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Introduction Coronavirus (COVID-19) has negatively impacted healthcare around the world. It has had a major impact on orthopaedic training. The independent sector has been proposed as a facility for future training. Our aim was to provide an overview of the current higher surgical trainees’ experience in the independent sector. Method Training orthopaedic registrars within the East of England deanery were asked to complete an electronic questionnaire of their training experience in the independent sector between 5th November to 2nd December 2020. Results 57 of 64 registrars (89%) from across all thirteen regional training hospitals responded. 44% attended the independent sector, but 7 only assisted (28%). No third year trainees went, but there was an even spread of other training years attending a mean of four sessions. Sixty-six indicative procedures were performed, all with supervisors scrubbed. Second year trainees performed the most cases with 4 on average. Completion of work based assessments was low. 20% trainees reported a negative experience. 80% enjoyed themselves. 52% felt they achieved their goals. 29% trainees felt that independent sector operating would compensate for the shortfall in training brought about by COVID-19. The main obstacles to independent sector training were lack of access and opportunity (51%) and poor induction and paperwork issues (22%) Conclusion This is the first deanery-wide assessment of access to and training within the independent sector due to COVID-19. Independent sector operating for orthopaedic trainees is feasible on scale and should be embedded to supplement training in the future. In their current state independent sector facilities are not easily and universally accessible to fulfil training needs.

Through a trainee research collaborative, we have studied the changes in practice of 12 TO departments across the East of England over the first four weeks of the UK lockdown and COVID-19 pandemic, comparing to activity levels with the corresponding period in 2019. We focused on changes in TO practice, training and redeployment of Trainees. Units differ considerably in several aspects of practice. We found a 97% reduction in elective operating, 64% reduction in elective outpatient activity and 37% reduction in operative trauma. 58% of trainees continued working in TO clinics, with an average of 6 operative cases over this period. Our modelling suggests that the impact on training will persist; counter-measures must be incorporated into central recovery planning.

ObjectiveNo studies currently exist with long-term follow-up of use of osteochondral allografting (OCA) for treatment of steroid-associated osteonecrosis of femoral condyles in young, active patients who wish to avoid total knee arthroplasty (TKA). We evaluate the extent to which fresh osteochondral allografts can (1) prevent or postpone need for prosthetic arthroplasty and (2) maintain long-term clinically meaningful decrease in pain and improvement in function at mean 11-year follow-up.DesignTwenty-five patients (33 knees) who underwent OCA transplantation for osteonecrosis of the knee between 1984 and 2013 were evaluated, including 22 females and 11 males with average age of 25 years (range, 16-48 years). Mean total allograft surface area was 10.6 cm2(range, 4.0-19.0 cm2). Evaluation included International Knee Documentation Committee (IKDC) scores, Knee Society function (KS-F) score, and modified (for the knee) Merle d’Aubigné-Postel (18-point) score.ResultsOCA survivorship was 90% at 5 years and 82% at 10 years. Twenty-eight of 33 knees (85%) avoided arthroplasty and 25 of 33 knees (73%) avoided other surgical intervention. Mean IKDC pain score improved ( P = 0.001) from 7.2 preoperatively to 2.8 at latest follow-up, mean IKDC function score increased ( P = 0.005) from 3.3 to 6.5, and mean IKDC total score improved ( P = 0.001) from 31.9 to 61.1. Mean KS-F score improved ( P = 0.003) from 61.7 to 87.5. Mean modified Merle d’Aubigné-Postel (18-point) score improved ( P < 0.001) from 11.4 to 15.1.ConclusionsOur findings suggest that OCA transplantation is a reasonable surgical treatment option for steroid-associated osteonecrosis of the femoral condyles, with durable long-term outcomes.

ObjectiveTo evaluate the outcome of patients who have undergone simultaneous osteotomy and osteochondral allograft (OCA) transplantation. Our hypothesis is that use of high tibial osteotomy and fresh OCA in a combined procedure is safe and effective without increasing morbidity in comparison to OCA alone.DesignA case series of 17 patients underwent tibial osteotomy and simultaneous OCA during a single surgery. Osteotomy was indicated when axial alignment was within the affected compartment. Patients had a minimum of 2 years of follow-up after surgery. The mean graft size was 8.7 cm2, with 82% located on the medial femoral condyle alone and 18% involving the medial femoral condyle and one or more other sites. Data collection included demographics, osteotomy correction, graft site(s) and area, and clinical evaluation. Failure was defined as conversion to arthroplasty.ResultsTwo of 17 patients (12%) failed at a mean of 9.3 years. The remaining 15 patients (88%) had intact allografts with mean survival of 8.1 years (SD 3.3). Five patients (29%) had an additional procedure, all undergoing osteotomy hardware removal. Of those with surviving allografts, mean pain and function scores improved significantly from the preoperative to postoperative assessment and International Knee Documentation Committee total scores improved significantly from 40.9 ± 15.4 preoperative to 75.5 ± 24.0 at latest follow-up ( P = 0.003); 92% of patients were satisfied with the results of the surgery. No postoperative complications occurred.ConclusionCombining high tibial osteotomy and OCA in properly selected patients is safe and effective.

Background: Osteochondral allograft (OCA) transplantation is an integral part of the cartilage repair paradigm, but insufficient data are available regarding return to sport or recreational activity after the procedure. Purpose: The purpose of this study was to determine if athletic patients undergoing OCA transplantation returned to sport, assess reasons for not returning to sport, and ascertain patient and graft-related characteristics that differed between those who returned or did not return to sport. The secondary aims were to assess graft survivorship and patient-reported subjective outcome measures (pain, function, satisfaction) among athletic patients undergoing OCA transplantation. Study Design: Case series; Level of evidence, 4. Methods: We identified 149 knees in 142 patients who participated in sport or recreational activity before a cartilage injury (45% highly competitive athletes and 55% well-trained and frequently sporting) and underwent OCA transplantation in the knee. The mean age was 31.2 years and 58.4% were male. Information on preinjury and postoperative participation in sport or recreational activity was collected. Patients not returning to sport after OCA transplantation were mailed a questionnaire to assess why. Postoperative pain, function, and satisfaction scores were obtained, and further surgery on the operative knee was documented. Results: At a mean follow-up of 6 years, 75.2% of knees returned to sport or recreational activity. Among those who did not return to sport, knee-related issues and lifestyle changes were cited as reasons why. Patients who did not return to sport were more likely to be female, have injured their knee in an activity other than sport, and have a larger graft size. The diagnosis and anatomic location also differed. Overall, 71% of knees reported having “very good” to “excellent” function, and 79% were able to participate in a high level of activity (moderate, strenuous, or very strenuous) postoperatively. After OCA transplantation, 25.5% of knees underwent further surgery; 14 knees (9.4% of entire cohort) were considered allograft failures. Among the 135 knees that had the graft remaining in situ, pain and function improved from preoperatively to the latest follow-up on all measures, and 91% of patients were satisfied with the results of the surgery. Conclusion: OCA transplantation is a successful treatment option for athletes and highly active patients who sustain a cartilage injury to their knee. The majority of patients returned to sport or recreational activity.

Study Design: Retrospective observational case series. Objectives: Lateral lumbar interbody fusion (LLIF) has been widely performed with recombinant human bone morphogenetic protein-2 (rhBMP-2), but the fusion rates using this graft alternative have not been well studied. We aimed to evaluate fusion rates in 1- and 2-level LLIF with rhBMP-2 and their relationship with fixation, as well as rates of BMP-related complications. Methods: Institutional review board (IRB)–approved spine registry cohort of 93 patients who underwent LLIF with rhBMP-2 (71 one-level cases and 22 two-level cases). Minimum 1-year clinical follow-up and computed tomography (CT) scan for fusion assessment. Postoperative CT scans were used to evaluate the rate of fusion in all patients. Instrumentation and complications were collected from chart and imaging review. Results: Average age was 65 years (67% female). For 1-level cases, 92% (65/71) had complete fusion and 8% (6/71) had either incomplete or indeterminate fusion. Three of the 6 patients who had incomplete or indeterminate fusion had bilateral pedicle screw instrumentation, 1 patient had unilateral posterior fixation, and 2 had no fixation. In 2-level cases, 86% (19/22) had complete fusion and 14% (3/22) had either incomplete or indeterminate fusion. The 3 patients who had incomplete or indeterminate fusion did not have fixation. Conclusion: Interbody fusion rates with rhBMP-2 via LLIF was 92% in 1-level cases and 86% in 2-level cases, indicating that rhBMP-2 may be used as a viable graft alternative to allograft options for LLIF. Higher rates of pseudarthrosis occurred when not using fixation.

Background:Previous studies showed clinical benefit and durable results of osteochondral allograft (OCA) transplantation for the treatment of femoral condyle lesions. However, the majority of these studies are difficult to interpret owing to the mixed results of different techniques and anatomic locations.Purpose:To evaluate the outcome of OCA transplantation with thin plug grafts for treatment of isolated femoral condyle osteochondral lesions.Study Design:Case series; Level of evidence, 4.Methods:This study included 187 patients (200 knees) who underwent OCA transplantation for isolated osteochondral lesions on the femoral condyle between 1999 and 2014. For all cases, a thin plug technique was used with commercially available surgical instruments and the minimum amount of bone necessary for fixation. Evaluation included International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and patient satisfaction. Frequency and type of further surgery were assessed. Failure of the allograft was defined as further surgery involving removal of the allograft.Results:Mean follow-up was 6.7 years (range, 1.9-16.5 years). The mean age of patients at the time of surgery was 31 years, and 63% were male. The medial femoral condyle was affected in 69% of knees. A single thin plug graft was used in 145 knees (72.5%), and 2 grafts were used in 55 knees (27.5%). Mean allograft area was 6.3 cm2, and graft thickness was 6.5 mm (cartilage and bone combined). Further surgery was required for 52 knees (26%), of which 16 (8% of entire cohort) were defined as allograft failures (4 OCA revisions, 1 arthrosurface, 6 unicompartmental knee arthroplasties, and 5 total knee arthroplasties). Median time to failure was 4.9 years. Survivorship of the allograft was 95.6% at 5 years and 91.2% at 10 years. Among patients with grafts remaining in situ at latest follow-up, clinically meaningful improvement in pain, function, and quality of life was reported. Satisfaction was reported by 89% of patients.Conclusion:OCA transplantation with a thin plug graft technique is a valuable procedure for the treatment of femoral condyle osteochondral lesions, resulting in significant improvement in clinical scores, high patient satisfaction, and low reoperation and clinical failure rates.

Background:Osteochondritis dissecans (OCD) of the knee can be difficult to treat. Cartilage restoration techniques are often indicated when the lesion or fragment cannot be salvaged and the patient remains symptomatic. Fresh osteochondral allograft (OCA) transplantation can restore both bone and cartilage defects characteristic of OCD.Hypothesis:We hypothesized that osteochondral allografting is a successful method for treating OCD of the knee.Study Design:Case series; Level of evidence, 4.Methods:This study comprised 135 patients (149 knees) who underwent OCA for OCD of the knee (type III or IV) between 1997 and 2013 and had a minimum follow-up of 2 years. The median age was 21 years (range, 12-55 years) and 75.8% of the patients were male. The mean allograft size was 7.3 cm2(range, 2.2-25 cm2). Evaluation included the following: frequency and type of reoperations; modified Merle d’Aubigné and Postel (18-point) scale; International Knee Documentation Committee (IKDC) pain, function, and total scores; and Knee Society function (KS-F) and knee (KS-K) scores. Clinical failure was defined as revision OCA or conversion to arthroplasty. Graft survivorship was determined.Results:The median follow-up time was 6.3 years (range, 1.9-16.8 years) and 62% of participants had more than 5-year follow-up. Thirty-four of 149 knees (23%) had reoperations, of which 12 (8%) were classified as allograft failures (7 OCA revisions, 3 unicompartmental knee arthroplasties, and 2 total knee arthroplasties). OCA survivorship was 95% at 5 years and 93% at 10 years. Of the 137 knees whose grafts were still in situ at the latest follow-up, the mean modified Merle d’Aubigné and Postel (18-point) score was 16.8; IKDC pain, function, and total scores were 2.1, 8.1, and 82.3; and KS-F and KS-K scores were 95.7 and 94.3, respectively. The majority of patients (95%) reported being satisfied with the outcome of their procedure.Conclusion:OCA transplantation was an effective treatment for OCD of the knee, with a low rate of graft failure, significant improvement in pain and function scores, and high patient satisfaction.

Background: The association between patient satisfaction and patient-reported outcomes after cartilage repair is not well understood. Purpose: To investigate the association of patient satisfaction with pain, function, activity level, and quality of life after fresh osteochondral allograft (OCA) transplantation in the knee. Study Design: Case-control study; Level of evidence, 3. Methods: This study comprised 371 patients (396 knees) who underwent primary OCA transplantation for osteochondral lesions in the knee between 1997 and 2015. Mean ± SD patient age was 31.8 ± 11.6 years, and 62% were male. The majority of grafts (62%) were located on the femoral condyle; the mean number of grafts per knee was 1.5 ± 0.8; and the median graft area was 6.9 cm2 (range, 1.8-50 cm2). Pain, function, activity level, and quality of life were evaluated pre- and postoperatively via International Knee Documentation Committee scores and Knee injury and Osteoarthritis Outcome Scores. Patient satisfaction with the results of the OCA transplantation was assessed postoperatively. All follow-up evaluations occurring at postoperative 1 year or later were included in the analysis. Results: The mean follow-up time was 5.5 years. Overall, the satisfaction rate was 88.1%, and this rate was constant over time. Satisfaction rates varied by diagnosis, age, sex, and anatomic location of the allograft. Postoperative International Knee Documentation Committee pain, function, and total scores differed between patients who were satisfied and not satisfied (all P < .001). All Knee injury and Osteoarthritis Outcome Score subscale results differed between those who were satisfied and not satisfied (all P < .001). Having a diagnosis of osteochondritis dissecans was the only variable that predicted which patients would be satisfied with the results of the allograft, after controlling for age, sex, anatomic location of the graft, and number of grafts. Conclusion: A consistently high and durable patient satisfaction rate after OCA transplantation was found. Satisfied patients reported lower pain and higher function, activity levels, and quality of life as compared with patients who were not satisfied. Patients with osteochondritis dissecans had a particularly high level of satisfaction with the OCA procedure.

The impact of self-reported metal allergy (SRMA) in total knee arthroplasty (TKA) remains controversial. In the absence of objective tests, SRMA is often used as a screening tool for implant selection. The objective of this study was to determine the effect of SRMA on early outcomes after TKA. Between 2010 and 2014, 168 patients with SRMA underwent TKA; 150 (89%) received nickel-free implants, and 18 (11%) received cobalt-chrome implants that contained nickel. Mean age was 67 years, and 95% were female. A cohort of 858 TKA patients (mean age, 68 years) without SRMA matched by sex served as the control group. Outcomes included Knee Society Score (function [KSS-F] and knee [KSS-K]), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, knee flexion, further surgery, and complications. No differences were seen in KSS-F and KSS-K between patients with and without SRMA. The mean WOMAC pain scores were 89.1 for patients with SRMA and 85.2 for patients without SRMA ( P =.030). Stiffness and physical function scores were similar. Knee flexion was similar. No differences were found between nickel-free and cobalt-chrome SRMA groups. Patients with SRMA and those without demonstrated similar early functional outcomes. Patients with SRMA who received standard cobalt-chrome implants had no significant difference in functional outcomes compared with patients with nickel-free implants. Better identifiers of patients at risk for adverse events due to implant material are needed. [ Orthopedics . 2019; 42(6):330–334.]

Background: Fresh osteochondral allograft (OCA) transplantation represents a biologic restoration technique as an alternative treatment option for larger osteochondral lesions of the talus (OLT). The purpose of this study was to evaluate midterm outcomes after OCA transplantation for the treatment of OLT. Methods: Nineteen patients (20 ankles) received partial unipolar OCA transplant for symptomatic OLT between January 1998 and October 2014. The mean age was 34.7 years, and 53% were male. The average graft size was 3.8 cm2. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), the Olerud-Molander Ankle Score (OMAS), and pain and satisfaction questionnaires. Failure of OCA was defined as conversion to arthrodesis or revision OCA transplantation. Results: Five of 20 ankles (25%) required further surgery, of which 3 (5%) were considered OCA failures (2 arthrodesis and 1 OCA revision). The mean time to failure was 3.5 (range, 0.9 to 6.7) years. Survivorship was 88.7% at 5 years and 81.3% at 10 years. The median follow-up of the 17 patients with grafts in situ was 9.7 years. The mean OMAS improved significantly from 40 points preoperatively to 71 points postoperatively ( P < .05; range, 5 to 55). The mean postoperative AAOS-FAM core score was 81.5 ± 15 (range, 40.5 to 96.6). Fifteen of 17 patients responded to follow-up questions regarding their ankle; 14 patients reported less pain and better function, and 13 patients were satisfied with the results of the procedure. Conclusion: Our study of midterm results after OCA transplantations showed that this procedure was a reasonable treatment option for large OLT. Level of Evidence: Level IV, case series.

Background: Few studies have evaluated the influence of anterior cruciate ligament (ACL) reconstruction on the outcome of cartilage repair. Hypothesis/Purpose: The purpose was to investigate the association between ACL reconstruction and functional outcomes after osteochondral allograft (OCA) transplantation. The hypothesis was that patients treated with OCA transplantation who had a history of ACL reconstruction would have inferior clinical outcomes and lower osteochondral graft survivorship when compared with a matched group of patients undergoing OCA transplantation without a history of ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: This study compared 31 knees that underwent OCA transplantation with a history of ACL reconstruction (OCA and ACL group) and 62 knees treated with isolated OCA transplantation (OCA group) that had an intact ACL. Groups were matched by age, diagnosis, year of surgery, and graft size. Minimum follow-up was 2 years. Frequency and type of reoperation were assessed. Clinical failure was defined as revision OCA transplantation or conversion to arthroplasty. Subjective outcome measures included International Knee Documentation Committee scores, Knee injury and Osteoarthritis Outcome Scores, and patient satisfaction. Results: Clinical failure occurred in 3 of 31 knees (9.7%) in the OCA and ACL group and 6 of 62 knees (9.7%) in the OCA group ( P ≤ .999). Five- and 10-year survivorship of the OCA was 94.7% and 82.3% for the OCA and ACL group and 93.4% and 79.6% for OCA group, respectively ( P = .979). Mean follow-up was 6.2 ± 3.3 years among all knees with grafts in situ. Changes from preoperative to latest follow-up visit (difference scores) on all subjective outcome measures were greater in the OCA group; however, none of the difference scores were statistically significant. Satisfaction with the results of OCA transplantation was reported in 78.3% of the OCA and ACL group and 71.7% of the OCA group ( P = .551). Conclusion: Treatment of cartilage lesions with OCA transplantation proved to be reliable and effective regardless of a history of ACL reconstruction as demonstrated by the improvements in outcome scores, long survivorship, and high satisfaction rates. History of ACL reconstruction did not influence outcome of OCA transplantation.

Background:Cartilage repair algorithms use lesion size to choose surgical techniques when selecting a cartilage repair procedure. The association of fresh osteochondral allograft (OCA) size with graft survivorship and subjective patient outcomes is still unknown.Purpose:To determine if lesion size (absolute or relative) affects outcomes after OCA transplantation.Study Design:Cohort study; Level of evidence, 3.Methods:The study included 156 knees in 143 patients who underwent OCA transplantation from 1998 to 2014 for isolated femoral condyle lesions. The mean age was 29.6 ± 11.4 years, and 62.9% were male. The majority of patients (62.2%) presented for cartilage repair because of osteochondritis dissecans. The mean graft area, used as a surrogate for absolute size of the lesion, was 6.4 cm2(range, 2.3-11.5 cm2). The relative size of the lesion was calculated as the tibial width ratio (TWR; ratio of graft area to tibial width) and affected femoral condyle ratio (AFCR; ratio of graft area to affected femoral condyle width) using preoperative radiographs. All patients had a minimum follow-up of 2 years. Further surgical procedures were documented, and graft failure was defined as revision OCA transplantation or conversion to arthroplasty. International Knee Documentation Committee (IKDC) pain, function, and total scores were obtained. Satisfaction with OCA transplantation was assessed.Results:The mean follow-up among patients with grafts remaining in situ was 6.0 years (range, 1.9-16.5 years). The OCA failure rate was 5.8%. Overall survivorship of the graft was 97.2% at 5 years and 93.5% at 10 years. No difference in postoperative outcomes between groups was found in absolute or relative size. Change in IKDC scores (from preoperative to latest follow-up) was greater for knees with large lesions compared to knees with small lesions, among all measurement methods. Overall satisfaction with the results of OCA transplantation was 89.8%.Conclusion:The size of the lesion, either absolute or relative, does not influence outcomes after OCA transplantation for isolated femoral condyle lesions of the knee.

Background:In most treatment algorithms, osteochondral allograft (OCA) transplantation is regarded as an alternative salvage procedure when other, previous reparative treatments have failed.Purpose:To compare the outcomes of a retrospective matched-pair cohort of (1) primary OCA transplantation and (2) OCA transplantation after failure of previous subchondral marrow stimulation.Study Design:Cohort study; Level of evidence, 3.Methods:An OCA database was used to identify 46 knees that had OCA transplantation performed as a primary treatment (group 1) and 46 knees that underwent OCA transplantation after failure of previous subchondral marrow stimulation (group 2). All patients had a minimum of 2 years’ follow-up. Patients in each group were matched for age (±5 years), diagnosis (osteochondral lesion, degenerative chondral lesion, traumatic chondral injury), and graft size (small, 2; medium, 5-10 cm2; large, >10 cm2). The groups had similar body mass indexes, sex distributions, and graft locations (femoral condyle, patella, and trochlea. The number and type of further surgeries after the OCA transplantation were assessed; failure was defined as any reoperation resulting in removal of the graft. Functional outcomes were evaluated by use of the modified Merle d’Aubigné-Postel (18-point) scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Knee injury and Osteoarthritis Outcomes Score (KOOS), and the Knee Society function (KS-F) scale. Patient satisfaction, according to a 5-point scale from “extremely satisfied” to “dissatisfied,” was recorded at the latest follow-up.Results:Eleven of 46 knees (24%) in group 1 had reoperations, compared with 20 of 46 knees (44%) in group 2 ( P = .04). The OCA was classified as a failure in 5 knees (11%) in group 1 and 7 knees (15%) in group 2 ( P = .53). At 10 years of follow-up, survivorship of the graft was 87.4% and 86% in groups 1 and 2, respectively. Both groups showed improvement in pain and function on all subjective scores from preoperatively to the latest follow-up (all P < .001). Results showed that 87% of patients in group 1 and 97% in group 2 were “satisfied” or “extremely satisfied” with the OCA transplantation.Conclusion:Favorable results were shown in both groups with significant improvement of functional scores and excellent survivorship. Despite the higher reoperation rate in the previously treated group, previous subchondral marrow stimulation did not adversely affect the survivorship and functional outcome of OCA transplantation.

Meriç, Gökhan (Balikesir Author), Objective: The objective of this study was to assess the outcome of osteochondral allograft (OCA) transplantation as a salvage procedure after various cartilage repair surgeries. Design: One hundred sixty-four knees in 163 patients (mean age = 32.6 years; range = 11-59 years; 55% males) were treated with OCA transplantation after subchondral marrow stimulation (SMS), osteochondral autograft transplantation (OAT), and autologous chondrocyte implantation (ACI). The majority of previous procedures were isolated SMS in 145 knees (88.4%). Mean allograft size was 8.5 +/- 7.9 cm(2). The most common location was in femoral condyle. The number and type of reoperations on the operative knee were assessed. Failure of the OCA transplantation was defined as any reoperation resulting in removal of the allograft. Functional outcomes were evaluated. Results: Sixty-eight knees had reoperations after OCA transplantation. Thirty-one knees (18.9%) were classified as allograft failures. The median time to failure was 2.6 +/- 6.8 years (range = 0.7-23.4 years). Survivorship of the graft was 82% at 10 years and 74.9% at 15 years. Patients whose grafts were still in situ had a mean of 8.5 +/- 5.6 years of follow-up. Scores on all functional outcomes scales improved significantly from preoperatively to latest follow-up. Eighty-nine percent of OCA transplantation patients reported being "extremely satisfied" or "satisfied." Conclusion: Despite the high reoperation rate, OCA transplantation is a successful salvage surgical treatment after cartilage repair procedures. This cohort showed improved survivorship and functional outcomes of OCA transplantation after SMS, ACI, and OAT., Coordination for the Improvement of Higher Education Personnel (CAPES) of Brazil

Primary fresh osteochondral allograft transplantation is a useful treatment option for osteochondral lesions in the knee. Clinical failure of primary osteochondral allograft transplantation may require further surgery, including revision osteochondral allograft transplantation.To evaluate outcomes of patients who have undergone revision osteochondral allograft transplantation of the knee.Case series; Level of evidence, 4.This series included 33 patients (33 knees) who underwent revision osteochondral allograft transplantation between 1983 and 2012, were at least 2 years out from surgery, and had a minimum 2-year follow-up. Clinical evaluations included the International Knee Documentation Committee pain, function, and total scores; Knee Society function score; and modified Merle d'Aubigné and Postel scale. Failure of the revision allograft was defined as conversion to partial or total knee arthroplasty.The mean follow-up after revision osteochondral allograft transplantation was 10 years, with 75% of patients having more than 5 years' follow-up. Thirteen patients (39%) had failed results after revision osteochondral allograft transplantation, with a mean time to failure of 5.5 years. The remaining 20 patients (61%) had surviving revision allografts, with a mean graft survival of 10 years. Mean pain and function scores at the last follow-up were improved. Survivorship of the revision allograft was 61% at 10 years.Revision osteochondral allograft transplantation of the knee demonstrated acceptable clinical outcomes, although they were inferior to primary allograft transplantation procedures. Revision osteochondral allograft transplantation may be considered an option for patients with a failed primary osteochondral allograft.

Objective The purpose of this study was to evaluate functional outcomes and allograft survivorship among patients with knee fracture who underwent fresh osteochondral allograft (OCA) transplantation as a salvage treatment option. Design Retrospective analysis of prospectively collected data. Setting Department of Orthopaedic Surgery at one hospital. Patients Fresh OCAs were implanted for osteochondral lesions after knee fracture in 24 males and 15 females with an average age of 34 years. Twenty-nine lesions (74%) were tibial plateau fractures, 6 (15%) were femoral condyle fractures, and 4 (10%) were patella fractures. Main Outcome Measurements Clinical evaluation included modified Merle d’Aubigné-Postel (18-point), International Knee Documentation Committee, and Knee Society function scores, and patient satisfaction. Failure of OCA was defined as revision OCA or conversion to total knee arthroplasty (TKA). Results Nineteen of 39 knees (49%) had further surgery. Ten knees (26%) were considered OCA failures (3 OCA revisions, 6 TKA, and 1 patellectomy). Survivorship of the OCA was 82.6% at 5 years and 69.6% at 10 years. Among the 29 knees (74%) that had the OCA still in situ, median follow-up was 6.6 years. Pain and function improved from preoperative to latest follow-up; 83% of patients reported satisfaction with OCA results. Conclusion OCA transplantation is a useful salvage treatment option for osteochondral lesions caused by knee fracture. Although the reoperation rate was high, successful outcome was associated with significant clinical improvement.

Fresh osteochondral allograft transplantation is an increasingly common treatment option for chondral and osteochondral lesions in the knee, but the long-term outcome is unknown.We determined (1) pain and function, (2) frequency and types of reoperations, (3) survivorship at a median of 13.5 years, and (4) predictors of osteochondral allograft failure in the distal femur.We evaluated 122 patients (129 knees) who underwent osteochondral allograft transplantation of the femoral condyle. Mean age was 33 years and 53% were male. Clinical evaluation included the modified Merle d'Aubigné-Postel (18-point), IKDC, and Knee Society function (KS-F) scores. We defined graft failure as revision osteochondral allografting or conversion to arthroplasty. We determined whether patient characteristics or attributes of the graft influenced failure. Minimum followup was 2.4 years (median, 13.5 years); 91% had more than 10 years of followup.Mean modified Merle d'Aubigné-Postel score improved from 12.1 to 16, mean IKDC pain score from 7.0 to 3.8, mean IKDC function score from 3.4 to 7.2, and mean KS-F score from 65.6 to 82.5. Sixty-one knees (47%) underwent reoperations. Thirty-one knees (24%) failed at a mean of 7.2 years. Survivorship was 82% at 10 years, 74% at 15 years, and 66% at 20 years. Age of more than 30 years at time of surgery and having two or more previous surgeries for the operated knee were associated with allograft failure.Followup of femoral condyle osteochondral allografting demonstrated durable improvement in pain and function, with graft survivorship of 82% at 10 years.

Objectives: Osteochondral allograft (OCA) transplantation is an integral part of the cartilage repair paradigm. There is little data regarding return to sport or recreational activity after OCA. The purpose of the present study was to 1) determine if athletic patients undergoing OCA returned to sport, 2) assess reason(s) why in those who did not, 3) and ascertain patient and graft-related characteristics that differed between those who returned or did not return to sport. Methods: Our institution’s OCA database was used to identify 149 knees in 142 patients who participated in sport or recreational activity prior to cartilage injury (45% highly-competitive athletes and 55% well-trained and frequently sporting) and had a minimum follow-up of 1 year (Table 1). The average age was 31 years and 59% were male. The majority of patients (68%) sustained a sports-related injury to their knee and 89% had undergone previous surgery (mean 2.1). Median time from onset of symptoms to OCA transplantation was 2.7 years. Pre-injury and postoperative participation in sport or recreational activity was collected. Patients not returning to their pre-injury level of sport were mailed a questionnaire to assess why, which included knee and lifestyle-related reason(s). Standard objective and subjective outcome measures were also obtained. Further surgery on the operative knee was documented. Results: At a mean follow-up of 6 years, 76% (113 of 149 knees) returned to sport or recreational activity. Among the 113, 28% returned to the same level of pre-injury sport, 48% partially returned (returned to one or more but not all of the same sports or activities), and 25% returned to a different sport or activity. Among the 24% (36 of 149 knees) who did not return to sport or activity, reasons included lifestyle events such as starting a family, changing careers, end of organized sports, knee-related issues, and worry about re-injuring the knee. Postoperatively, 79% of knees were able to participate in a high level of activity (moderate, strenuous, or very strenuous activities), and 71% reported having “very good” to “excellent” function. Thirty-eight of 149 knees (26%) had further surgery following the OCA, of which 14 knees (9% of entire cohort) were considered OCA failures. Survivorship of the OCA at 6 years was 90%. Patients who did not return to sport following OCA were more likely to be female, have injured their knee in an activity other than sports, and had a larger graft size (Table 1). Diagnosis and anatomical location also differed between groups. Conclusion: OCA transplantation is a successful treatment option for athletes and highly active patients who sustain a cartilage injury to their knee. The majority of patients (76%) returned to sport or recreational activity following the OCA and 28% of those patients returned to the same level of pre-injury sport or activity. Patients often reported that their failure to return to sport was due to lifestyle characteristics such as family or career changes rather than knee-related problems.

The objective was to determine the safety, feasibility, and effects of anti-gravity gait training on functional outcomes (Knee Injury and Osteoarthritis Outcome Score [KOOS], the Timed Up and Go test [TUG], Numerical Rating Scale [NRS] for pain) with the AlterG® Anti-Gravity Treadmill® device for total knee arthroplasty (TKA) rehabilitation. Subjects (N = 30) were randomized to land-based vs anti-gravity gait training over 4 weeks of physical therapy after TKA. Adverse events, complications, and therapist satisfaction were recorded. All patients completed rehabilitation protocols without adverse events. KOOS, TUG, and NRS scores improved in both groups with no significant differences between groups. For the AlterG group, Sports/Recreation and Quality of Life subscales of the KOOS had the most improvement. At the end of physical therapy, TUG and NRS pain scores improved from 14 seconds to 8 seconds and from 2.8 to 1.1, respectively. Subjectively, therapists reported 100% satisfaction with the AlterG. This initial pilot study demonstrated that the AlterG Anti-Gravity Treadmill device was safe and feasible. While functional outcomes improved over time with use of the anti-gravity gait training, further studies are needed to define the role of this device as an alternative or adjunct to established rehabilitation protocols.

PURPOSE Healing touch (HT), a nurse-initiated modality, has potential to improve postoperative pain control and restore balance to a patient's energy field to facilitate self-healing. We hypothesized that addition of HT to standard pharmacologic intervention would reduce pain, anxiety, and opioid consumption, and would improve ambulation distance, knee flexion, and patient satisfaction with quality of care in bilateral total knee arthroplasty. SAMPLE Forty-one patients were prospectively randomized to an HT group (n = 20) or a standard treatment (ST) group (n = 21). METHODS For the HT group, HT was administered once daily between 2 daily physical therapy sessions. Pain was assessed using a visual analog scale (VAS) before surgery, before and after HT daily (HT group), or between physical therapy sessions daily (ST group). Anxiety was measured using State-Trait Anxiety Inventory (STAI). Opioid analgesic consumption was converted into dose equivalents (DE; 10 mg morphine intravenous = 1 DE). Satisfaction was assessed at the 1-month postoperative visit. FINDINGS Demographics were similar. Pain VAS was lower in the HT group than in the ST group but was not significant. Within the HT group, pain VAS after the HT treatment was significantly diminished compared with pre-HT pain VAS (p < .05) except on postoperative Day 1. State anxiety was lower in the HT group but reached significance (p = .046) only on postoperative Day 2. Total opioid DE was lower in the ST group by 0.5 DE. Twenty percent more in the ST group reported overall pain as moderate/severe. One month after surgery, 95% of the HT group, compared with 87% of the ST group, felt that their pain was adequately controlled during the hospital stay. DISCUSSION Healing touch provides another tool that nurses can use to decrease pain in patients undergoing postoperative bilateral total knee arthroplasty.

Evidence-based medicine integrates research findings, clinical expertise, and patient values to provide the highest quality patient care. An orthopaedic outcomes database can assist surgeons in assessing associations between surgical procedures, function, survivorship, complication rates, patient satisfaction, and quality of life as guidance for practice. Outcomes are used to validate techniques or procedures, to benchmark best practices, and to identify areas requiring more clinical research. Tracking the success and failure rates of implants and surgical procedures is important. An outcomes database allows for short-term, midterm, and long-term prospective follow-up studies of specific cohorts and also facilitates studies that are retrospective in design. Several countries have initiated orthopaedic outcomes registries or databases. The oldest registry is the Swedish Knee Arthroplasty Register that was started in 19751. Other countries have followed with the development of their own joint registries in England, New Zealand, Germany, Finland, Denmark, and Norway2-7. In 1994, the American Academy of Orthopaedic Surgeons (AAOS) attempted to create an outcomes evaluation system. The Musculoskeletal Outcomes Data Evaluation and Management System did not come to fruition and was terminated in 2000. The attempt was made to collect information on patients undergoing total hip and knee arthroplasty or spine surgery. Difficulties were multifactorial, but were mainly due to inadequate data, record-keeping, or follow-up, which made cleaning the data to extract useful information impossible8. Although the United States lacks a national orthopaedic registry, several institutions have developed their own databases. For example, Mayo Clinic initiated a database in 1969 that included over 56,000 joint arthroplasties by 19979. The Anderson Orthopaedic Research Institute has over two decades' worth of hip and knee arthroplasty outcomes in its database10, while the Center for Hip and Knee Surgery in Indiana11, the Hospital for Special …

This preliminary prospective study to determine the rate of deep venous thrombosis (DVT) examined 277 patients undergoing total knee or total hip arthroplasty (TKA or THA) who were randomized to use a portable, continuous enhanced circulation therapy (CECT) compression device and low-molecular-weight heparin (LMWH) or to receive LMWH alone. Patients were screened for DVT using duplex ultrasound at hospital discharge and followed clinically for 3 months. In TKA, 5 DVTs (6.6%) occurred in the CECT + LMWH group compared with one pulmonary embolism and 14 DVTs (19.5%) in the LMWH group (P = .018). In THA, 1 DVT (1.5%) occurred in the CECT + LMWH group and 2 DVTs (3.4%) occurred in the LMWH group. This preliminary study demonstrated significant reduction in rate of DVT after TKA when the CECT device was combined with LMWH.

Purpose: This prospective, randomized, double-blind study with a placebo group and 2 experimental groups evaluated the efficacy of continuous low-dose bupivacaine infiltration by infusion pump after arthroscopic rotator cuff repair. Methods: Sixty patients undergoing arthroscopic rotator cuff repair received a bolus injection in the subacromial space of 35 mL of 0.25% bupivacaine with 1:200,000 epinephrine at surgical closure and were randomized to 1 of 3 groups: 0.25% bupivacaine at 2 mL/hr (n = 20), 0.25% bupivacaine at 5 mL/hr (n = 20), or saline at 5 mL/hr (n = 20) via infusion pump into the subacromial space. Pain was evaluated using the visual analog scale (VAS) and narcotic consumption was measured until 48 hours after surgery and converted to dose equivalents (DE). Results: Sixty patients used the infusion pump for a mean of 43.9 hours (range, 15.50 to 50.75 hrs). Mean total narcotic consumption, expressed in DEs, was 2.24 for the 2-mL group, 3.52 for the 5-mL group, and 2.32 for the placebo group. Mean pain score was 2.9 for the 2-mL group, 3.6 for the 5-mL group, and 3.3 for the placebo group. There were no differences in operating room time or infusion pump use time among groups. The 2-mL group had a nonsignificant trend toward less pain and lower narcotic consumption. The 5-mL group evidenced a nonsignificant trend toward more pain and higher narcotic consumption. Conclusions: This study neither supports nor refutes the use of infusion pumps. We hypothesized that the placebo group would experience greater pain than the 5-mL group; however, a nonsignificant trend toward the contrary occurred. A trend toward less pain in the 2-mL group was not significant. Level of Evidence: Level II, randomized controlled trial of therapeutic treatment that lacks statistical significance and narrow confidence intervals.

Evidence-based nursing practice provides the highest quality of patient care. In an orthopaedic setting, the study of outcomes across a patient population offers the ability to determine associations between the treatment regime and function, complication rates, patient satisfaction, and quality of life as evidence for practice. These associations give the orthopaedic nursing community valuable insight into patient results. An outcomes database can both assist nurses in assessing the results of their nursing interventions and in providing the basis for submitting papers to journals and scientific symposiums. These papers can provide information and education for establishment of an evidence-based nursing practice. This article describes the planning, development, and implementation of a comprehensive orthopaedic outcomes program including nursing intervention outcomes at one institution. We offer a step-by-step guide based on our experience for other institutions that plan to initiate an outcomes program with inclusion of nursing outcomes.

Background:Osteochondral allograft (OCA) transplantation is a recognized treatment modality for cartilage damage in the knee. Few reports are available on outcomes of OCA in the patellofemoral joint, and there are no reports on lesions isolated to the femoral trochlea.Purpose:To evaluate graft survivorship and clinical outcomes in patients who had an OCA to the femoral trochlea.Study Design:Case series; Level of evidence, 4.Methods:An OCA database was used to identify 29 knees in 28 patients (mean age, 30.2 years; range, 12-47 years; 8 female, 20 male) who were treated with a fresh OCA transplant limited to the femoral trochlea. The primary outcome was graft survivorship, and the minimum follow-up was 2 years. Clinical outcomes were assessed by the modified Merle d’Aubigné-Postel (18-point) score; Knee Society function (KS-F) score; International Knee Documentation Committee (IKDC) pain, function, and total scores; and University of California, Los Angeles (UCLA) activity score. The OCA patient satisfaction score (5-point scale from extremely satisfied to dissatisfied) was also reported.Results:The mean follow-up period was 7.0 years (range, 2.1-19.9 years). Graft survivorship was 100% at 5 years and 91.7% at 10 years. One patient was converted to a total knee arthroplasty 7.6 years after OCA surgery. The mean modified Merle d’Aubigné-Postel score improved from 13.0 to 16.1, the mean KS-F score from 65.6 to 85.2, and the mean IKDC total score from 38.5 to 71.9; the mean UCLA score was 7.9 postoperatively. Eighty-nine percent of patients were extremely satisfied or satisfied with the outcome of surgery.Conclusion:Fresh OCA transplantation resulted in excellent clinical outcomes in this patient cohort with articular cartilage damage to the femoral trochlea. The procedure resulted in improved pain and function and high patient satisfaction.

Background: The Press-Fit Condylar total knee arthroplasty implant design has been used by many orthopaedic surgeons over the last twenty years. The design has survived with relatively minor modifications and remains a popular implant system today. The present study represents the fourteen to seventeen-year results for our patients who were described in our previous report on the eight to ten-year results. Methods: The senior author performed 160 consecutive total knee arthroplasties with use of the Press-Fit Condylar cruciate-retaining device in 134 patients between 1986 and 1989. The mean age of the patients at the time of the index procedure was 70.5 years. Follow-up data were available for sixty-three of sixty-four surviving knees. Surviving patients were followed for a mean of 15.8 years. The knees were evaluated on the basis of Knee Society function and clinical scores, radiographs, and survivorship analysis. Results: The mean Knee Society function score was 65, and the mean clinical score was 89. The overall survival rate of the knee was 91.5% with revision for any reason as the end point and 97.2% with aseptic loosening as the end point. The rate of revision of the tibial insert because of wear-related aseptic loosening was 2.5%. We found no relationship between revision and the shelf life or method of sterilization of the polyethylene insert. Radiolucent lines were present in 62% (twenty-one) of thirty-four knees; all radiolucent lines were nonprogressive. None of the implants were loose according to the criteria of the Knee Society. Conclusions: This long-term analysis indicates that the Press-Fit Condylar total knee implant is a successful implant system with excellent longevity. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Objective: To assess the outcome of osteochondral allograft (OCA) transplantation as the primary treatment for cartilage injury in patients with no previous surgical treatment. Study Design: Case series. Patients were identified in our outcomes database. Patients undergoing primary OCA transplantation with no prior surgical treatment and a minimum of 2 years follow-up were selected. Pain and function were evaluated preoperatively and postoperatively. Patient satisfaction was assessed. Reoperations following OCA transplantation were captured. Failure was defined as revision OCA or conversion to arthroplasty. Results: Fifty-five patients (61 knees) were included in the analysis. The study consisted of 30 males and 25 females (mean age = 32.9 years; range = 15.7-67.8 years). The most common diagnoses for the OCA transplantation were osteochondritis dissecans (44.3%) and avascular necrosis (31.1%). Pain and function improved preoperatively to postoperatively on all outcome scales ( P < 0.01). The majority of patients (86%) were “extremely satisfied” or “satisfied.” OCA survivorship was 89.5% at 5 years and 74.7% at 10 years. At latest follow-up (mean = 7.6 years; range = 1.9-22.6 years), OCA remained in situ in 50 knees (82%). Eighteen knees (29.5%) had further surgery; 11 OCA failures and 7 other surgical procedure(s). Of the failed knees (mean time to failure = 3.5 years; range = 0.5-13.7 years), 8 were converted to arthroplasty, 2 had OCA revisions, and 1 had a patellectomy. Conclusions: OCA transplantation is an acceptable primary treatment method for some chondral and osteochondral defects of the knee. Failure of previous treatment(s) is not a prerequisite for OCA transplantation.

Meriç, Gökhan (Balikesir Author), Introduction: Osteochondral allograft (OCA) transplantation is a suitable treatment option for large osteochondral defects. Magnetic resonance imaging (MRI) is an objective, reproducible, noninvasive monitoring tool for postoperative assessment after cartilage surgery. Objective: To correlate Osteochondral Allograft MRI Scoring System (OCAMRISS) in patients undergoing OCA transplantation in the knee with clinical outcomes and determine interobserver agreement of this scoring system. Methods: Fifteen patients underwent OCA transplantation in the knee and received a postoperative MRI. Four examiners read each MRI and completed an OCAMRISS. Interobserver agreement and intraclass correlation coefficients (ICCs) were assessed. Clinical outcomes were evaluated. Correlation between the OCAMRISS and clinical outcomes was calculated using Spearman's correlation coefficients. Results: Interobserver agreement on individual features of the OCAMRISS was superior (kappa = 0.81-1.0) in 65% of comparisons, substantial (kappa = 0.61-0.8) in 14%, moderate (kappa = 0.41-0.6) in 18%, and fair (kappa = 0.21-0.4) in 3%. Agreement among readers was very strong for the cartilage, bone, ancillary, and total scores with 96% of comparisons having an ICC >0.80. International Knee Documentation Committee (IKDC) function scores were correlated with OCAMRISS cartilage score (rho = 0.53, P = 0.044) and total score (rho = 0.67, P = 0.006). The Knee injury and Osteoarthritis Outcome Score (KOOS) sports/recreation subscale was correlated with OCAMRISS ancillary score (rho = 0.58, P = 0.049) and total score (rho = 0.64, P = 0.024). No correlation was observed with subchondral bone features of OCAMRISS and any of the outcome scores. Conclusions: The recently described OCAMRISS is a reproducible grading system for in vivo evaluation after osteochondral allograft transplantation., Scripps Clinic Medical Group grant Coordinating of Improvement of Higher Education Personnel-Capes/Brazil VA Clinical Science Research and Development Career Development Award - IK2CX000749

The need for prophylaxis against venous thromboembolic disease following lower-extremity joint replacement is well documented and accepted. Although low molecular weight heparin is approved for inpatient and extended prophylaxis beyond the hospital environment, orthopedic surgeons must determine the duration of injectable low molecular weight heparin based on the period of venous thromboembolic disease risk and on patient compliance with self-administration of medication at home. Lack of confidence in patients' ability to self-administer injections may contribute to hesitancy in prescribing injectable prophylaxis. This observational study evaluated the effectiveness of a self-injection education program. Findings demonstrate that when properly instructed, patients safely and efficaciously self-administer low molecular weight heparin at home. With shorter hospital stays, self-administration of low molecular weight heparin may optimize the clinical outcomes of orthopedic patients.

Pamela Garcia Pulido , James Neal , Shawn Halpin , Khalid Hamandi * a Foundation Year 2, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom Department of Neuropathology, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom Department of Radiology, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom d The Welsh Epilepsy Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom

Following surgery, total knee arthroplasty (TKA) patients experience considerable pain. All available effective analgesia agents produce some unwanted side effects. Sixty consenting elective TKA patients were randomized to receive bupivacaine 20 mL 0.5% (100 mg) or 20 mL normal saline injected into the joint space after capsule closure. Patients were interviewed up to 24 hours after surgery for pain and pain relief. Narcotic usage was recorded. The bupivacaine group had lower pain scores and reduced narcotics during the 24-hour period, with a 23-minute shorter time to discharge from the postanesthesia care unit than the placebo group (P = .02). Although a bupivacaine bolus injected at capsule closure results in decreased pain levels (P = .07) and narcotic consumption (P = .09), it is not statistically significantly better than placebo.

Objectives: Cartilage repair for femoral condyle lesions comprise the majority of the biological procedures performed in the knee joint. Treatment options have evolved but there is still uncertainty regarding longer-term clinical outcomes with current surgical techniques. The objective of this study was to evaluate outcome of osteochondral allograft (OCA) transplantation utilizing dowel type grafts for the treatment of isolated femoral condyle cartilage lesions. Methods: This study comprised 187 patients (200 knees) who underwent OCA transplantation for isolated cartilage lesions on the femoral condyle between 1999 and 2014. Mean patient age was 31.1 ± 11.6 years, 62.6% were male, and the medial femoral condyle was affected in 69% of the knees. For all cases, dowel technique was used with commercially available surgical instruments utilizing the minimum amount of bone necessary for fixation (modern technique). A single graft was used in 145 knees (72.5%), two grafts were used in 55 knees (27.5%). Average allograft area was 6.3 cm2 (range, 2.3 to 13 cm2) and graft thickness was 6.5 ± 1.4 mm (cartilage and bone combined). All patients had a minimum follow-up of 2 years. Evaluation included International Knee Documentation Committee (IKDC) scores; Knee injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction. The frequency and type of further surgery was assessed. OCA failure was defined as a further surgery that involved removal of the allograft. An additional subgroup analysis on location comparing medial to lateral femoral condyle grafts was performed Results: The average follow-up was 6.7 years (range, 1.9 to 16.5 years). IKDC scores improved from preoperatively to latest follow-up for pain (5.5 to 2.7), function (3.4 to 7.3) and total scores (43.7 to 76.2) (all p

Background:The treatment of patellofemoral cartilage injuries can be challenging. Osteochondral allograft (OCA) transplantation has been used as a treatment option for a range of cartilage disorders.Purpose:To evaluate functional outcomes and survivorship of the grafts among patients who underwent OCA for patellar cartilage injuries.Study Design:Case series; Level of evidence, 4.Methods:An institutional review board–approved OCA database was used to identify 27 patients (28 knees) who underwent isolated OCA transplantation of the patella between 1983 and 2010. All patients had a minimum 2-year follow-up. The mean age of the patients was 33.7 years (range, 14-64 years); 54% were female. Twenty-six (92.9%) knees had previous surgery (mean, 3.2 procedures; range, 1-10 procedures). The mean allograft area was 10.1 cm2(range, 4.0-18.0 cm2). Patients returned for clinical evaluation or were contacted via telephone for follow-up. The number and type of reoperations were assessed. Any reoperation resulting in removal of the allograft was considered a failure of the OCA transplantation. Patients were evaluated pre- and postoperatively using the modified Merle d’Aubigné-Postel (18-point) scale, the International Knee Documentation Committee (IKDC) pain, function, and total scores, and the Knee Society function (KS-F) score. Patient satisfaction was assessed at latest follow-up.Results:Seventeen of the 28 knees (60.7%) had further surgery after the OCA transplantation; 8 of the 28 knees (28.6%) were considered OCA failures (4 conversions to total knee arthroplasty, 2 conversions to patellofemoral knee arthroplasty, 1 revision OCA, 1 patellectomy). Patellar allografting survivorship was 78.1% at 5 and 10 years and 55.8% at 15 years. Among the 20 knees (71.4%) with grafts in situ, the mean follow-up duration was 9.7 years (range, 1.8-30.1 years). Pain and function improved from the preoperative visit to latest follow-up, and 89% of patients were extremely satisfied or satisfied with the results of the OCA transplantation.Conclusion:OCA transplantation was successful as a salvage treatment procedure for cartilage injuries of the patella.

Primary glenohumeral osteoarthritis with posterior wear of the glenoid and posterior subluxation of the humerus (Walch type B) presents a challenge to the treating surgeon. Our hypothesis was that glenoids with biconcavity (B2) would be associated with worse outcomes (functional scores and complications) than B1 glenoids.We retrospectively analyzed prospectively collected data on 112 anatomic total shoulder arthroplasties (104 patients) with B glenoids. Preoperative computed tomography identified 64 B1 glenoids and 48 B2 glenoids (50 and 37 available for follow-up).A significant difference between B1 and B2 glenoids was noted in average retroversion (11° vs. 16°; P.001) and average posterior humeral subluxation (65% vs. 75%; P.001). No significant difference was seen in mean age (69.5 vs. 69.2 years) or body mass index (28.5 vs. 27.4) at time of surgery. At average follow-up of 60 months (range, 23-120 months), glenoid component radiolucencies (51.6%, B1; 47.9%, B2), range of motion, preoperative and postoperative scores of the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire, and patient satisfaction were not significantly different between the 2 groups. Four revisions (4.6%) were documented for acute postoperative infection (2.3%), subscapularis failure (1.1%), and glenoid loosening (1.1%).Although biconcave glenoids commonly have more severe retroversion and posterior subluxation of the humerus, we were unable to find a clinical or radiographic difference in outcome of patients with B1 or B2 glenoids treated with anatomic total shoulder arthroplasty at intermediate-term follow-up. Continued clinical and radiographic follow-up of these cohorts will be necessary to assess any future divergence in outcome.

Objectives: Osteochondritis dissecans (OCD) of the knee can be difficult to treat. Cartilage restoration techniques are often indicated when the lesion or fragment cannot be salvaged. Fresh osteochondral allograft (OCA) transplantation can restore both bone and cartilage defect as a treatment modality. We hypothesize that osteochondral allografting is a successful method for treating osteochondritis dissecans of the knee. Methods: Between 1983 and 2010, 164 patients (181 knees) underwent OCA for OCD of the femoral condyle(s) (type III or IV). Minimum two-year follow-up was available on 149 patients (165 knees). Median age was 25 years (range, 14 to 55) and 73% were male. Mean allograft size was 7.2 cm2(range, 2 to 23 cm2). Evaluation included frequency and type of reoperations, modified Merle d’Aubigné-Postel (18-point) scale, International Knee Documentation Committee (IKDC) pain and function scores, and Knee Society function (KS-F) score. Clinical failure was defined as revision OCA or conversion to arthroplasty. Graft survivorship was determined. Results: Median follow-up time was 7.7 years (range, 2 to 28.4 years). 78% had more than 5-year follow-up. Fifty-one of 165 knees (31%) had reoperations, of which 21 (13%) were classified as allograft failures (13 OCA revisions, 5 UKA, and 3 TKA). OCA survivorship was 93% at 5 years, 87% at 10 years, and 77% at 20 years. Of the 144 knees whose grafts were still in situ, 91% were rated good/excellent, 8% were rated fair, and 1% was rated poor. Mean modified Merle d’Aubigné-Postel (18-point) scale was 17, mean IKDC pain and function scores were 2 and 8, and mean KS-F score was 93. 88% of patients reported satisfaction. Conclusion: Osteochondral allograft transplantation was an effective treatment for osteochondritis dissecans of the knee, with significant improvement in pain and function scores and high patient satisfaction. Graft survivorship was 87% at 10 years.

At 14- to 17-year followup, we reported successful outcomes of the Press-fit Condylar total knee arthroplasty (TKA) system in 160 TKAs performed between 1986 and 1989. However, there are few published reports on TKA survivorship and patient function that include patients evaluated into the third decade after surgery.The study purpose was to determine (1) the survivorship of the implant; and (2) knee function in patients with this TKA system at a mean 20-year followup.We ascertained revision status of all living patients (42 of 160 knees) and all patients (22 knees) who died since the previous study. Among patients alive at the latest followup, Knee Society function scores were obtained and radiographs were evaluated. Kaplan-Meier survivorship analysis with 95% confidence intervals was performed with revision for any reason and aseptic loosening as endpoints. A competing risks analysis with 95% confidence intervals was also performed for revision for any reason as the endpoint.At the mean 20-year (range, 19-25 years) followup, all living patients retained their original implants from the index TKA, exclusive of three polyethylene exchanges. This study demonstrates an 87% Kaplan-Meier survivorship for revision for any reason (95% confidence interval [CI], 80%-92%) and a 98% Kaplan-Meier survivorship for revision for aseptic loosening (95% CI, 93%-99%). Competing risks survivorship was 79% (95% CI, 70%-85%) at 25 years for revision for any reason. Mean Knee Society function score was 46.9. Since the previous study, three revisions have been performed, all for polyethylene wear.The Press-fit Condylar implant system continues to be successful, maintaining longevity up to 25-year followup. This is one of the longest followup studies, reporting continued successes over 20 years, and should serve as a benchmark for current-generation implants.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: Venous thromboembolic events, either deep venous thrombosis or pulmonary embolism, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.) with or without aspirin compared with current pharmacological protocols for prophylaxis against venous thromboembolism in patients undergoing elective primary unilateral arthroplasty of a lower-extremity joint. Methods: A multicenter registry was established to capture the rate of symptomatic venous thromboembolic events following primary knee arthroplasty (1551 patients) or hip arthroplasty (1509 patients) from ten sites. All patients were eighteen years of age or older with no known history of venous thromboembolism, coagulation disorder, or solid tumor. Use of the compression device began perioperatively and continued for a minimum of ten days. Patients with symptoms of deep venous thrombosis or pulmonary embolism underwent duplex ultrasonography and/or spiral computed tomography. All patients were evaluated at three months postoperatively to document any evidence of deep venous thrombosis or pulmonary embolism. Results: Of 3060 patients, twenty-eight (0.92%) had venous thromboembolism (twenty distal deep venous thrombi, three proximal deep venous thrombi, and five pulmonary emboli). One death occurred, with no autopsy performed. Symptomatic venous thromboembolic rates observed in patients who had an arthroplasty of a lower-extremity joint using the mobile compression device were noninferior (not worse than), at a margin of 1.0%, to the rates reported for pharmacological prophylaxis, including warfarin, enoxaparin, rivaroxaban, and dabigatran, except in the knee arthroplasty group, in which the mobile compression device fell short of the rate reported for rivaroxaban by 0.06%. Conclusions: Use of the mobile compression device with or without aspirin for patients undergoing arthroplasty of a lower-extremity joint provides a noninferior risk for the development of venous thromboembolism compared with current pharmacological protocols. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. Peer Review This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Increased knee flexion after total knee arthroplasty (TKA) may contribute to patients’ increased satisfaction and more active lifestyles. This study evaluated a TKA component designed for high flexion (more than 125°). The design features an anatomic sagittal femoral radius with short, flared femoral condyles to allow for femoral rollback. Fifty TKA procedures in 47 patients were evaluated prospectively regarding clinical outcomes using Knee Society knee and function scores, Short Form 12 physical component scores, and flexion measured clinically and by digital lateral supine active flexion radiographs. Preoperative and 1-year postoperative radiographs were analyzed by an independent observer. Mean maximum flexion measured clinically was 115° preoperatively and 120° one year postoperatively, with 76% of TKAs achieving more than 120° and 44% achieving more than 125°. Sex, body mass index, and preoperative flexion were not predictors of postoperative flexion. Mean flexion by radiograph was 108° preoperatively and 111° one year postoperatively, with 31% of knees achieving more than 120° and 14% more than 125°. Mean Knee Society knee and function scores and the Short Form 12 physical component scores were 52, 55, and 32 preoperatively, respectively, and 89, 77, and 40 one year postoperatively, respectively. Of the 50 knees, 84% had improvement in their Knee Society function scores, and 76% had improvement in their Short Form 12 physical component scores. The study revealed evidence of increased early postoperative flexion with the use of a cruciate-retaining high-flexion TKA design.

Median 14-year follow-up (mean 11.8 years) of a cemented primary posterior cruciate-retaining total knee arthroplasty (TKA) utilizing the Press-Fit Condylar (PFC) Sigma design was evaluated in 77 patients (79 TKA). Follow-up assessment included implant survivorship, x-rays, Knee Society rating system, and clinical evaluation. Radiographic analysis demonstrated minor non-progressive osteolysis in 40% (10/25) knees. Two revisions, one for instability at 4 years and one for polyethylene wear at 10 years were performed. Survivorship of the PFC Sigma knee implant was 97% using revision for any reason and 100% using aseptic loosening as endpoints. The PFC Sigma had excellent survivorship at 14 years, the longest clinical follow-up reported.

INTRODUCTION: Prevention of venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), has been at the forefront of orthopaedic care for many years for lower extremity arthroplasty, which is at high risk for VTE. Risk of bleeding increases in total hip arthroplasty (THA) with low-molecular-weight heparin (LMWH) prophylaxis. A mobile compression device (MCD) that allows patients to move freely in hospital and at home may be safer. HYPOTHESIS: The study hypothesized that patients using MCD would have less major bleeding than patients using LMWH without affecting the efficacy of thrombosis prevention in THA. SAMPLE: Following THA, 395 patients at 9 healthcare sites in the United States were randomized to receive either MCD or LMWH for VTE prophylaxis. METHODS: A mobile compression device was applied in the operating room and continued for 10 days with or without aspirin 81 mg daily. Low-molecular-weight heparin was started the morning after surgery and continued for 10 days. Days 10–12 following surgery, bilateral duplex ultrasound was performed on all patients. Bleeding events were recorded during treatment and VTE events were recorded for 3 months. Number of hours of device use was recorded. FINDINGS: Major bleeding events occurred in 11 patients, all in the LMWH group (6%). Venous thromboembolism occurrence was similar, 5.1% in the MCD group and 5.3% in the LMWH group. The MCD group used the device 83% of possible usable time. DISCUSSION: Findings of significantly less major bleeding in the MCD group than the LMWH group supported our hypothesis with no significant difference in VTE.

Flexion following total knee arthroplasty in the US population generally falls between 100° and 120°. Because of these relatively low flexion arcs, total knee arthroplasty prosthetic designs emerged allowing “high flexion” (≥125°). We hypothesized that a high-flexion implant design, Scorpio Non-Restrictive Geometry cruciate-retaining knee prosthesis, would allow clinical early maximum flexion of at least 125°. A prospective observational cohort study enrolled 87 unselected patients (94 knees) evaluated preoperation and 3 months and 1 year postoperation for clinical flexion, arc of motion, and Knee Society scores. At 1 year, 67% of knees had improved flexion and 23% achieved flexion of at least 125°. Clinically, flexion improved by 6.9° and total arc of motion improved by 10.6° from preoperation to 1-year postoperation. Although this high-flexion design allows increased flexion, many patients fail to achieve flexion of at least 125°.

Perioperative pain management after total joint replacement continues to be a concern for orthopaedic nurses. In our institution, the results of routine post-hospital stay surveys had shown below average scores in the area of pain management. This began as a quality management issue, became a pain subcommittee issue, and drew in the research nurses to ask what we can learn from this process. Changing the method of handling pain management is not easy, but it makes a difference in patients' hospital experiences. We learned that cooperation and expertise from multiple departments within the institution and some organizations outside the institution is needed to bring about change. We learned that education of not just staff members but also patients on pain management affected the outcome. This article describes our journey to enhance pain management in our institution.

Total knee arthroplasty (TKA) is a commonly performed procedure for the treatment of end-stage arthritis of the knee. Pain control following TKA is difficult to manage in some patients. We examined the use of a postoperative intraarticular injection of 100 mL of 0.2% (200 mg) ropivacaine in a double-blind, prospective, placebo-controlled pilot study to evaluate its use as a pain control modality. All patients received general anesthesia. Postoperatively, patients were placed on intravenous patient-controlled analgesia with morphine. The ropivacaine group showed an early trend in lower visual analog scale (VAS) scores when compared with the placebo group. Patients receiving ropivacaine used a similar amount of narcotics compared with the placebo group. Intraarticular ropivacaine used for pain control after TKA demonstrated no statistically significant difference in lowering VAS scores or narcotic usage; therefore, intraarticular ropivacaine as a single modality is not recommended for effective pain management.

This study examined long-term survivorship of primary total hip arthroplasty (THA) using cementless Harris-Galante porous femoral and Harris-Galante porous I or II acetabular components. Of 113 hips (101 patients) studied, 60 hips (53 patients) were available for follow-up at a mean of 17.2 years after surgery. A total of 10 hips had documented revision, and 2 hips had failed radiographically. The average Harris hip score was 82. Radiographically, 12 hips demonstrated eccentric wear, 8 had osteolysis, and 1 had a broken tine. The overall survival rate was 87.7%; the mean volumetric wear rate was 74.96 mm 3 ; and the mean polyethylene linear penetration rate was 0.153 mm/y, similar to that of well-cemented THA in other series. This long-term outcome for an early-generation cementless THA is promising and provides a standard by which to judge the newer generation of cementless implants.

Outcomes of femoral head and nonconstrained liner exchange in treating hip instability were evaluated. Forty-eight modular component exchanges performed in 45 patients for recurrent hip dislocations were retrospectively reviewed. Mean follow-up was 4.7 years. Overall success rate was 73% (35/48 hips). Thirty-two (67%) of 48 hips experienced no further dislocations. Three patients had 1 dislocation each with no subsequent dislocations. Ten patients (13 hips) had additional surgery to stabilize their hips (27% failure rate). Demographic, clinical, and implant variables were not associated with outcome. Isolated modular component exchange can be successful in treating recurrent hip dislocations; however, a significant failure rate, not easily predicted, exists. This represents the largest series of modular head and nonconstrained liner exchange for hip dislocation (122/125).

Use of handheld devices with electronic patient diaries (EPDs) can improve the quality of patient-reported information collected in clinical and research settings. EPDs have advantages compared with traditional paper-based instruments that include decreased data entry error and decreased time spent on data management. Orthopaedic pain management, which is often dependent on patient-reported pain levels, can benefit from the use of EPDs. A pilot survey was conducted to compare two self-report pain diary methods in shoulder surgery patients: (a) EPD or (b) paper entry. Compliance was lower in the EPD group, which was attributed to insufficient ease of use. Handheld technology can be used by nurses to improve and streamline patient care by capturing clinical data, by organizing and reporting home health services, and by providing references for evidence-based practice. Handheld technology can facilitate the transformation of clinical documentation of assessments, interventions, and outcomes into evidence-based decision making in orthopaedic nursing.