The aim of this study was to examine the functional outcome at ten years following lateral closing wedge high tibial osteotomy for medial compartment osteoarthritis of the knee and to define pre-operative predictors of survival and determinants of functional outcome. 164 consecutive patients underwent high tibial osteotomy between 2000 and 2002. A total of 100 patients (100 knees) met the inclusion criteria and 95 were available for review at ten years. Data were collected prospectively and included patient demographics, surgical details, long leg alignment radiographs, Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and Knee Society scores (KSS) pre-operatively and at five and ten years follow-up. At ten years, 21 patients had been revised at a mean of five years. Overall Kaplan-Meier survival was 87% (95% confidence interval (CI) 81 to 94) and 79% (95% CI 71 to 87) at five and ten years, respectively. When compared with unrevised patients, those who had been revised had significantly lower mean pre-operative WOMAC Scores (47 (21 to 85) vs 65 (32 to 99), p < 0.001), higher mean age (54 yrs (42 to 61) vs 49 yrs (26 to 66), p = 0.006) and a higher mean BMI (30.2; 25 to 39 vs 27.9; 21 to 36, p = 0.005). Each were found to be risk factors for revision, with hazard ratios of 10.7 (95% CI 4 to 28.6; pre-operative WOMAC < 45), 6.5 (95% CI 2.4 to 17.7; age > 55) and 3.0 (95%CI 1.2 to 7.6; BMI > 30). Survival of patients with pre-operative WOMAC > 45, age < 55 and BMI < 30 was 97% at five and ten years. WOMAC and KSS in surviving patients improved significantly between pre-operative (mean 61; 32 to 99) and five (mean 88; 35 to 100, p = 0.001) and ten years (mean 84; 38 to 100, p = 0.001). Older patients had better functional outcomes overall, despite their higher revision rate. This study has shown that improved survival is associated with age < 55 years, pre-operative WOMAC scores > 45 and, a BMI < 30. In patients over 55 years of age with adequate pre-operative functional scores, survival can be good and functional outcomes can be significantly better than their younger counterparts. We recommend the routine use of pre-operative functional outcome scores to guide decision-making when considering suitability for high tibial osteotomy.
The purpose of this review is to examine the validity of positive claims regarding the direct anterior approach (DAA) with a fracture table for total hip arthroplasty. Recent literature regarding the DAA was searched and specific claims investigated including improved early outcomes, speed of recovery, component placement, dislocation rates, and complication rates. Recent literature is positive regarding the effects of total hip arthroplasty with the anterior approach. While the data is not definitive at present, patients receiving the anterior approach for total hip arthroplasty tend to recover more quickly and have improved early outcomes. Component placement with the anterior approach is more often in the "safe zone" than with other approaches. Dislocation rates tend to be less than 1% with the anterior approach. Complication rates vary widely in the published literature. A possible explanation is that the variance is due to surgeon and institutional experience with the anterior approach procedure. Concerns remain regarding the "learning curve" for both surgeons and institutions. In conclusion, it is not a matter of should this approach be used, but how should it be implemented.
OBJECTIVE -To review evidence for a relationship between dermal neurovascular dysfunction and other components of the metabolic syndrome of type 2 diabetes.RESEARCH DESIGN AND METHODS -We review and present data supporting concepts relating dermal neurovascular function to prediabetes and the metabolic syndrome. Skin blood flow can be easily measured by laser Doppler techniques.RESULTS -Heat and gravity have been shown to have specific neural, nitrergic, and independent mediators to regulate skin blood flow. We describe data showing that this new tool identifies dermal neurovascular dysfunction in the majority of type 2 diabetic patients. The defect in skin vasodilation is detectable before the development of diabetes and is partially correctable with insulin sensitizers. This defect is associated with C-fiber dysfunction (i.e., the dermal neurovascular unit) and coexists with variables of the insulin resistance syndrome. The defect most likely results from an imbalance among the endogenous vasodilator compound nitric oxide, the vasodilator neuropeptides substance P and calcitonin gene-related peptide, and the vasoconstrictors angiotensin II and endothelin. Hypertension per se increases skin vasodilation and does not impair the responses to gravity, which is opposite to that of diabetes, suggesting that the effects of diabetes override and counteract those of hypertension.CONCLUSIONS -These observations suggest that dermal neurovascular function is largely regulated by peripheral C-fiber neurons and that dysregulation may be a component of the metabolic syndrome associated with type 2 diabetes. Diabetes Care 24:1468 -1475, 2001A number of functional disturbances are found in the dermal microvasculature of diabetic subjects. These include decreased microvascular blood flow (1), increased vascular resistance (2), decreased tissue PO 2 (3), and altered vascular permeability characteristics, such as loss of the anionic charge barrier and decreased charge selectivity. Decreased microvascular blood flow and increased vascular resistance in diabetes could result from alterations in dermal neurovascular function, such as impaired dilator responses to substance P, calcitonin gene-related peptide (CGRP), and reactivity to nociceptive stimulation. Diabetes also disrupts vasomotion-the rhythmic contraction exhibited by arterioles and small arteries (4,5). Unmyelinated C-fibers, which constitute the central reflex pathway, are assumed to be damaged in diabetic neuropathy, contributing to abnormalities in cutaneous blood flow (6). Warm thermal sensation is a functional measure of C-fibers in the periphery, and the impairment of this function was paralleled by a reduction of vasomotion. These findings support an interaction between small unmyelinated C-fiber function and vasomotion, although it is not clear whether the neurological deficit precedes or follows the loss of baseline vascular response. A clear relationship between skin microvascular insufficiency and neuropathy has not yet been established. It is possible that ski...
Computer-aided navigation in total knee arthroplasty (TKA) promises improved alignment, performance, and survivorship. Previous meta-analyses demonstrated that navigation yields better component alignment; however, they did not discuss other indicators of performance. This meta-analysis compares navigated (NAV) and conventional (CONV) TKAs and includes clinical outcomes and adverse events. Forty-seven studies (22 randomized trials) of varying methodological quality involving 7,151 TKAs created the sample population. Statistical analyses included analysis of variance of weighted means and random effects modeling. As seen in previous meta-analyses, NAV is favored over CONV TKA. Analysis of surgical characteristics found that length of surgery and tourniquet times were lower for CONV, but not significant. Meta-analysis found that tourniquet times favored CONV but not a strong relationship for length of surgery. Analysis of individual adverse events did not reveal any significant differences. However, when examining adverse events in their totality, the NAV experienced significantly fewer complications. TKA performed with imageless navigation improves component alignment, provides for lower blood loss, improves clinical outcomes as measured by Knee Society and WOMAC scores, and has fewer total adverse events. Published data are insufficient to determine any correlations between component alignment and outcomes.
BackgroundThere is now a clear trend with increased usage of cementless femoral stems for all ages and most patients. As the number of total hip arthroplasties (THAs) performed annually continues to increase with expanding indications for THA and demands for improved quality of life, so will the prevalence of THA in the elderly and aging populations. This is worrisome as the risk of complications with cementless femoral stems increases in elderly patients and those with poor bone quality. The purpose of this study is to analyze the available data from comparative studies to determine whether cementless femoral stems are overused and whether cemented stems warrant increased consideration.MethodsUsing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searches were performed to find original studies comparing cementless and cemented femoral stems; large population registry studies and reports were also included.ResultsThis systematic review documents that older patients with cementless fixation increase the risk of revision, there is no clear fixation advantage in midaged patients, and younger patients fare better with cementless fixation. Complications after THA create burdens on the health care system and on patients.ConclusionsUsing evidence-based data should be better guidance in selecting the most reliable implants for THA. Although cementless femoral fixation for THA has evolved to the “new standard,” it has not been proven to be the “gold standard” for all patients.
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