Previous cartilage surgery is associated with inferior patient-reported outcomes after knee arthroplasty

Purpose: The hypothesis of the present study assumed that a history of focal cartilage lesions would not affect Knee Injury and Osteoarthritis Outcome scores (KOOSs) following knee arthroplasty compared to a matched national cohort of knee arthroplasty patients. Methods: Fifty-eight knee arthroplasty patients with previous surgery for focal cartilage lesions (cartilage cohort) were compared to a matched cohort of 116 knee arthroplasty patients from the Norwegian Arthroplasty Register (control group). Age, sex, primary or revision arthroplasty, type of arthroplasty (total, unicondylar or patellofemoral), year of arthroplasty surgery and arthroplasty brand were used as matching criteria. Demographic data and KOOS were obtained through questionnaires. Regression models were employed to adjust for confounding factors. Results: Mean follow-up post knee arthroplasty surgery was 7.6 years (range 1.2–20.3) in the cartilage cohort and 8.1 (range 1.0–20.9) in the control group. The responding patients were at the time of surgery 54.3 versus 59.0 years in the cartilage and control group, respectively. At follow-up the control group demonstrated higher adjusted Knee Injury and Osteoarthritis Outcome subscores than the previous focal cartilage patients with a mean adjusted difference (95% confidence interval in parentheses): Symptoms 8.4 (0.3, 16.4), Pain 11.8 (2.2, 21.4), Activities of daily living (ADL) 9.3 (−1.2, 18.6), Sport and recreation 8.9 (−1.6, 19.4) and Quality of Life (QoL) 10.6 (0.2, 21.1). The control group also demonstrated higher odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores with odds ratio: Symptoms 2.7 (1.2, 6.4), Pain 3.0 (1.3, 7.0), ADL 2.1 (0.9, 4.6) and QoL 2.4 (1.0, 5.5). Conclusion: Previous cartilage surgery was associated with inferior patient-reported outcomes after knee arthroplasty. These patients also exhibited significantly lower odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores. Level of Evidence: Level III.publishedVersio

The Long-Term Risk of Knee Arthroplasty in Patients with Arthroscopically Verified Focal Cartilage Lesions: A Linkage Study with the Norwegian Arthroplasty Register, 1999 to 2020

Background: Focal cartilage lesions are common in the knee. The risk of later ipsilateral knee arthroplasty remains unknown. The purposes of the present study were to evaluate the long-term cumulative risk of knee arthroplasty after arthroscopic identification of focal cartilage lesions in the knee, to investigate the risk factors for subsequent knee arthroplasty, and to estimate the subsequent cumulative risk of knee arthroplasty compared with that in the general population. Methods: Patients who had undergone surgical treatment of focal cartilage lesions at 6 major Norwegian hospitals between 1999 and 2012 were identified. The inclusion criteria were an arthroscopically classified focal cartilage lesion in the knee, an age of ≥18 years at the time of surgery, and available preoperative patient-reported outcomes (PROMs). The exclusion criteria were osteoarthritis or “kissing lesions” at the time of surgery. Demographic data, later knee surgery, and PROMs were collected with use of a questionnaire. A Cox regression model was used to adjust for and investigate the impact of risk factors, and Kaplan-Meier analysis was performed to estimate cumulative risk. The risk of knee arthroplasty in the present cohort was compared with that in the age-matched general Norwegian population. Results: Of the 516 patients who were eligible, 322 patients (328 knees) consented to participate. The mean age at the time of the index procedure was 36.8 years, and the mean duration of follow-up was 19.8 years. The 20-year cumulative risk of knee arthroplasty in the cartilage cohort was 19.1% (95% CI, 14.6% to 23.6%). Variables that had an impact on the risk of knee arthroplasty included an ICRS grade of 3 to 4 (hazard ratio [HR], 3.1; 95% CI, 1.1 to 8.7), an age of ≥40 years at time of cartilage surgery (HR, 3.7; 95% CI, 1.8 to 7.7), a BMI of 25 to 29 kg/m2 (HR, 3.9; 95% CI, 1.7 to 9.0), a BMI of ≥30 kg/m2 (HR, 5.9; 95% CI, 2.4 to 14.3) at the time of follow-up, autologous chondrocyte implantation (ACI) at the time of the index procedure (HR, 3.4; 95% CI, 1.0 to 11.4), >1 focal cartilage lesion (HR, 2.1; 95% CI, 1.1 to 3.7), and a high preoperative visual analog scale (VAS) score for pain at the time of the index procedure (HR, 1.1; 95% CI, 1.0 to 1.1). The risk ratio of later knee arthroplasty in the cartilage cohort as compared with the age-matched general Norwegian population was 415.7 (95% CI, 168.8 to 1,023.5) in the 30 to 39-year age group. Conclusions: In the present study, we found that the 20-year cumulative risk of knee arthroplasty after a focal cartilage lesion in the knee was 19%. Deep lesions, higher age at the time of cartilage surgery, high BMI at the time of follow-up, ACI, and >1 cartilage lesion were associated with a higher risk of knee arthroplasty.publishedVersio

Intraarticular location predicts cartilage filling and subchondral bone changes in a chondral defect: A randomized, blind, long-term follow-up trial involving 82 rabbit knees

Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.Background and purpose: The natural history of, and predictive factors for outcome of cartilage restoration in chondral defects are poorly understood. We investigated the natural history of cartilage filling subchondral bone changes, comparing defects at two locations in the rabbit knee. Animals and methods: In New Zealand rabbits aged 22 weeks, a 4-mm pure chondral defect (ICRS grade 3b) was created in the patella of one knee and in the medial femoral condyle of the other. A stereo microscope was used to optimize the preparation of the defects. The animals were killed 12, 24, and 36 weeks after surgery. Defect filling and the density of subchondral mineralized tissue was estimated using Analysis Pro software on micrographed histological sections. Results: The mean filling of the patellar defects was more than twice that of the medial femoral condylar defects at 24 and 36 weeks of follow-up. There was a statistically significant increase in filling from 24 to 36 weeks after surgery at both locations. The density of subchondral mineralized tissue beneath the defects subsided with time in the patellas, in contrast to the density in the medial femoral condyles, which remained unchanged. Interpretation: The intraarticular location is a predictive factor for spontaneous filling and subchondral bone changes of chondral defects corresponding to ICRS grade 3b. Disregarding location, the spontaneous filling increased with long-term follow-up. This should be considered when evaluating aspects of cartilage restoration

Antibiotic-loaded bone cement in prevention of periprosthetic joint infections in primary total knee arthroplasty: A register-based multicentre randomised controlled non-inferiority trial (ALBA trial)

Introduction The current evidence on the efficacy of antibiotic-loaded bone cement (ALBC) in reducing the risk of periprosthetic joint infections (PJI) after primary joint reconstruction is insufficient. In several European countries, the use of ALBC is routine practice unlike in the USA where ALBC use is not approved in low-risk patients. Therefore, we designed a double-blinded pragmatic multicentre register-based randomised controlled non-inferiority trial to investigate the effects of ALBC compared with plain bone cement in primary total knee arthroplasty (TKA). Methods and analysis A minimum of 9,172 patients undergoing full-cemented primary TKA will be recruited and equally randomised into the ALBC group and the plain bone cement group. This trial will be conducted in Norwegian hospitals that routinely perform cemented primary TKA. The primary outcome will be risk of revision surgery due to PJI at 1-year of follow-up. Secondary outcomes will be: risk of revision due to any reason including aseptic loosening at 1, 6, 10 and 20 years of follow-up; patient-related outcome measures like function, pain, satisfaction and health-related quality of life at 1, 6 and 10 years of follow-up; risk of changes in the microbial pattern and resistance profiles of organisms cultured in subsequent revisions at 1, 6, 10 and 20 years of follow-up; cost-effectiveness of routine ALBC versus plain bone cement use in primary TKA. We will use 1:1 randomisation with random permuted blocks and stratify by participating hospitals to randomise patients to receive ALBC or plain bone cement. Inclusion, randomisation and follow-up will be through the Norwegian Arthroplasty Register. Ethics and dissemination The trial was approved by the Western Norway Regional Committees on Medical and Health Research Ethics (reference number: 2019/751/REK vest) on 21 June 2019. The findings of this trial will be disseminated through peer-reviewed publications and conference presentations. Trial registration number NCT04135170.publishedVersio

Focal Cartilage Defects in the Knee

In comparing four patient groups awaiting knee surgery treatment, patients with focal cartilage defects in their knees presented major problems with pain and functional impairment, their quality of life evaluated by KOOS being affected to the same extent as in patients scheduled for knee replacement. Eighty four patients with knee cartilage defects ICRS grade 3 and 4 completed follow up median 6.1 years (5-8y) after the detection of the defect by knee arthroscopy. During the follow up, the patients improved their knee function, regardless of having cartilage repair or not. They did not, however, regain normal knee function. Moreover, radiological changes in the affected knee were present in 28 % at the 6-year follow up. In an experimental study the intraarticular location of a focal cartilage defect showed to predict the natural history of defect filling and subchondral mineralized tissue changes in the rabbit knee. This knowledge should be considered in evaluating results of cartilage repair in animal models. By comparing two commonly used techniques for cartilage repair in the same model, mosaic plasty resulted in higher degree of tissue filling than microfracture technique. Large standard deviations, however, imply unpredictable results in the single case – even in a standardized animal model. Mosaic plasty affected the subchondral mineralized tissues more than microfracture technique, the implications of the latter, however, being unknown

Injuries among male and female World Cup alpine skiers

Background: Limited knowledge exists on injuries among professional alpine skiers. Objective: To describe the risk of injury and the injury pattern among competitive World Cup alpine skiers during the competitive season. Methods: We performed retrospective interviews with all World Cup athletes from 10 nations at the end of the 2006-07 and 2007-08 winter seasons and recorded all acute injuries occurring during the 4.5-month competitive season. If the athlete was not present, we interviewed their coaches or medical personnel. Results: A total of 191 acute injuries were recorded among 521 World Cup alpine skiers. As many as 86 injuries (45%) occurred during World Cup/World Ski Championship competitions, corresponding to an injury rate of 9.8 injuries per 1000 runs (95% confidence interval, 7.8 to 11.9). We found the injury rate to increase with increasing speed (slalom 4.9 injuries per 1000 runs, 95% CI 2.5 to 7.4 - giant slalom 9.2, 5.1 to 13.3 - super-G 11.0, 5.2 to 16.8 - downhill 17.2, 11.6 to 22.7). The most frequently injured body part was knee with 68 injuries (36%) and 37 of these were severe. The overall injury rate was higher in males compared to females, but not for knee injuries. Conclusions: The risk of injury among World Cup athletes in alpine skiing is even higher than previously reported and the knee is the most commonly injured body part and with many severe injuries. Injury rate increased with higher speed and was higher among males compared to females

6-year follow-up of 84 patients with cartilage defects in the knee : knee scores improved but recovery was incomplete

Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.Background and purpose: The natural history of focal cartilage injury is largely unknown. In this study we investigated 6-year outcomes in patients with arthroscopically verified, focal, fullthickness cartilage injuries of the knee. Methods: In a previous report (baseline study) of 993 knee arthroscopies, 98 patients were less than 50 years old at baseline and showed grade 3–4 focal cartilage injury, as assessed with the International Cartilage Repair Society (ICRS) scale. In the present study, 84 of the 98 patients completed follow-ups at median 6.1 (5.3–7.8) years after baseline assessments. At baseline, the patients had undergone different types of cartilage repair (n = 34) or had no treatment or only debridement (n = 64) for their cartilage injury. The follow-up included evaluations with the ICRS knee evaluation form, the Lysholm score, and other knee evaluation tests. 68 patients underwent radiographic assessments with weight bearing. Results: Improvements compared to baseline were noted in the average ICRS functional score, visual analog scale (VAS) pain score, and the patients’ rating of the function in the affected knee compared to the contra-lateral knee. However, the average ICRS activity level had decreased from baseline. The average Lysholm score was 76 (SD 21). 19 patients had Kellgren-Lawrence grades 2–3 in the affected knee and 6 patients had grades 2–3 in the contralateral knee. There was a statistically significant difference between affected and contralateral knees. Interpretation: Patients with arthroscopically diagnosed ICRS grade 3–4 cartilage injuries in the knee may show improvement in knee function over the following 5–8 years, with or without cartilage repair. However, knee function remains substantially affected. Further studies are needed to determine whether cartilage surgery can yield better functional outcomes than non-surgical or less invasive surgical treatments