Treatment of advanced trigger finger by ulnar superficialis slip resection: Long-term outcome and predictive factors for poor prognosis

The aim of this study was to evaluate the outcome of ulnar superficialis slip resection and to determine predictive factors for poor prognosis in patients with advanced trigger finger. Over a 5-year-period, 55 patients (58 fingers) were included. After surgery, two groups were identified: group 1, with complete extension or <10° extension deficit in the proximal interphalangeal (PIP) joint (n = 27 fingers/27 patients); and group 2, with ≥10° residual PIP extension deficit (n = 31 fingers/28 patients). Factors associated with PIP extension deficit were assessed on logistic regression. There was a median extension gain of 20° (range, 10-30°) after surgery. The difference between pre- and post-operative extension deficits was significant (p < 0.001). There was no significant inter-group difference in DASH score (p > 0.9). Two predictive factors were found: >12 months' preoperative symptom duration (OR = 1.02; p = 0.045), and lack of self-rehabilitation (OR = 20; p < 0.001). Ulnar superficialis slip resection was effective in advanced trigger finger. Hand surgeons should operate early on these patients, and encourage self-rehabilitation. LEVEL OF EVIDENCE: 4.

Both arthroscopic and open posterior knee capsulotomy are effective in terms of extension recovery and functional improvement-systematic review

PURPOSE

To assess the recovery of extension and improvement in functional scores after an arthroscopic or open posterior knee capsulotomy in the setting of an extension deficit.

METHODS

A systematic search of articles published between 1980 and 2020 was performed in the MEDLINE/PubMed database, EMBASE/Ovid database and Web of Science database. The inclusion criteria consisted of patients with primary extension deficits > 5° who underwent an arthroscopic or open posterior knee capsulotomy. The assessed outcomes were preoperative and postoperative range of motion and functional outcome scores. Randomized controlled trials, cohort studies and case series with a follow-up longer than 6 months were included. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for case series. The certainty of evidence was assessed using the GRADE approach.

RESULTS

Of 226 records identified through database searching, 7 studies were included in the final analysis. The outcomes of 107 patients with a mean age of 34.1 (range 15-63) years were available. In all the included studies, a posterior capsulotomy resulted in the restoration of knee extension to normal or nearly normal values (mean postoperative extension deficit: 0.4-4.2 degrees) with a significant increase in functional outcome scores. No neurovascular complications were reported within the studies. Due to the diverse methodology of studies, the direct comparison of arthroscopic versus open approaches was not possible. Concerning the risk of bias assessment, the greatest concerns raised the selection of participants among the included studies and the methods of outcome measurement. The certainty of evidence was very low according to the GRADE.

CONCLUSIONS

Both arthroscopic and open posterior capsulotomy of the knee results in restoration of normal or nearly normal knee extension and significant improvement in functional outcomes.

LEVEL OF EVIDENCE

IV.

Correlation between weight-bearing asymmetry and bone mineral density in patients with bilateral knee osteoarthritis

Background

Although unloading of the joint is related to reduction of the local bone mineral density (BMD), little attention had been paid to the relationship between loading asymmetry and side-to-side difference of BMD in patients with bilateral knee osteoarthritis (OA). The aim of the present study was to evaluate and clarify the relationship between gait parameters and bone mineral density in those patients.

Methods

A total of 36 knees in eighteen patients (mean age = 73.7 ± 6.3 years, mean body mass index = 26.7 ± 3.8 kg/m²) with bilateral medial knee OA were enrolled in the present study. All subjects performed relaxed standing and level walking at our gait laboratory after informed consent was obtained. First, ground reaction force was calculated on bilateral knees during standing. The knees in each patient were divided into higher and lower force side for the definition of dominant side limb. Second, gait parameters in each subject were obtained. To analyze the factors that affect the weight-bearing distribution in both limbs, clinical data and biomechanical parameters were compared between knees. Clinical data included radiographic OA grade, femorotibial angle, and BMD at the bilateral femoral neck.

Results

Knees on higher force side were significantly more extended than on lower force side in standing (P = 0.012) and knee excursion during weight acceptance phase in gait was significantly larger in higher side than in lower side (P = 0.006), while the other parameters were not significantly different. As to the clinical data, higher force side had greater BMD, compared to lower force side. In terms of Kellgren–Lawrence scale and femorotibial angle on plain radiographs, there were no significant differences between higher and lower force side.

Conclusions

Based on loading asymmetry in the present study, lower BMD was observed on Lower force side in patients with knee OA. Therefore, it is helpful for orthopedic surgeons to examine side-to-side differences of bone mineral density or extension limitation during standing for evaluation of the loading condition in patients with bilateral knee OA.

Internal rotation of the tibial component in total knee arthroplasty can lead to extension deficit

PURPOSE

Stiffness is a common problem following total knee arthroplasty (TKA). Mal-rotated components have been claimed to be the major cause of pain and limited motion after TKA. The present study investigates whether intra-operative intentional malrotation of the tibial component would change in vivo kinematics. The hypothesis is excessive internal rotation of the tibial component would result in postoperative extension deficit.

METHODS

Thirty-one patients were enrolled in this study. After completing bony cuts and proper soft tissue balancing, the femoral and tibial trials were impacted and fixed using small pins. Lateral radiographs were used to measure and compare intraoperative full knee extension during normal and after intentional internal rotation of the tibial component. The extension deficit angles were also compared between the posterior stabilised (PS) and cruciate retaining (CR) implants.

RESULTS

For normal tibial component rotation, the median (interquartile range) extension deficit was 0° (4). The mean tibial trial intentional internal rotation was 21.2° (± 4.5). The median (interquartile range) extension deficit significantly increased to 6° (4) after tibial component internal rotation (p = 0.001). The use of PS spacers resulted in a significantly greater extension deficit after intentional internal rotation 9° (5) compared to that of the CR implant 1° (4) (p = 0.001).

CONCLUSION

Internal rotation of the tibial component in total knee arthroplasty can lead to postoperative extension deficit. This could be attributed to interference with "screw home" mechanism that requires full external rotation of the tibia on the femur. Consequently, this deficit may cause pain and knee stiffness following TKA.

LEVEL OF EVIDENCE

III.

Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review

PURPOSE

Arthrofibrosis is the most common post-operative complication of anterior cruciate ligament (ACL) reconstruction. Risk factors and management strategies for arthrofibrosis remain unclear. The purpose of this review was to: (a) describe existing definitions of arthrofibrosis, and (b) characterize the management strategies and outcomes of arthrofibrosis treatment.

METHODS

MEDLINE, EMBASE, and PubMed were searched from database inception to search date (March 21, 2016) and screened in duplicate for relevant studies. Data regarding patient demographics, indications, index surgery, management strategy, and outcomes were collected.

RESULTS

Twenty-five studies of primarily level IV evidence (88%) were included. A total of 647 patients (648 knees) with a mean age of 28.2 ± 1.8 years (range 14-62 years) were treated for arthrofibrosis following ACL reconstruction and followed for a mean 30.1 ± 16.9 months (range 2 months-9.6 years). Definitions of arthrofibrosis varied widely and included subjective definitions and the Shelbourne classification system. Patients were treated by one or more of: arthroscopic arthrolysis (570 patients), manipulation under anaesthesia (MUA) (153 patients), oral corticosteroids (31 patients), physiotherapy (81 patients), drop-casting (17 patients), epidural therapy combined with inpatient physiotherapy (six patients), and intra-articular interleukin-1 antagonist injection (four patients). All studies reported improvement in range of motion post-operatively, with statistically significant improvement reported for 306 patients (six studies, p range <0.001 to =0.05), and one study (18 patients) reporting significantly better results if arthrofibrosis was treated within 8 months of reconstruction (p < 0.03). The greatest improvements for extension loss were seen with drop-casting (mean 6.2° ± 0.6° improvement), whereas MUA produced the greatest improvement for flexion deficit (mean 47.8° ± 3.3° improvement).

CONCLUSIONS

Arthrofibrosis is poorly defined and outcome measures range varies widely. Amongst the studies included in this review, arthrofibrosis was most commonly managed surgically by arthroscopic arthrolysis, and most patients showed at least some improvement, including six studies that reported statistically significant change in ROM. In studies that used a step-wise approach to treating arthrofibrosis, more than half of patients were successfully treated without an operation. A more well-defined concept of arthrofibrosis, along with large, prospective studies will provide a clearer understanding of how to describe and manage this complication. The issue of arthrofibrosis following ACL reconstruction is clinically relevant as it represents a common complication of a commonly performed operation that nonetheless remains poorly defined and without clear treatment guidelines.

LEVEL OF EVIDENCE

Systematic Review of Level III and IV Studies, Level IV.

The cyclops lesion after bicruciate-retaining total knee replacement

The cyclops lesion is a localized anterior arthrofibrosis most commonly seen following anterior cruciate ligament reconstruction. The lesion forms at the anterior cruciate ligament insertion creating a painful extension block between femoral intercondylar notch and tibial plateau. We present 2 cases (3 knees) in which cyclops lesions appeared atypically following bicruciate-retaining total knee replacement. Two lesions occurred in a single patient following bilateral knee replacement. One lesion occurred in an active sportswoman. All 3 resolved following arthroscopic debridement. We describe the presentation of this unusual complication and suggest keys to its diagnosis, treatment, and prevention.

Acquired femoral flexion deformity due to physeal injury during medial patellofemoral ligament reconstruction

BACKGROUND

Reconstruction of the medial patellofemoral ligament (MPFL) is the most frequent surgical procedure performed in patients with patellar instability. Recently, concerns regarding physeal injury during femoral tunnel placement for anatomical MPFL reconstruction in children have been discussed.

METHODS

This is the first case to report partial posterior physeal growth arrest and subsequent flexion deformity of the distal femur after MPFL reconstruction in a skeletally immature patient. The cause and treatment are discussed.

RESULTS

Postoperative knee extension deficit and recurrent patellar instability were successfully treated with revision surgery including, distal femoral extension osteotomy, medialization of the tibial tuberosity, trochleoplasty and MPFL graft tensioning.

CONCLUSION

This case highlights that care should be taken during femoral tunnel placement for anatomic graft fixation to avoid physeal injuries in skeletally immature patients.

Extension deficit after anterior cruciate ligament reconstruction: Is arthroscopic posterior release a safe and effective procedure?

BACKGROUND

Postoperative extension deficits following anterior cruciate ligament (ACL) reconstruction can cause major limitation during daily life. The purpose of this study was to evaluate the efficiency of an all-arthroscopic approach and posterior capsule release for the treatment of persistent knee extension deficits following ACL reconstruction.

METHODS

Between 2009 and 2013 a total of 10 patients with knee flexion contractures after ACL reconstruction were assessed following an all-arthroscopic approach and posterior capsulotomy. The clinical outcomes were reviewed using the range of motion (ROM), Tegner Activity Level, Lysholm score and visual analogue pain scale (VAS).

RESULTS

Four women and six men with a median age of 34years (range: 17 to 49years) were included in the study. The median follow-up period was 25months (range: 14 to 69months). The median preoperative extension deficit was 15° (range: 10 to 20°) compared to the normal contralateral knee. Postoperatively at final follow-up the median extension deficit was one degree (range: 0 to five degrees) (P<0.01). The median preoperative Lysholm score improved from 52 (range: 32 to 67) to 92 (range: 84 to 100) postoperatively (P<0.01), while the median Tegner Activity Level improved from three (range: two to six) to six (range: three to seven) respectively (P<0.02). The median VAS status for pain decreased from five (range: one to 10) to one (range: 0 to three) (P<0.01). No complications were observed.

CONCLUSIONS

Arthroscopic posterior capsulotomy is a safe and effective additional procedure in the treatment of persistent knee extension deficits following ACL reconstruction with excellent results regarding ROM and subjective outcomes.

LEVEL OF EVIDENCE

Level IV.