The Ideal Timing of Bilateral Total Knee Arthroplasty: Simultaneous Versus Staged

Objectives

The ideal timing for patients undergoing bilateral total knee arthroplasty (TKA) remains unknown. The purpose of this study was to compare 90-day outcomes between unilateral, simultaneous bilateral, and staged bilateral TKA.

Methods

The PearlDiver database was used to retrospectively identify 231,119 patients undergoing primary TKA during 2015-2020, of which 67,956 (29.4%) were bilateral. Bilateral TKA patients were divided into cohorts of simultaneous bilateral TKA and staged bilateral TKA at 1-14 days, 15-30 days, 31-90 days, and 91-365 days. Each bilateral TKA cohort underwent one-to-one matching with unilateral TKA patients based on age, gender, year, Elixhauser Comorbidity Index (ECI), and a history of obesity, diabetes, and tobacco use. Ninety-day outcomes were compared between matched groups via univariate and multivariate analysis. In staged bilateral TKA groups, outcomes were collected beginning after the second TKA.

Results

Compared to unilateral TKA, simultaneous bilateral TKA was associated with higher rates of venous thromboembolism (VTE; odds ratio [OR] 1.28, 95% confidence interval [CI] 1.07-1.54, p=0.007), acute kidney injury (AKI; OR 1.47, CI 1.17-1.84, p=0.001), blood transfusion (OR 6.81, CI 5.43-8.65, p<0.001), and any complication (OR 1.63, CI 1.49-1.78, p<0.001). Staged bilateral TKA at any time interval studied was associated with a similar or decreased risk of individual complications, emergency department visits, readmissions, reoperations, and any complication relative to unilateral TKA.

Conclusion

Simultaneous bilateral TKA is associated with an increased risk of adverse events compared to unilateral TKA. However, bilateral TKA staged at a short interval appears safe in appropriately selected patients.

A qualitative evaluation of internet information on hip and knee osteoarthritis

BACKGROUND

Hip and knee arthritis are two of the most common conditions that result in referral to orthopaedic outpatient clinics. Many patients now use the internet to research their condition and to inform their decision about treatment options. This has implications for the process of informed consent.

AIM

To assess the quality of patient information on the internet regarding hip and knee arthritis.

METHODS

'Hip arthritis' and 'Knee arthritis' were entered as search terms into a popular search engine. To adjust for temporal variation, the process was repeated one month and one year later. Of the 200 results analysed, 83 websites met the inclusion criteria. The quality of patient information presented on these websites was assessed using a validated scoring instrument by two independent observers.

RESULTS

Most websites assessed were of poor quality; nearly half of all websites did not mention any risks or complications associated with surgical intervention for these conditions.

CONCLUSIONS

As part of their professional obligation to provide a robust process of informed consent, clinicians should be aware of the variable quality of patient information available on the internet. As such, they should be prepared to advise their patients about quality websites where reliable information can be sought.

Complications and costs of patellofemoral arthroplasty versus total knee arthroplasty

BACKGROUND

Patellofemoral arthroplasty (PFA) is an alternative to total knee arthroplasty (TKA) for the treatment of patellofemoral arthritis. Although PFA may preserve native kinematics and accelerate recovery, it has been associated with higher revision rates. The purpose of this study is to compare complication rates and costs between PFA and TKA.

METHODS

Using the PearlDiver database, 6,179 patients with isolated patellofemoral arthritis treated with PFA or TKA from 2010-2015 were retrospectively reviewed with 5-year follow up. PFA and TKA patients were matched by age, sex, and Elixhauser Comorbidity Index via a 1:1 stepwise algorithm. Five-year costs and complications were compared between matched cohorts. The lifetime costs of PFA and TKA were evaluated with Markov decision modeling.

RESULTS

Compared to TKA, PFA was associated with fewer Emergency Department (ED) visits (6.1% vs 3.9%, p = 0.004) but a higher 5-year revision rate (9.9% vs 4.2%, p < 0.001). After multivariate regression, PFA was independently more likely to require revision (odds ratio 2.60, 95% confidence interval 1.32-4.71, p = 0.003). PFA was associated with lower total healthcare costs at every time point between 3 months ($18,014 vs $26,473, p < 0.001) and 5 years ($20,837 vs $27,942, p < 0.001). On average, the lifetime cost of PFA per patient was $5,235 less than for TKA ($26,343 vs $31,578).

CONCLUSIONS

PFA is a less expensive alternative to TKA with a similar risk of medical complications but is associated with a significantly higher 5-year revision rate. Future studies should examine the reasons for PFA failure and methods to mitigate this risk.

[Analysis of reinjection periodicity in knee osteoarthritis with different types of hyaluronic acids]

OBJECTIVE

To evaluate the periodicity of hyaluronic acid (HA) reinjection in patients with knee osteoarthritis. Secondary aim: To relate the degree of arthrosis with the time between infiltrations and the possible study by subgroups between the different commercial preparations.

DESIGN

Retrospective observational study.

MATERIALS AND METHOD

Review of medical records and X-rays of patients with knee osteoarthritis that had been treated with intra-articular HA at the Rehabilitation Service in the period between January 2017 and June 2019.

VARIABLES

Socio-demographic, Laterality, Intervention Date, Degree of Arthrosis according to Kellgren and Lawrence, HA used, Time between filtrations. Statistical analysis carried out by Kaplan-Meier curves, taking into account the reinfiltration as final event, and Kruskal-Wallis test for non-parametric quantitative data.

RESULTS

We analysed 110 infiltration acts in 67 patients: average age at the time of infiltration 72.12 years, 85.1% women, 59.1% right knee. 4 types of HA: 33 cases at 1%. MW: 0.9MDa (HA1), 12 at 1.5%. MW: 1.5-2MDa (HA2), 42 at 2%. MW: 1.2MDa (HA3) and 6 Hylan G-F20. MW: 6MDa (HA4). We reinfiltrated in 31 occasions (28.2%). Average of months (IC 95%) between infiltrations: HA1 6.9 (5.7-8.16), HA2 12.5 (0-35), HA3 9.3 (5.5-13.1), HA4 5 (3-6.9). In 2 cases where it was not possible to establish the type of infiltrated formulations, the mean value between reinfiltrations was 8.5 (5.6-11.4) There were no statistically significant results by relating the HA type or the degree of arthrosis with the reinfiltration time.

CONCLUSIONS

In our study, we observe that the HA3 presented a longer time between infiltrations in comparison with other types, with no possibility to detect significant differences.

How do people with knee osteoarthritis perceive and manage flares? A qualitative study

Background

Acute flares in people with osteoarthritis (OA) are poorly understood. There is uncertainty around the nature of flares, their impact, and how these are managed.

Aim

To explore understandings and experiences of flares in people with knee OA, and to describe self-management and help-seeking strategies.

Design & setting

Qualitative interview study of people with knee OA in England.

Method

Semi-structured interviews were undertaken with 15 people with knee OA. Thematic analysis was applied using constant comparison methods.

Results

The following four main themes were identified: experiencing pain; consequences of acute pain; predicting and avoiding acute pain; and response to acute pain. People with OA described minor episodes that were frequent, fleeting, occurred during everyday activity, had minimal impact, and were generally predictable. This contrasted with severe episodes that were infrequent, had greater impact, and were less likely to be predictable. The latter generally led to feelings of low confidence, vulnerability, and of being a burden. The term ‘flare’ was often used to describe the severe events but this was applied inconsistently and some would describe a flare as any increase in pain. Participants used numerous self-management strategies but tended to seek help when these had been exhausted, their symptoms led to emotional distress, disturbed sleep, or pain experience worse than usual. Previous experiences shaped whether people sought help and who they sought help from.

Conclusion

Severe episodes of pain are likely to be synonymous with flares. Developing a common language about flares will allow a shared understanding of these events, early identification, and appropriate management.

Factors associated with pain intensity and magnitude of limitations among people with hip and knee arthritis

Background

The pain and limitations associated with osteoarthritis of the hip and knee have a notable variation that does not correspond directly with pathophysiology. The purpose of this study is to assess the influence of location of the arthritis on pain intensity and magnitude of limitations accounting for personal and psychological factors.

Methods

One hundred and fifty four patients with osteoarthritis of the hip (41 patients) or the knee (113 patients) were enrolled in this prospective cross sectional cohort study. Patients answered questionnaires which included demographics, site of arthritis (hip or knee), laterality (unilateral or bilateral), pain intensity, Patient-Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test (PROMIS PF CAT), and psychologic questionnaires including the Tampa Scale of Kinesiophobia (TSK-4), Pain Catastrophizing Scale (PCS-4), Generalized Anxiety Disorder (GAD-2) and Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test (PROMIS Dep CAT). Kellgren-Lawrence classification was classified by the treating surgeon. Associations of these factors with pain and function were assessed using bivariate and multivariable regression models.

Results

In a multivariable model accounting for potential confounding, magnitude of limitations was independently associated with years of education, work status, time spent exercising, catastrophic thinking (PCS-4), and symptoms of depression. They accounted for 50% of variability in physical function, with the major contributor being catastrophic thinking. The model for pain intensity included time spent exercising and fear of painful movement (TSK-4). Anatomic site and radiographic severity of arthritis were not associated with either physical function or pain in our patient sample.

Conclusions

This study confirms that limitations and pain from osteoarthritis of the hip and knee are more closely related to personal and psychological factors, less effective cognitive coping strategies such as catastrophic thinking and kinesiophobia in particular, than to pathological and anatomical factors such as location and severity of arthritis. Care that incorporates incremental correction of common misconceptions that accompany the nociception from osteoarthritis have the potential to improve function and comfort in people with osteoarthritis.

Level of Evidence

Prognostic Level II.

Finite element analysis of biomechanical effects of residual varus/valgus malunion after femoral fracture on knee joint

OBJECTIVE

Post-operative femoral shaft fractures are often accompanied by a residual varus/valgus deformity, which can result in osteoarthritis in severe cases. The purpose of this study was to investigate the biomechanical effects of residual varus/valgus deformities after middle and lower femoral fracture on the stress distribution and contact area of knee joint.

METHODS

Thin-slice CT scanning of lower extremities and MRI imaging of knee joints were obtained from a healthy adult male to establish normal lower limb model (neutral position). Then, the models of 3°, 5°, and 10° of varus/valgus were established respectively by modifying middle and lower femur of normal model. To validate the modifying, a patient-specific model, whose BMI was same to former and had 10° of varus deformity of tibia, was built and simulated under the same boundary conditions.

RESULT

The contact area and maximum stress of modified models were similar to those of patient-specific model. The contact area and maximum stress of medial tibial cartilage in normal neutral position were 244.36 mm² and 0.64 MPa, while those of lateral were 196.25 mm² and 0.76 MPa. From 10° of valgus neutral position to 10° of varus, the contact area and maximum stress of medial tibial cartilage increased, and the lateral gradually decreased. The contact area and maximum stress of medial meniscus in normal neutral position were 110.91 mm² and 3.24 MPa, while those of lateral were 135.83 mm² and 3.45 MPa. The maximum stress of medial tibia subchondral bone in normal neutral position was 1.47 MPa, while that of lateral was 0.65 MPa. The variation trend of medial/lateral meniscus and subchondral bone was consistent with that of tibial plateau cartilage in the contact area and maximum stress.

CONCLUSION

This study suggested that varus/valgus deformity of femur had an obvious effect on the contact area and stress distribution of knee joint, providing biomechanical evidence and deepening understanding when performing orthopedic trauma surgery or surgical correction of the already existing varus/valgus deformity.

Ten-year survival rate of 89% after distal femoral osteotomy surgery for lateral compartment osteoarthritis of the knee

PURPOSE

The purpose of this study was to assess the accuracy, safety, and survival of distal femoral osteotomy (DFO) surgery for lateral compartment OA of the knee.

METHODS

A retrospective cohort study was conducted at a single UK centre, using prospectively collected data over an 8-year period (2009-2017). All patients had pre-operative radiographic analysis and digital planning of their deformity correction in addition to post-operative analysis of the achieved correction and yearly face-to-face follow-up. Complications (defined as an undesirable medical or surgical event as a direct result of the operation), reoperations, and failure (defined as conversion to arthroplasty or revision) were recorded.

RESULTS

From a total of 83 patients, 81 patients undergoing 86 primary DFOs were included in this study, with a mean follow-up of 99 months (SD 27 months). The mean pre-operative percentage Mikulicz point was 78.7% (SD 19.1%) and post-operative 35.9% (SD 14.8%). The mean accuracy of correction (intended correction - achieved correction) was an 8.2% overcorrection (SD 13.7%). The complication rate was 4.7%. Using Kaplan-Meier analysis, the mean survival was 113 months (95% CI 106-120) with the probability of surviving 10 years 89%.

CONCLUSION

DFO for valgus alignment and lateral compartment arthritis is associated with low complications, long-term joint preservation, and the prevention of arthroplasty surgery. However, the accuracy of correction still requires improvement in intra-operative technique.

LEVEL OF EVIDENCE

IV.

Ozone Treatment Unveils the Veil of Candida parapsilosis Infection in the Knee Joint: A Case Report and Literature Review

Candida infection is common, while Candida parapsilosis infection in the knee joint is rare. Local symptoms of Candida infections in the knee are atypical, rarely associated with systemic symptoms, and difficult to distinguish from other types of knee arthritis. We here report a special case of C. parapsilosis infections in the knee joint. A patient had previously undergone knee puncture in a private clinic for the treatment of osteoarthritis and developed a left knee joint infection with C. parapsilosis. However, the patient only showed more severe local knee symptoms, and there was no systemic manifestation associated with any Candida infection. Surprisingly, after receiving ozone lavage, the patient showed symptoms of a systemic infection such as fever and chills. There was no positive finding in the blood cultures. Finally, the synovial fluid cultures showed a C. parapsilosis infections. After antifungal treatment and another knee ozone therapy, the patient did not experience recurrence of the infections. It is suggested that in this special case, the strong sterilization with ozone caused the destruction of C. parapsilosis, leading to a transient systemic toxin reaction. In addition, we reviewed the 17 cases of C. parapsilosis infections that have been reported thus far.

Effects of resistance exercise using the elastic band on the pain and function of patients with degenerative knee arthritis

[Purpose] This study examined the effects of resistance exercise using the elastic band on the pain and function of patients with degenerative knee arthritis. [Participants and Methods] Thirty patients with degenerative knee arthritis were classified into an experimental group of 15 patients on whom resistance exercise using the elastic band was applied and a control group of 15 patients on whom conservative physical therapy was applied. Both groups received treatments three times a week for four weeks. Pain was measured by the visual analogue scale and function was evaluated by the Korean Western Ontario and McMaster Universities Osteoarthritis Index (K-WOMAC). [Results] The intragroup comparison showed significant decreases in the visual analogue scale and the K-WOMAC in both the experimental and control groups. In the intergroup comparison after treatment, the experimental group showed significantly lower visual analogue scale and K-WOMAC values than the control group. [Conclusion] The results suggest that resistance exercise using the elastic band is an effective intervention for the pain and function of patients with degenerative knee arthritis.

Preoperative psychological distress no reason to delay total knee arthroplasty: a register-based prospective cohort study of 458 patients

INTRODUCTION

Total knee arthroplasty (TKA) is effective in alleviating pain and improving function in patients with knee arthritis. Psychological factors are known to affect patient satisfaction after TKA. It is important to determine the effectiveness of TKA in patients with presurgical anxiety and/or depression to avoid excluding them from surgery.

MATERIALS AND METHODS

A prospective cohort study was conducted on all patients who underwent TKA during 2016-2018. Patients were divided into four groups: with anxiety, without anxiety, with depression, and without depression. Outcome measures comprised both generic and knee-specific instruments. Each patient group was compared regarding changes in outcome measures one year after surgery. Between-group comparison was also performed.

RESULTS

Of the 458 patients with complete data, 15.3% and 9.6% had experienced presurgical anxiety and depression, respectively. All patient groups displayed statistical (P < 0.001) and clinical improvement in all outcome measures. Patients with presurgical anxiety and/or depression generally displayed less improvement, though the only significant mean differences concerned the Knee Injury and Osteoarthritis Outcome Score (KOOS)-sport score in the non-anxiety and non-depression groups (P = 0.006 and 0.03, respectively), a higher proportion of clinically improved KOOS pain in the non-anxiety group (P = 0.03), and the general health state in the anxiety and depression groups (P = 0.004 and 0.04, respectively).

CONCLUSIONS

All patients improved in outcome measures 1 year after TKA, regardless of presurgical psychological state. Patients with presurgical anxiety and/or depression benefit greatly from surgery and should not be discriminated against based on presurgical psychological distress, though this fact should not eliminate the preoperative psychological assessment of patients.

LEVEL OF EVIDENCE

II.

Improving Patient Reported Outcomes and Preventing Depression and Anxiety in Older Adults With Knee Osteoarthritis: Results of a Sequenced Multiple Assignment Randomized Trial (SMART) Study

OBJECTIVE

Older adults with knee osteoarthritis (OA) and comorbid subsyndromal depressive symptoms are at elevated risk for incidental major depression or anxiety disorders. Using an indicated prevention paradigm, the authors conducted a sequenced multiple assignment randomized trial (SMART) to: 1) evaluate the effect of cognitive behavioral therapy (CBT) and physical therapy (PT), together with the temporal ordering of these interventions, on patient-reported global impression of change (P-GIC), mood, anxiety, and pain; and 2) compare the strategies' impact on incidence of common psychiatric disorders over 12-months.

METHODS

This intervention development trial compared four adaptive strategies delivered in two stages (each up to 8 weeks), contrasted with enhanced usual care (EUC). The strategies were CBT followed by an increased dose of CBT (CBT-CBT), CBT followed by PT (CBT-PT), PT followed by an increased dose of PT (PT-PT), and PT followed by CBT (PT-CBT). Participants (n = 99) were aged 60 years and older and met clinical criteria for knee OA and subthreshold depression. Response was defined as at least "much better" on the P-GIC. Participants were assessed quarterly for 12 months for incidence of psychiatric disorders.

RESULTS

Stage 1 response was higher for PT (47.5%) compared to CBT (20.5%). Non-responders receiving an additional dose of the same intervention experienced a response rate of 73%, higher than for switching to a different intervention. All strategies were superior to EUC (5%). Although not powered to detect effects on disorders, neither intervention strategy nor response status affected 12-month incidence of depression and anxiety disorders.

CONCLUSION

As response rates were similar for PT-PT and CBT-CBT, it may be dose and not type of these interventions that are necessary for clinical benefit. For non-responders, this finding may guide providers to stay the clinical course for up to 12 weeks before switching. These results support future trials of SMART designs in late-life depression prevention.

Local ice cryotherapy decreases synovial interleukin 6, interleukin 1β, vascular endothelial growth factor, prostaglandin-E2, and nuclear factor kappa B p65 in human knee arthritis: a controlled study

Background

The aim of this study was to assess the anti-inflammatory effects of local cryotherapy in human non-septic knee arthritis.

Methods

In the phase I of the study, patients were randomized to receive either ice (30 min; N = 16) or cold CO₂ (2 min; N = 16) applied twice during 1 day at an 8-h interval on the arthritic knee. In phase II, 16 other ice-treated arthritic knees according to the same protocol were compared to the contralateral non-treated arthritic knees (N = 16). The synovial fluid was analyzed just before the first cold application, then 24 h later. IL-6, IL-1β, TNF-α, IL-17A, VEGF, NF-kB-p65 protein, and PG-E2 levels were measured in the synovial fluid and compared before/after the two cold applications.

Results

Forty-seven patients were included (17 gouts, 11 calcium pyrophosphate deposition diseases, 13 rheumatoid arthritides, 6 spondyloarthritides). Local ice cryotherapy significantly reduced the IL-6, IL-1β, VEGF, NF-kB-p65, and PG-E2 synovial levels, especially in the microcrystal-induced arthritis subgroup, while only phosphorylated NF-kB-p65 significantly decreased in rheumatoid arthritis and spondyloarthritis patients. Cold CO₂ only reduced the synovial VEGF levels. In the phase II of the study, the synovial PG-E2 was significantly reduced in ice-treated knees, while it significantly increased in the corresponding contralateral non-treated arthritic knees, with a significant inter-class effect size (mean difference − 1329 [− 2232; − 426] pg/mL; N = 12).

Conclusions

These results suggest that local ice cryotherapy reduces IL-6, IL-1β, and VEGF synovial protein levels, mainly in microcrystal-induced arthritis, and potentially through NF-kB and PG-E2-dependent mechanisms.

Trial registration

Clinicaltrials.gov, NCT03850392—registered February 20, 2019—retrospectively registered

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1965-0) contains supplementary material, which is available to authorized users.

Under-corrected knees do not fail more than aligned knees at 8 years in fixed severe valgus total knee replacement

PURPOSES

A fixed severe valgus knee is a surgical challenge. A safe post-operative Hip-Knee-Ankle angle (HKA) range of 180° ± 4 was recommended, but recent studies mentioned equal results from outliers of this range. Nevertheless, no distinction was made between varus and valgus knees, as well as over-corrected or under-corrected knees. Did post-operative nonaligned total knee replacements (TKR) from fixed severe valgus knees behave differently from the properly aligned population? Did over-corrected knees behave differently from under-corrected knees?

METHODS

Through a multi-center retrospective cohort study, we provided 557 knees of at least 10° of minimal pre-operative valgus; in this population 75 presented a post-operative Hip-Knee-Ankle angle (HKA) outside of the 180° ± 4 range; 23 of them had at least 5° of varus; 52 of them had at least 5° of valgus. Median pre-operative HKA of the entire cohort was 194° (range 190-198). Median follow-up was 8 years (range 5-11); Knee Society Score (KSS) results, HKA, Femoral and Tibial Mechanical Angles (FMA, TMA) and complication rates were obtained. The outlier group (HKA ≤ 175 or ≥ 185) was compared to the control group (HKA 180 ± 4); over-corrected (HKA ≤ 175) and under-corrected (HKA ≥ 185) sub-groups were individually tested against the control group.

RESULTS

The outlier group had a lower Final Knee Score than the aligned group (p = 0.023). In the over-corrected sub-group, median post-operative FMA was 88° (SD 4°) and median TMA was 87° (SD 4°). The complication rate was higher (p = 0.019). Knee (p = 0.018), Function (p = 0.034) and Final Knee Scores (p = 0.03) were statistically lower than in the control group. In the under-corrected sub-group, mean post-operative FMA was 93° (SD 2°) and mean TMA was 91° (SD 2°). The complication rate was lower (p = 0.019) and there was no difference with the control group concerning KSS.

CONCLUSIONS

In case of pre-operative fixed severe valgus knee, one should avoid over-correcting HKA angle and especially the TMA. Over-correction of a severe preoperative valgus in a post-operative varus was prejudicial for TKA survival. Keeping a severe valgus knee in low valgus to avoid using a more constrained implant and/or ligament releases will not decrease the 5-10 year implant survival and functional scores.

LEVEL OF EVIDENCE

Level IV-Case series.

Unicompartmental knee replacement - Current perspectives

Unicompartmental knee replacement (UKR) is an effective treatment for end-stage, symptomatic unicompartmental osteoarthritis of the knee. However, certain aspects of the procedure are still debated. These areas of discussion include patient selection criteria, implant design and the discrepancy in survival rates between national registries and independent case series. These may contribute in limiting the more widespread acceptance of unicompartmental knee replacement. The aim of this paper is to review the up-to-date evidence on UKR and discuss the most relevant controversies regarding this procedure.

Patellofemoral arthroplasty: Current concepts

Isolated patellofemoral arthritis (IPA) is a debilitating condition characterised by a loss of articular cartilage on the patella facets, the trochlear groove or both. By definition, patients with IPA must have normal cartilage in the tibiofemoral compartments of their knee. It is therefore logical to pursue arthroplasty which corrects the abnormality while sparing healthy bone and preserving the knee's native kinematics, which is the premise underpinning patellofemoral arthroplasty (PFA). However, its use remains controversial, with many surgeons still favouring total knee replacement (TKR) in these patients. This paper provides a comprehensive review of PFA in the literature to date and concludes, in carefully selected patients, PFA is worthy of consideration as a functionally superior and economically beneficial joint-preserving procedure - delaying TKR until implant failure or tibiofemoral osteoarthritis progression.

One-stage computer-assisted total knee arthroplasty and tibial osteotomy

Same-stage tibial osteotomy may deserve consideration in candidates to total knee arthroplasty (TKA) who have severe bone deformities, particularly at extra-articular sites. This strategy obviates the need for either a major and technically difficult ligament release procedure, which may compromise ligament balancing, or the use of a semi-constrained prosthesis. This technical note describes a one-stage, computer-assisted technique consisting in TKA, followed by corrective tibial osteotomy to obtain an overall mechanical axis close to 180° without extensive ligament balancing. This technique provided satisfactory outcomes in 8 patients followed-up for at least 3years, with no specific complications or ligament instability and with a hip-knee-ankle angle close to 180°. After planning, intra-operative computer assistance ensures accurate determination of both implant position and the degree of correction achieved by the osteotomy.

Sleep quality among elderly high-altitude dwellers in Ladakh

It has been already known that people who temporarily stay at high altitude may develop insomnia as a symptom of acute mountain sickness. However, much less is known about people living at high altitude. The aim of this study was to determine the effect of high altitude environment on sleep quality for the elderly who have been living at high altitude for their whole lives. A cross-sectional study was conducted in Domkhar valley at altitudes of 2800-4200m, Ladakh. Sleep quality was assessed using Insomnia Severity Index (ISI). Measurement items include body mass index, blood pressure, blood sugar, hemoglobin, timed Up and Go test, oxygen saturation during wakefulness, respiratory function test, Oxford Knee Score (OKS), and Geriatric Depression Scale (GDS), and so on. The participants were Ladakhi older adults aged 60 years or over (n=112) in Domkhar valley. The participation rate was 65.1% (male: female=47:65, mean age: 71.3 years and 67.9 years, respectively). The prevalence of the high score of ISI (8 or more) was 15.2% (17 out of 112). Altitude of residence was significantly correlated with ISI. Stepwise multiple regression analysis showed that OKS and altitude of residence were significantly related with ISI.

Knee Arthritis Without Other Joint Symptoms in the Elderly With Seronegative Elderly Onset Rheumatoid Arthritis

Elderly onset Rheumatoid arthritis (EORA) has important clinical distinctions when compared with younger onset RA (YORA). In knee arthritis of elderly patients, infection, crystal-induced arthritis or EORA should be suspected if elevation of CRP in the preoperative examination and turbid joint effusion in their knee joint are found. Furthermore, if joint swelling and effusion remain after performing total knee arthroplasty (TKA), the infection after TKA, implant debris-related arthritis and EORA should be considered. However, it is difficult to diagnose patients as EORA if Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are negative. The differential diagnosis is very important.

Future trends for unicompartmental arthritis of the knee: injectables & stem cells

Arthritis is one of the most frequent musculoskeletal problems, causing pain, disability, and a significant economic burden. In this article, we discuss current nonsurgical injectable treatment options as well as future trends for cartilage lesions and early arthritis of the knee. We cover some potential treatments for knee osteoarthritis, including stem cell and gene therapies.

The clinical outcome of patellofemoral arthroplasty

Patellofemoral arthroplasty has a long record of use in the treatment of isolated patellofemoral arthritis, with outcomes influenced by patient selection, surgical technique, and trochlear implant design. The trochlear components have evolved from inlay-style to onlay-style designs, which have reduced the incidence of patellar instability. Minimizing the risk of patellar instability with onlay-design patellofemoral arthroplasties has enhanced mid-term and long-term results and leaves progressive tibiofemoral arthritis as the primary failure mechanism beyond 10 to 15 years.