The symptoms and the quantitative assessment rating scale of knee osteoarthritis,the pain index of knee and the TCM symptom scores were recorded in both groups. And the synovial fluid and serum of patients were collected to detect the expression of matrix metalloproteinase. [Results]The symptoms and the quantitative assessment rating scale of knee osteoarthritis,the pain index of knee and TCM symptom scores of the 2 groups in the 1 st week,the 12 th week and the 24 th week after the treatment were significantly lower than those before the treatment,and the difference was statistically significant( P < 0. 05). Two therapeutic methods had certain therapeutic effects on the recovery from traumatic knee osteoarthritis,and could significantly improve the TCM syndrome. There were better therapeutic effects on oral decoction of traditional Chinese medicine than oral glycosaminoglycans hydrochloride capsules on treating traumatic knee osteogenesis( P < 0. 05). The expression level of MMP3 was decreased significantly in both groups( P <0. 001),while the expression level of MMP13 had no significant change in both groups( P >0. 05). The expression level of MMP1 was decreased significantly in the observation group( P < 0. 001),but there was no significant change in the control group after treatment( P >0. 05). [Conclusions]Two treatment methods have been effective in this clinical study. We found that the expression level of MMP3 was decreased significantly after treatment in 2 therapies,which can be clinically applied.

State-of-the-Art management of knee osteoarthritis

Osteoarthritis(OA) is the most common type of arthritis found in the United States' population and is also the most common disease of joints in adults throughout the world with the knee being the most frequently affected of all joints. As the United States' population ages along with the increasing trends in obesity prevalence in other parts of the world, it is expected that the burden of OA on the population, healthcare system, and overall economy will continue to increase in the future without making major improvements in managing knee OA. Numerous therapies aim to reduce symptoms of knee OA and continued research has helped to further understand the complex pathophysiology of its disease mechanism attempting to uncover new potential targets for the treatment of OA. This review article seeks to evaluate the current practices for managing knee OA and discusses emerging therapies on the horizon. These practices include non-pharmacological treatments such as providing patient education and self-management strategies, advising weight loss, strengthening programs, and addressing biomechanical issues with bracing or foot orthoses. Oral analgesics and anti-inflammatories are pharmacologicals that are commonly used and the literature overall supports that some of these medications can be helpful for managing knee OA in the short-term but are less effective for long-term management. Additionally, more prolonged use significantly increases the risk of serious associated side effects that are not too uncommon. Diseasemodifying osteoarthritis drugs are being researched as a treatment modality to potentially halt or slow disease progression but data at this time is limited and continued studies are being conducted to further investigate their effectiveness. Intra-articular injectables are also implemented to manage knee OA ranging from corticosteroids to hyaluronans to more recently plateletrich plasma and even stem cells while several other injection therapies are presently being studied. The goal of developing new treatment strategies for knee OA is to prolong the need for total knee arthroplasty which should be utilized only if other strategies have failed. High tibial osteotomy and unicompartmental knee arthroplasty are potential alternatives if only a single compartment is involved with more data supporting unicompartmental knee arthroplasty as a good treatment option in this scenario. Arthroscopy has been commonly used for many years to treat knee OA to address degenerative articular cartilage and menisci, however, several high-quality studies have shown that it is not a very effective treatment for the majority of cases and should generally not be considered when managing knee OA. Improving the management of knee OA requires a multi-faceted treatment approach along with continuing to broaden our understanding of this complex disease so that therapeutic advancements can continue to be developed with the goal of preventing further disease progression and even potentially reversing the degenerative process.

Five Strand Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction Provides No Benefit over the Gold Standard Four Strand Repair for Anterior Stability of the Knee: A Prospective Cohort Study

The Four-Strand Hamstring Tendon Autograft has been long established as the gold standard for surgical reconstruction of the Anterior Cruciate Ligament. Some studies have suggested wider grafts, such as a Five-Strand hamstring graft, may provide greater strength and a larger scaffold for incorporation of the graft into the bone tunnels, leading to greater postoperative anterior stability of the knee. 28 (n = 18 Four-Strand and n = 10 Five-Strand) patients with planned ACL reconstructive surgery by a single surgeon were recruited for this study. The KT-1000 Arthrometer (MED metric, CA, USA) was used to quantify AP translation in the subjects’ knees before (T0) and after surgery at 6 (T1) and 12 (T2) weeks. At 12 weeks there was significantly higher (p = 0.01) mean anterior laxity on Maximum Manual Test in the Five- Strand group (9.1 ± 1.7 mm) than the Four Strand Group (6.9 ± 2.3 mm). Further, there were significantly higher mean side-to-side differences (p = 0.01) on Maximum Manual Test in the Five-Strand cohort (5.1 ± 3.5 mm) compared to the Four-Strand cohort (1.9 ± 2.2 mm). A significantly larger positive mean change in anterior laxity (p = 0.02) from 6 - 12 weeks was evident in the Five-Strand group (1.4 ± 0.9) than the Four-Strand group (-0.3 ± 1.9 mm). No significant correlations were seen between graft widths and measures of anterior stability on KT-1000. This study illustrated that there was no benefit to using a Five-Strand Hamstring Tendon Autograft when compared to the gold standard Four-Strand Repair specifically with regards to anterior stability of the knee.

Patient specific guides for total knee arthroplasty are ready for primetime

AIM: To present the radiological results of total knee arthroplasty(TKA) with use of patient specific matched guides(PSG) from different manufacturer in patients suffering from severe osteoarthritis of the knee joint.METHODS: This study describes the results of 57 knees operated with 4 different PSG systems and a group operated with conventional instrumentation(n = 60) by a single surgeon. The PSG systems were compared with each other and subdivided into cut- and pin PSG. The biomechanical axis [hip-knee-ankle angle(HKA)], varus/valgus of the femur [frontal femoral component(FFC)] and tibia(frontal tibial component) component, flexion/extension of the femur [flexion/extension of the femur component(LFC)] and posterior slope of the tibia [lateral tibial component(LTC)] component were evaluated on long-leg standing and lateral X-rays. A percentage of > 3° deviation was seen as an outlier. RESULTS: The inter class correlation coefficient(ICC) revealed that radiographic measurements between both assessors were reliable(ICC > 0.8). Fisher exact test was used to test differences of proportions. The percentage of outliers of the HKA-axis was comparable between both the PSG and conventional groups(12.28% vs 18.33%, P < 0.424) and the cut- and pin PSG groups(14.3% vs 10.3%, P < 1.00). The percentage of outliers of the FFC(0% vs 18.33%, P < 0.000), LFC(15.78% vs 58.33%, P < 0.000) and LTC(15.78% vs 41.67%, P < 0.033) were significant different in favour of the PSGgroup. There were no significant differences regarding the outliers between the individual PSG systems and the PSG group subdivided into cut- and pin PSG.CONCLUSION: PSG for TKA show significant less outliers compared to the conventional technique. These single surgeon results suggest that PSG are ready for primetime.

Controversial role of arthroscopic meniscectomy of the knee: A review

The role of arthroscopic partial meniscectomy(APM) in reducing pain and improving function in patients with meniscal tears remains controversial. Five recent highquality randomized controlled trials(RCTs) compared non-operative management of meniscal tears to APM, with four showing no difference and one demonstrating superiority of APM. In this review, we examined the strengths and weaknesses of each of these RCTs, with particular attention to the occurrence of inadvertent biases. We also completed a quantitative analysis that compares treatment successes in each treatment arm, considering crossovers as treatment failures. Our analysis revealed that each study was an excellent attempt to compare APM with non-surgical treatment but suffered from selection, performance, detection, and/or transfer biases that reduce confidence in its conclusions. While the RCT remains the methodological gold standard for establishing treatment efficacy, the use of an RCT design does not in itself ensure internal or external validity. Furthermore, under our alternative analysis of treatment successes, two studies had significantly more treatment successes in the APM arm than the non-operative arm although original intention-totreat analyses showed no difference between these two groups. Crossovers remain an important problem in surgical trials with no perfect analytical solution. With the studies available at present, no conclusion can be drawn concerning the optimal treatment modality for meniscal tears. Further work that minimizes significant biases and crossovers and incorporates sub-group and cost-benefit analyses may clarify therapeutic indications.

Three-dimensional reconstructed magnetic resonance scans:Accuracy in identifying and defining knee meniscal tears

AIM To determine whether three-dimensional(3D) reconstruction from conventional magnetic resonance imaging(MRI) is able to accurately detect a meniscal tear, and define the configuration.METHODS Thirty-three patients' 3T MRI scan data were collected and sagittal uni-planar 3D reconstructions performed from the preoperative MRI. There were 24 meniscal tears in 24 patients, and nine controls. All patients had arthroscopic corroboration of MRI findings. Two independent observers prospectively reported on all 33 reconstructions. Meniscal tear presence or absence was noted, and tear configuration subsequently categorised as either radial, bucket-handle, parrot beak, horizontal or complex.RESULTS Identification of control menisci or meniscal tear presence was excellent(Accuracy: observer 1 = 90.9%; observer 2 = 81.8%). Of the tear configurations, bucket handle tears were accurately identified(Accuracy observer 1 and 2 = 80%). The remaining tear configurations were notaccurately discernable.CONCLUSION Uni-planar 3D reconstruction from 3T MRI knee scan sequences are useful in identifying normal menisci and menisci with bucket-handle tears. Advances in MRI sequencing and reconstruction software are awaited for accurate identification of the remaining meniscal tear configurations.

Advanced concepts in knee arthrodesis

The aim is to describe advanced strategies that can beused to diagnose and treat complications after knee arthrodesis and to describe temporary knee arthrodesis to treat infected knee arthroplasty. Potential difficult complications include nonunited knee arthrodesis, limb length discrepancy after knee arthrodesis, and united but infected knee arthrodesis. If a nonunited knee arthrodesis shows evidence of implant loosening or failure, then bone grafting the nonunion site as well as exchange intramedullary nailing and/or supplemental plate fixation are recommended. If symptomatic limb length discrepancy cannot be satisfactorily treated with a shoe lift, then the patient should undergo tibial lengthening over nail with a monolateral fixator or exchange nailing with a femoral internal lengthening device. If a united knee arthrodesis is infected, the nail must be removed. Then the surgeon has the option of replacing it with a long, antibiotic cement-coated nail. The authors also describe temporary knee arthrodesis for infected knee arthroplasty in patients who have the potential to undergo insertion of a new implant. The procedure has two goals: eradication of infection and stabilization of the knee. A temporary knee fusion can be accomplished by inserting both an antibiotic cement-coated knee fusion nail and a static antibiotic cement-coated spacer. These advanced techniques can be helpful when treating difficult complications after knee arthrodesis and treating cases of infected knee arthroplasty.

全膝关节置换中BrainlabKnee3导航辅助间隙平衡技术的应用优势

背景:近年来,计算机导航技术辅助关节置换逐渐受到医疗领域的关注。文献报道计算机导航在全膝关节置换中的应用临床效果不一。为了探索新一代Brainlab Knee 3导航系统的临床效果,进行了此项研究。目的:分析计算机导航系统(Brainlab Knee 3)结合间隙平衡技术在全膝关节置换中的应用效果。方法:2020年11月至2021年5月大连市第二人民医院关节外科收治71例行全膝关节置换患者,导航组35例,术中采用计算机导航结合间隙平衡技术行全膝关节置换;传统组36例,术中采用传统手术器械定位截骨。比较两组患者术中内、外侧关节间隙差;膝关节活动度、KSS评分;髋膝踝角;冠状面股骨组件角、冠状面胫骨组件角和矢状面胫骨组件角偏差值。结果与结论:①导航组伸直位内外侧间隙差0,1,2 mm的患者分别为19,14,2例;屈膝90°位内外侧间隙差0,1,2 mm的患者分别为18,15,2例。传统组伸直位内外侧间隙差0,1,2 mm的患者分别为10,20,6例;屈膝90°位内外侧间隙差0,1,2 mm的患者分别为10,15,8例。②导航组手术时间长于传统组(P<0.05),导航组有2例患者术后形成下肢肌间静脉血栓,传统组患者均无并发症。③置换后6,12个月两组患者膝关节活动度均明显增加,导航组膝关节活动度高于传统组(P<0.05)。④置换后12个月两组患者KSS评分均明显增加,导航组KSS评分高于传统组(P<0.05)。⑤置换后6个月髋膝踝角、冠状面股骨组件角、冠状面胫骨组件角、矢状面胫骨组件角偏差值均显著小于传统组(P<0.05)。⑥结果表明,采用计算机导航结合间隙平衡技术辅助全膝关节置换对关节活动度、下肢力线、胫骨假体组件位置的准确性方面具有优势,置换后关节功能恢复良好。

Why total knees fail-A modern perspective review

Historically, the most common mechanism of total kneearthroplasty(TKA) failures included aseptic loosening, instability and malalignment. As polyethylene production improved, modes of failure from polyethylene wear and subsequent osteolysis became less prevalent. Newer longitudinal studies report that infection has become the primary acute cause of failure with loosening and instability remaining as the overall greatest reasons for revision. Clinical database and worldwide national registries confirm these reports. With an increasing amount of TKA operations performed in the United States, and with focus on value-based healthcare, it is imperative to understand why total knees fail.

Perioperative pain control after total knee arthroplasty: An evidence based review of the role of peripheral nerve blocks

Over the last decades,the number of total knee arthroplasty procedures performed in the United States has been increasing dramatically.This very successful intervention,however,is associated with significant postoperative pain,and adequate postoperative analgesia is mandatory in order to allow for successful rehabilitation and recovery.The use of regional anesthesia and peripheral nerve blocks has facilitated and improved this goal.Many different approaches and techniques for peripheral nerve blockades,either landmark or,more recently,ultrasound guided have been described over the last decades.This includes but is not restricted to techniques discussed in this review.The introduction of ultrasound has improved many approaches to peripheral nerves either in success rate and/or time to block.Moreover,ultrasound has enhanced the safety of peripheral nerve blocks due to immediate needle visualization and as consequence needle guidance during the block.In contrast to patient controlled analgesia using opioids,patients with a regional anesthetic technique suffer from fewer adverse events and show higher patient satisfaction;this is important as hospital rank-ings and advertisement have become more common worldwide and many patients use these factors in order to choose a certain institution for a specific procedure.This review provides a short overview of currently used regional anesthetic and analgesic techniques focusing on related implications,considerations and outcomes.

Use of antibiotic-loaded cement in total knee arthroplasty

Bone cement has the capacity to release antibiotic molecules if any antibiotic is included in it, and these elution properties are improved as cement porosity is increased. In vitro studies have shown high local antibiotic concentration for many hours or few days after its use. Antibiotic loaded bone cement(ALBC) is helpful when treating an infection in total knee arthroplasty(TKA) revision surgery. The purpose of this paper was to review the evidence for the routine use of ALBC in TKA in the literature, its pros and cons. Many authors have recommended the use of ALBC also in primary TKA for infection prophylaxis, but the evidence based on data from National Registries, randomized clinical trials and meta-analysis suggest a protective effect of ALBC against infection when used in hips, but not(or only mild) in knees. A possible explanation to this finding is that the duration and quantity of locally elevated antibiotic levels after surgery are smaller in TKA, due to the smaller amount of cement used for fixation in TKA-only a layer in the bone surface. There are some concerns about the routine use of ALBC in primary TKA as prophylaxis against infection: Firstly, there is a risk of hypersensivity or toxicity even when the chance is highly improbable. Secondly, there is a reduction in the mechanical properties of the cement, but this can be probably neglected if the antibiotic is used in low doses, not more than 1 g per 40 g cement package. Another significant concern is the increased economic cost, which could be overlooked if there were enough savings in treating fewer prosthetic infections. Finally, there is also a risk of selection of antibiotic-resistant strains of bacteria and this could be the main concern. If used, the choice of the antibiotic mixed in ALBC should consider microbiological aspects(broad antimicrobial spectrum and low rate of resistant bacteria), physical and chemical aspects(thermal stability, high water solubility), pharmacological characteristics(low risk to allergic reactions or toxicity) and economic aspects(not too expensive). The most commonly used antibiotics in ALBC are gentamicin, tobramycin and vancomycin. In conclusion, there is a paucity of randomized clinical trials in the use of ALBC in primary TKAs and the actual evidence of the effect of ALBC in reducing the risk of infection is insufficient. This, in addition to concerns about patient safety, risks of increase in the antibiotic resistance of microorganisms and the increase in costs in the procedure, lead us to recommend a cautious use of ALBC, perhaps only in high-risk patients(immunocompromised, morbidly obese, diabetic and patients with previous history of fracture or infection around the knee) unless the benefits of ALBC use were fully proven. Meanwhile, the rigorous use of peri-operative prophylactic systemic antibiotics and adoption of efficient antiseptic procedures and improved surgical techniques must be considered the gold standard in infection prevention in TKA surgery.

Elevated levels of interleukin-1β, interleukin-6, tumor necrosis factor-α and vascular endothelial growth factor in patients with knee articular cartilage injury

BACKGROUND Inflammatory cytokines play a vital role in the occurrence of osteoarticular injury and inflammation. Whether inflammation-associated factors interleukin-1β(IL- 1β), IL-6, tumor necrosis factor-α(TNF-α) and vascular endothelial growth factor (VEGF) are involved in the pathogenesis of keen articular cartilage injury remains poorly understood. AIM To measure the levels of inflammatory factors [IL-1β, IL-6, TNF-α and VEGF] in patients with knee articular cartilage injury. METHODS Fifty-five patients with knee articular cartilage injury were selected as patient groups, who were divided into three grades [mild (n = 20), moderate (n = 19) and severe (n = 16)] according to disease severity and X-ray examinations. Meanwhile, 30 healthy individuals who underwent physical examination were selected as the control group. The levels of IL-1β, IL-6, TNF-α and VEGF were measured by ELISA and immunohistochemical staining. RESULTS Compared with the control group, patient groups displayed significantly higher levels of IL-1β, IL-6, TNF-α and VEGF, and the extent of increase was directly proportional to the severity of injury (P < 0.05). In addition, the number of cells with positive staining of IL-1β, IL-6, TNF-α and VEGF in the synovial membrane were significantly increased, along with increased disease severity (P < 0.05). After treatment, the scores of visual analogue scale and the Western Ontario and McMaster University of Orthopaedic Index in patient groups were 2.26 ± 1.13 and 15.56 ± 7.12 points, respectively, which were significantly lower than those before treatment (6.98 ± 1.32 and 49.48 ± 8.96). Correlation analysis suggested that IL-1β and TNF-α were positively correlated with VEGF. CONCLUSION IL-1β, IL-6, TNF-α and VEGF levels are increased in patients with knee articular cartilage injury, and are associated with the disease severity, indicating they might play an important role in the occurrence and development of knee articular cartilage injury. Furthermore, therapeutically targeting them might be a novel approach for the treatment of keen articular cartilage injury.

Synovial lipomatosis: A rare cause of knee pain in an adolescent female

Synovial lipomatosis is a benign proliferative disease of the subsynovial adipose which can lead to a variety of presentations. Cases of synovial lipomatosis in children or adolescents are rare. This case report describes an adolescent patient with a rare bilateral presentation of synovial lipomatosis. She had been treated for years prior to her presentation for juvenile idiopathic arthritis. She presented with chronic bilateral knee pain, swelling, and mechanical symptoms. Bilateral MR imaging demonstrated effusions, hypertrophy of the synovium, and polyp-like projections of tissue with the same signal intensity as fat which is pathognomonic for synovial lipomatosis. Arthroscopic synovectomy and extensive debridement of polyp like fat projections of the right knee was performed. Histopathology was consistent with the synovial lipomatosis diagnosis. Postoperatively, the patient was satisfied with her outcome with improved pain relief and function in her right knee.

Efficacy of Slow Reversal Hold and Isometrics in Improving Muscle Strength, Increasing Range of Motion, and Reducing Pain in Patients with Osteoarthritis of Knee

Osteoarthritis of knee is a common problem in the elderly population worldwide. Physical therapy has been shown to be useful in decreasing pain and increasing mobility in this population. The aim of this study was to study the effectiveness of slow reversal hold and isometric exercise techniques in reducing pain, increasing muscle strength, and increasing range of motion for knee flexion in patients with osteoarthritis of knee. The other aim of this study was to compare the relative effectiveness of these two interventions. 60 subjects participated in this study and were randomly assigned either to the slow reversal hold group (n = 30) or, to the isometrics exercise group (n = 30). All subjects performed their respective exercises for 3 weeks. Pain scores using the visual analog scale, muscle strength using manual muscle testing of quadriceps and hamstrings, and range of motion (ROM) for knee flexion using a goniometer were recorded both pre-treatment and post-treatment for both left and right knees. Both the interventions showed a significant decrease in pain scores, an increase in muscle strength, as well as an increase in the ROM. However, ROM was significantly increased in the slow reversal hold group as compared to the isometrics group in both knees. It was concluded that both exercise techniques could be useful in patients with osteoarthritis of knee for decreasing pain and increasing muscle strength. Slow reversal hold technique might be a better technique than isometrics for increasing ROM for knee flexion.