Science method

Arthroscopy - Science method

Endoscopic examination, therapy and surgery of the joint.
Questions related to Arthroscopy
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If an MRI knee scan identifies a meniscal tear; what factors are taken into consideration to send for arthroscopy? If the scan has been generated from a GP referral: is there vetting to decide urgent or routine orthopaedic appointment from the results and onward freferral? Does it matter what type of tear? Do certain tears warrant more immediate intervention? If the scan also shows OA / degeneration, how much does that affect the decision to go ahead with a scope?
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Clinical evaluation of the knee joint remains the gold standard in deciding about the management in such scenario. Locked meniscus or bucket handle tears generally needs urgent treatment. As far as degenerative tears are concerned clinical examination commensurating with MRI findings can guide us about mode of treatment
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While the patellar tendon was more popular in the early 1990s, the hamstring tendon appeared more frequently starting in the late 1990s and steadily increased. The patellar tendon plateaued in the 1990s. Double-bundle reconstruction had an interesting timeline, with a rapid increase in publications from 2005 to a peak in 2011; that trend has been decreasing. The anterolateral ligament started appearing in 2013 and is showing an increasing trend. Allografts have seen a slow and steady increase,starting in 1985, it witnessed a dip from 1997 to 2001. The trend from then has been steadily increasing. (https://doi.org/10.1177%2F2325967119856883).
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An interesting methodology and analysis with some great results. Also demonstrating the fantastic influence of Freddie Fu in this field!
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RASL.
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RASL procedure gives disappointing results
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How many different conditions is this your preferred method of surgical treatment? Please list them.
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Posterior impingment
FHL tendinitis
OCL talus zone 7-8-9 of Rankin
Ankle arthrodesis
Subtalar arthrodesis
Os trigono disseases
Haglund´s syndrome
Achilles tendinophaty insertional and corporal
FHL transfer
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Arthroscopy has widened immensely its use in knee surgery. In my opinion its application today outweighs the need for it in degenerative disease of the knee.. What is your opinion and experience ?
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Non-surgical management is an option that is available via physical therapy. Proper exercise prescription could assist in increasing functional status and thus, minimize arthritic symptoms experienced by those with chronic meniscus damage and progressing degeneration. The following link demonstrates that altered gait mechanics may be a result of arthroscopy thus adding to the potential risk of osteoarthritis. The introduction in this article also provides other sources that discuss the risk of arthroscopy and advanced arthritis. 
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Would like any literature or experience on patients that continue to have pain several months after an ankle arthroscopy. These patients have had an aggressive debridement with or without an OCD and reimaging results in negative pathology. They are not showing success with physical therapy. CRPS has been ruled out as well. Is there success with revision arthroscopy? Does knee arthroscopy literature offer any similar results or recommendations? Even though the joint mechanics and kinematics are different it would be helpful to know. 
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punt
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I'm mostly interested in whether X-ray or MRI was used, whether operated or contralateral knee was measured and which parameters were considered.
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Hi
Usually MRI images are considered for meniscus implant sizing for better precision. These articles may help you,
Thanks and regards,
Mamatha
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Some arthroplasty surgeons advocate for an individualized DVT prophylaxis regimen following hip and knee arthroplasty, one that balances safety and efficacy, based on an individual patient risk factors for developing a DVT. However, there seems to be a lack of high-quality data to guide surgeons when making this determination. 
These are the only studies I could find:
1) Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007 Dec;89(12):2648-57. PubMed PMID: 18056497.
2) Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. Thromboembolism Prophylaxis in Hip Arthroplasty: Routine and High Risk Patients. J Arthroplasty. 2015 Dec;30(12):2299-303. Epub 2015 Jul 2. PubMed PMID: 26182980.
3) Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. The Effectiveness of a Risk Stratification Protocol for Thromboembolism Prophylaxis After Hip and Knee Arthroplasty. J Arthroplasty. 2016 Jun;31(6):1299-306.  Epub 2015 Dec 17. PubMed PMID: 26777547
4) González Della Valle A, Serota A, Go G, Sorriaux G, Sculco TP, Sharrock NE, Salvati EA. Venous thromboembolism is rare with a multimodal prophylaxis protocol after total hip arthroplasty. Clin Orthop Relat Res. 2006 Mar;444:146-53. PubMed PMID: 16446593.
5) Bohl DD, Maltenfort MG, Huang R, Parvizi J, Lieberman JR, Della Valle CJ. Development and Validation of a Risk Stratification System for Pulmonary Embolism After Elective Primary Total Joint Arthroplasty. J Arthroplasty. 2016 Mar 17. PubMed PMID: 27067463.
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Risk stratified approach ensures patient safety. An interesting comparative study of 3 common agaents is: Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty.
What would  be really interesting is to find studies with surgery site and systemic complications following aggressive thromboprophlylaxis as an end point rather than diagnosis of DVT!!! Surprisingly, the number is extremely limited. 
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Recently AAOS recommended against any benefit provided by viscosupplementation. The insurance companies stopped supporting this treatment. After this, there was an editorial in the journal "Arthroscopy" against the recommendations of AAOS. To this editorial, the AAOS authors gave a rebuttal.
I have personally used this treatment in many patients. The results are mixed. But still there are quite a good number of patients who feel significant improvment in their symptoms.
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If the results are mixed, then the indications should be made clear. I never use viscosupplemenation injectoins in advanced OA (i.e.grade 4 ) because in the majority of these patients it fails, and the patients are disappointed.
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I'm trying to do flow cytometric analysis of the inflammatory cell infiltrate in the arthritic joints in mice.  I've been targeting the ankle and "wrist" joints. I've tried to wing it (flushing with 1 mL PBS/2 mM EDTA/10% FBS using a 25G needle) but the variability from mouse to mouse is very high.  I haven't found an article that describes the precise methodology for flushing the joints for flow or cytokine analysis. Does anyone have a protocol they trust?
With thanks,
Michael
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Hey Mike :) What you describe is exactly what I did earlier - however I believe I went with 3 separate flushes rather than just one - typically helps to get everything out when you flush more than once (a bit like a BAL). I also remember using joints which were cut out right before and after the ankle so I had access to the joint quite easily and the liquid that came out was pretty clear. It was a bit messy but I got plenty of inflammatory cells and not much blood. The results we got then were pretty consistent. I'll send you the PDF by email. 
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like the knee Joint theree is a provocation of the periferal nerve around the Joint.
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Anaesthetic nerve block is more commonly associated with Sensory neuropathy ( most common complication). It is regularly done for shoulder arthroscopy for post operative pain control
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It looks like that this pathology seems misdiagnosed and mistreated in some countries all other the world. Nevertheless, the responsibility of this structure seems well established and, as far as I know, there is no doubt about it's responsibility for severe anterior knee pain, osteomalacy, osteochondritis or severe impingement.
What is your feeling about it and which therapeutic options are yours for these specific pathological situations: fast and easy arthroscopy or conservative treatment?
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Thank you Lauren for this very good answer. I do agree with most of these relevant points even if I'm now much more aggressive with this recurrent pathology... Some authors confirmed that point and on my own experience results of arthroscopic debridements are really good... Nice day!
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Hip arthroscopy is getting more and more popular, especially for femoroacetabular impingement syndrome. Is there a rationale to apply it in cases with femoral head osteonecrosis, for example for early diagnostics and treatment ? 
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This is a really good question that perfectly highlights the place of hip arthroscopy in diagnosis and treatment of hip diseases!!!
I do agree with all the answers already given and surgeries mentioned, but regarding HIP AVN - and as previously said - we're talking about a vascular bone disorder for which all the evidence-based treatments do not require any invasive or non-invasive  primary joint approach. As previously said, and except some side-related pathologies such as labrum defects, inflammatory lesions, loosed bodies, ..., for which arthroscopy might be primarily indicated, the most efficient treatments usually require (if necessary and possible) a bony trans-cervical approach for drilling and grafting, and not a joint approach or intra-articular vision. So, I'm not sure that pre-collapse non-arthritic AVN core decompressions might really be improved by arthroscopic-assisted techniques and that the assessment of articular cartilage and underlying subchondral bone status is useful enough to modify either diagnosis or therapeutic protocol. For diagnosis as well, I would not recommend to use such techniques that are not specific enough regarding MR Imaging...
The problem remains the same with complementary treatments such as Autologous Conditioned Serum (ACS) injections that do not require any intra-articular vision.
And we should remind some rare cases of AVN described after simple arthroscopy  that were related to vascular traction during joint expansion...
See: Hip Int. 2011 Sep-Oct;21(5):623-6. doi: 10.5301/HIP.2011.8693.
Avascular necrosis of the femoral head after hip arthroscopy.
Sener N1, Gogus A, Akman S, Hamzaoglu A.
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Interested in learning best ways to immobilise human subject's lower limbs with out causing much inconvenience to the subjects.
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Thanks you all for your expert advise, we will be using ankle and knee brace to immobilise our study participants. We think cast will be too impracticable for our study.
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I usually perform distalization of tibial tubercle as the first procedure to correct the patella alta. If need be, I add MPFL reconstruction as the second staged procedure. I never had to add trochlear plasty.
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I do have considerable experience with trochleaplasty but feel that it is not indicated in grade 1dysplasia.  I therefore agree with a combined TT Transfer with MPFL Reconstruction in this patient. 
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Removal of haematoma is supposed to be chondroprotective, but does this justify the additional application of arthroscopy during or before open reduction and internal fixation? How about visual control of intraarticular steps? Is it possible to find additional pathologies as cartilage flakes and treat this? Is arthroscopy in fracture treatment limited to special joints?
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I think arthroscopy in fracture domain should be an adjuvant means. In some cases it is selective surgery.
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Some experts say that up to 7 mm full thickness of longitudnal tears, and any length of partial thickness for longitudnal tears reaching to only one surface (femoral or tibial) can be left untouched.
I have always been wary about leaving them behind because I feel they are the trigger points for future extensions.
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Dear Ravi
The treatment of a meniscal injury will depend on its location, size, time of occurrence, age and level of sports activity of the patient. In my opinion, the treatment may be non-surgical for elderly patients with low functional demands and the remaining patients i performl arthroscopic surgery, even with minimal damage because I agree with you that this minimal lesion can evolve and cause more damage than it was
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I like this old study by Hubbard from the JBJS. It is a well designed study with a clearly defined patient cohort and they showed a clear benefit to debriding focal osteoarthritic lesions of the medial femoral condyle.
Since this study there have been three sham surgical trials on knee arthroscopy, each greeted with a media fanfare, the problem for me is that despite these studies being interesting to a degree, I am not convinced that knee arthroscopy is as dead in the water as some physicians seem to want it to be. Why?
Well, there are some serious flaws in all these studies in terms of patient groups (heterogeneity/symptoms/stage of OA/type of OA lesions etc), outcome measures and study power. For example in the trials of Moseley and Kirkley they took heterogeneous groups of patients with diffuse OA of different stages and showed that a general bit of non-specific debridement (ie no chondroplasty/microfracture etc) did not improve outcome. While in the recent study by Sihvonen patients had no mechanical symptoms, and isolated knee pain with no arthritic lesions.
From what I can see we have learnt some interesting things from these sham surgical trials, for example we know that a general bit of non-specific debridement is probably not a good thing for people with knee pain related to diffuse osteoarthritis and no mechanical symptoms, and we have also learnt that a meniscectomy is not a good thing in terms of relieving pain in patients with an isolated degenerate meniscus, no osteoarthritis and no mechanical symptoms.
It will be interesting in the years ahead to see the role of knee arthroscopy become better defined, in my opinion the baby should not be thrown out with the bath water at this stage. We know focal osteoarthritis lesions respond better with surgery, and the role of modern treatments like chondroplasty/MACI/ACI needs to be better determined. The problem is I don't think that knee arthoscopy is of no value in the treatment of knee pain as a result of more diffuse osteoarthritis, I just think the evidence is not good enough to tell us the answer yet, it all depends on what one does once inside the knee and in which specific patient groups one intervenes.........
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It's OK, Jonathan.
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I see that the arthroscopic synovectomy gains in popularity nowadays. However, the idea of synovectomy in RA is to remove possibly the whole synovial membrane (total or subtotal synovectomy) so that the inflammatory process loses its ground. I wonder if this is possibly by means of arthroscopy ?
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Of course the drug therapies today are more efficient than those some 40 years ago in "almost all cases". Anyway, what about the rest of primary cases that do not respond positively.
Furthermore, I am sorry to state but I don't think the removed synovium is replaced by only fibrous scar tissue. In 2 months after subtotal synovectomy (which is the typical procedure) the synovium regenerates quite well. The only difference is that the regenerated synovial membrane is richer on fibrous elements and poorer on blood vessels. This fact is favorable as far as a renewed inflammation is expected. Of course during this period of regeneration an appropriate exercises program is administered to avoid restricted range of joint motion.
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During the anterior cruciate ligament reconstruction, my hanstring graft (STG) has fell on the floor accidently twice. I did not have option of the allograft. I only had the options of either harvesting the same side BTB or contralateral hamstring or using the same graft after cleansing it. I exercised the last option of washing the graft with 500 ml saline, soaking it in cidex for 30 minutes and again washing it with saline. I was fortunate enough that in both the patients there was no infection. Both the patients have completed 2 years and 5 years follow up and the KT assessment as well as functional assessment is good.
But is it the right way to go in this situation or we should always harvest another new graft?
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Dear Ravi
Below comments from Bernard R. Bach, MD, - What Do You Do If You Drop the Graft on the Floor? Healio Orthopedics.
Great care must be taken to avoid contamination during harvest and or preparation of the graft for anterior cruciate ligament (ACL) reconstruction. Our protocol emphasizes that the surgeon who harvests the graft personally walks the tissue to the back table to reduce the risk of dropping the graft. Handing off of a freshly harvested graft to other members of the surgical team for preparation simply increases the likelihood dropping the graft. With this protocol, the senior author has not dropped any grafts in over 20 years of practice, including more than 1700 knee ligament procedures. Careful attention must be paid during preparation on the back table as well. The fully prepared graft is placed in a marked kidney basin. All operative personnel are informed to prevent the graft from being inadvertently passed off the sterile field
When the graft is brought to the operative field for graft placement, if it is wrapped in a laparotomy sponge, theoretically the only contaminated portion would be the sutures extending beyond the sponge if the graft were dropped.
If the graft is dropped, the salvage falls into one of several possible categories, namely cleaning the graft, using an alternative graft (auto or allograft), or stopping the procedure and completing the surgery at another time with a different graft.
One study showed a 58% rate of positive culture when the graft was dropped and left on the operating room floor for 15 s. Molina et al have shown that a 90-s soak in chlorhexadine gluconate is the most effective method to resterilize the graft
Another report found that a 30-min soak in 4% chlorhexadine followed by a 30-min soak in triple antibiotic solution (gentamicin, clindamycin, polymixin), followed by sterile saline wash was 100% effective in sterilizing contaminated rabbit patellar tendon grafts. In that same study, 10% povidone-iodine was 100% ineffective, as was triple antibiotic soak used in isolation.
A survey of sports medicine specialists found that most would choose cleansing the graft to manage the problem of a dropped graft. Forty-three surveyed surgeons reported having cleansed a contaminated graft and none reported postoperative infections.3
Another option is choosing an alternative graft. This requires preoperative consent from the patient or intraoperative consent from a family member and may be problematic for a patient who expects one graft type but ends up with another. Some surgeons routinely consent their patients for the use of an allograft should the autograph become contaminated or otherwise compromised. Again, if this option is selected, preoperative discussion with the patient is best because cultural or religious beliefs may preclude the use of cadaveric tissue.
Our preference would be cleansing the graft using a 30-min soak in 4% chlorhexadine gluconate followed by lavage with sterile saline, then another 30-min soak in triple antibiotic solution (0.1% gentamicin, 0.1% clindamicin, 0.05% polymyxin) and another sterile saline wash. Washing the chlorhexadine is crucial because chlorhexadine-induced chondrolysis has been reported.4 While this protocol is time consuming, it has solid scientific backing and would allow one to proceed with the same graft as planned preoperatively. One could consider a course of postoperative antibiotics, although we would refrain from this as it would likely only mask an underlying infection, delaying its definitive treatment. In addition, we recommend full disclosure to the patient regarding the incident and the low likelihood of any residual difficulties.
References
1. Molina ME, Nonweiller DE, Evans JA, DeLee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000;16:373-378.
2. Goebel ME, Drez D Jr, Heck SB, Stoma MK. Contaminated rabbit patellar tendon grafts: in vivo analysis of disinfecting methods. Am J Sports Med. 1994;22:387-391.
3. Izquierdo R Jr, Cadet ER, Bauer R, Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21:1348-1353.
4. Van Huyssteen AL, Bracey DJ. Chlorhexadine and chondrolysis in the knee. J Bone Joint Surg Br. 1999;81-B:995-996.
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The arthroscopic surgery of each joint is emerging as a separate sub specialty with an increase in the number of pathological conditions and the emerging technical procedures.
At the same time the arthroscopy is an art which requires a fine balance of hand eye coordination.
Especially in the developing countries, the number of orthopaedic surgeons expert in the art of arthroscopy are a few. So should the practice of arthroscopy by individual surgeons be region wise restrictive or a surgeon who has mastered the art of "hand eye coordination" be promoted to practice arthroscopy on all the joints.
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In my humble opinion we should distinguish what we consider basic arthroscopic surgery and arthroscopic surgery with high specialization , for many years as head of a Department of Orthopaedic Surgery and Traumatology of a University Hospital , with specialized sections in different pathologies , my opinion is that during training as a specialist, the medical trainee should know the basic techniques of arthroscopic of knee surgery ( meniscectomy , biopsy, synovectomy ) and to know shoulder entrance gates and have the knowledge to make an acromioplasty . After the period of specialization a time of special training and a long learning curve is absolutely necessary to perform more complex techniques in knee and shoulder , or be able to perform arthroscopic surgery of ankle , hip or wrist
I believe that to perform these techniques with a high degree of efficacy and safety , it is necessary take into acount , the category of the hospital, its technical possibilities and the demand for care prior to making the decision to initiate these
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Recently, a new randomized controlled clinical trial comparing partial menistectomy and sham surgery in patients without relevant osteoarthritis of the affected knee has been published (Sihvonen et al., NEJM 2013: http://www.nejm.org/doi/full/10.1056/NEJMoa1305189).
In summary, clinical outcome at 12 months in the "partial menistectomy" group was no better when compared to sham surgery, while significant improvement from baseline was found in both groups.
What is your interpretation of the results of this study ? What conclusion can be drawn by this study ? Do you think the study has significant limitations ? What do you consider the reason for improvement in the sham arm of the surgery ?
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With all respect to the authors of the study and the editorial board of the journal, we should be very cautious in interpreting the results of a single study that supports an idea or concept that is in contrast to the current clinical practice and our common sense. As we all know, there is despite the possibility of scientific fraud (which I would exclude in this case, but look at historic fake studies etc.) there is a lot of room for bias and error.
First of all, we do not know, how exactly the partial meniscectomy was performed (radical, little resection…, although described by the authors. Several surgeons might have different understandings of the same terms…). I do share the critizism, that there is no information about mechanical axis, joint load etc., patella problems… which probably would have been asked for in an orthopaedic journal…!
The number of patients n=146 is very small, especially for a multicentre study!
The fact, that the authors cannot find a difference between both groups, does not mean, that there isn’t one (type-II-error). This is a frequent misinterpretation in orthopaedic manuscripts.
I have calculated the power of the study results based on the means, standard deviations and sample size provided in Table 1 of the paper with the following results:
Power one-sided power two-sided
Lysholm knee score 0.05 0.05
WOMET score 0.33 0.28
Score for knee pain after exercise 0.22 0.15
Score for knee pain at rest 0.19 0.12
15D score 0.26 0.17
(G*Power Version 3.0.10, Franz Faul, University of Kiel, Germany. Post-hoc analysis, t-test, n1=n2, α-error 0.05)
A power of 0.8 or more usually is considered to be good. This was intended by the authors in an a priori power-analysis. They fail by far to meet an acceptable power of their analysis.
If I take the results for the scores with their SD and calculate an a priori sample estimation, the necessary number of patients in the study would have been: 336914, 381, 699, 965 and 567 in the same order of scores as above!
It is interesting, that the authors do not comment on this, although apparently statistical consultancy was given.
There are some other issues: the patients in both groups were overweight (mean).
A left meniscus lesion does something harmful with the knee: it causes swelling, does mechanically damage the cartilage, activate inflammation cascades and enzymes and cytokines… This is very difficult to measure and is not considered in the sham group. What do the authors think, happended to the torn meniscus?
After successful partial medial meniscectomy I would expect the patient to be in the following condition after one year postoperative: no limping, full weight-bearing, no giving way or locking, no pain, no swelling, no problem climbing stairs, no problem to perform squatting. This “perfect” patient would result in a Lysholm score of 100 points. Noticable pain during heavy exertion, swelling during heavy exertion, little problems climbing stairs and limitation of sqatting not more than 90 degrees would be a less favourable but acceptable result. This patient would still have a Lysholm score of 84 points! Both groups only reach 60 point one year after surgery / sham surgery! Why is that? There are probably other reasons than only the meniscus…
My greatest concern is the last sentence in the conclusion: “These results argue against the current practice of performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear.” This is not true. As explained above, the authors did not prove, that there is no difference between both groups but instead they were not able to show a difference. To transfer this into the clinical setting, the sentence would be: “These results argue against an attempt to stop performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear (because the uselessness or inability to show a benefit after one year of intervention could not be shown).” This is a complete different story.
The Editors of the NEJM should be aware of this. I don’t know, why they did not intervene…
This study probably started with good intentions. Now it probably will cause a lot of discussion and misinterpretation of the findings and in my personal opinion, will not help to treat our patients better.
My personal conclusion: although we all can be wrong with “gut feelings”, you can never beat common sense with statistics.
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MRI analysis- measurement of bone marrow edema- quantification of volume?
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Dear Michael,
even though, it has been more than one year, since you came up with this question, I remembered it when I found this publication on this topic. Maybe it helps you.
Osteoarthritis Cartilage. 2013 Jun;21(6):806-14. doi: 10.1016/j.joca.2013.03.007. Epub 2013 Mar 18.
A rapid, novel method of volumetric assessment of MRI-detected subchondral bone marrow lesions in knee osteoarthritis.
Ratzlaff C, Guermazi A, Collins J, Katz JN, Losina E, Vanwyngaarden C, Russell R, Iranpour T, Duryea J.
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Since King, 1936 classic research:“For meniscal lesions to heal they must communicate with the peripheral vasculature of the meniscus.” a lot of things have been said. Nowadays, proper patient selection plays a key role in successful outcomes. What do you think?
Presentation Meniscal Injury
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Dear Gustavo
Criteria are:
1. Age of patient
2. Time of injury (Acute or Chronic)
3. Area of injury
4. How extended is the injury
5. Complexity of injury
6. Activity of patient
So young active patient with acute extended unstable tear of meniscal injury situated in the red zone mainly and without ligament injuries (or injuries that are planned to be repaired or reconstructed during surgery), would be better to have this fixed.
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Does anybody have the experience of observing cartilage regeneration by itself directly or indirectly (for example, by radiography)?
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Dear Shaw-Ruey Lyu, cartilage repair may occur spontaneously, but it depends on a lot of parameters as cause for cartilage lesion, size, depth, configuration, general health of the joint, systemic conditions, biomechanics etc. E.g. in case of osteochondral lesions the subchondral bone layer is opened and progenitor cells may invade the forming fibrin clot and finally differentiate into cartilage like tissue. This is a similar mechanism as it is supposed to occur after microfracturing. Stem cells may also invade from the synovia, but again success varys with the different influencing factors. Best regards, Hagen Schmal.