Radiographic vs. MRI vs. arthroscopic assessment and grading of knee osteoarthritis - are we using appropriate imaging?

Purpose Radiographs and MRI scans are commonly used imaging techniques in the assessment of knee osteoarthritis. However, it currently remains uncertain how good a representation of the actual condition of the knee joint these investigations provide. By comparing them against arthroscopic findings the aim of our study was to conclude how accurate these imaging techniques are at grading knee osteoarthritis. Methods This was a retrospective study looking at knee arthroscopies performed at a tertiary centre over a 5 year period. The Outerbridge grade given at arthroscopy was correlated with pre-operative radiograph and MRI scores, so as to assess the reliability of these imaging techniques at predicting the actual severity of knee osteoarthritis seen. Results Kellgren-Lawrence (KL) grading of radiographs was moderately correlated with Outerbridge grades from arthroscopy for the medial compartment of the knee (Spearman’s rho (SR) 0.483, p < 0.001), with a milder correlation in the lateral compartment (SR 0.218, p = 0.003). MRI reporting of knee osteoarthritis was moderately correlated with Outerbridge grades in the medial compartment (SR 0.451, p < 0.001), mildly correlated for both the lateral (SR 0.299, p < 0.001) and patellofemoral joint compartments (SR 0.142, p = 0.054). KL and MRI grading was moderately correlated for the medial compartment (SR 0.475, p < 0.001) and mildly correlated for the lateral compartment (SR 0.277, p < 0.001). Conclusion The ability of radiographs to represent the actual condition of knee osteoarthritis is underestimated. KL grading especially best represents the disease seen in the medial compartment of the knee joint, with a moderate correlation to Outerbridge scores given on arthroscopic assessment. We suggest that whilst MRI is a useful tool in the investigation of knee symptoms, it is often unnecessarily used in patients with OA, when in fact, radiographs alone would be sufficient. Evidence level III

Time Matters: Knee Cartilage Defect Expansion and High-Grade Lesion Formation while Awaiting Autologous Chondrocyte Implantation

Objective The objective of this study was to assess potential risk factors, including time delay until implantation, for knee cartilage defect expansion or new high-grade defect formation between biopsy and Autologous Chondrocyte Implantation (ACI) or Matrix Autologous Chondrocyte Implantation (MACI). Study design Consecutive knee ACI and MACI cases by a single surgeon ( n = 111) were reviewed. The relationship between time between biopsy and staged implantation and (1) progression in primary cartilage defect size and (2) development of a new high-grade (Outerbridge grade ≥3) cartilage defect were determined with adjustment for demographics, body mass index, smoking status, coronal alignment, initial cartilage status, and prior surgery. Results Average size of the primary defect at time of biopsy was 4.50 cm2. Mean time to chondrocyte implantation was 155 days. Defect expansion increased 0.11 cm2 (standard error = 0.03) per month delay to implantation ( P = 0.001). Independent predictors of defect expansion were male sex, smaller initial defect size, and delay to implantation (adjusted mean = 0.15 cm2 expansion per month). A total of 16.2% of patients ( n = 18/111) developed a new high-grade defect. Independent predictors of a new secondary defect were Outerbridge grade 2 changes (vs. 0-1) on the surface opposing the index defect and delayed implantation (per month increase, adjusted odds ratio = 1.21, 95% confidence interval: 1.01-1.44; P = 0.036). Conclusions Patients undergoing 2-stage cell-based cartilage restoration with either ACI or MACI demonstrated long delays between stages of surgery, placing them at risk for expanding defects and development of new high-grade cartilage defects. Patients who were male, had smaller initial defect size, and longer time between surgeries were at greater risk for defect expansion. Level of Evidence III, retrospective comparative study.

Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity

Background: Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients. Purpose: To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses. Results: A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively( P = .6288). The average body mass index was significantly higher in the male group ( P < .0001). GLL was more common in women (38.6%) than men (13.6%) ( P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) ( P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° ( P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001). Conclusion: In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.

Influential factors of postoperative outcomes of symptomatic lateral discoid meniscus

Background: Discoid lateral meniscus (DLM) have a higher rate of tear and degeneration for its abnormal shape and structure. Arthroscopy is the main treatment for symptomatic DLM, however, postoperative clinical outcomes vary widely resulting from effects of diverse factors. Therefore, the present research aims to explore the factors influencing postoperative clinical outcomes of symptomatic DLM . Methods: Patients with discoid meniscus who underwent arthroscopic surgery at our hospital from 9/2008 to 9/2015 were selected according to the inclusion and exclusion criteria. Gender, body mass index (BMI) ,and 18 other factors were selected as potential predictors that might affect postoperative outcomes . Knee function was assessed by the Lysholm, Tegner, International Knee Documentation Committee (IKDC) and Ikeuchi scales. Univariate analyses (rank-sum test and chi-squared test) and multivariate analyses (ordered logistic regression and logistic regression) were used to detect the risk factors bearing on postoperative outcomes. P<0.05 was considered statistically significant. Results: A total of 502 patients were enrolled. Female gender was an influencing factor for Lysholm (P=0.002, odds ratio (OR) =2.713), Tegner (P=0.001, OR=2.526) , IKDC (P=0.022, OR=1.735) and Ikeuchi scores (P=0.010, OR=2.164). BMI was negatively correlated with Lysholm (P=0.007, OR=1.119) and IKDC (P=0.029, OR=1.088) scores. Work intensity was negatively related to IKDC (P=0.038, OR=1.492) and Ikeuchi (P=0.014, OR=1.689) scores. Age of onset was inversely correlated with Tegner (P<0.001, OR=1.109) score.Symptoms duration and IKDC (P=0.002, OR=1.020) had an inverse correlation. Lack of cartilage lesions was a protective factor in terms of Tegner score (P<0.001, OR=0.261). Outerbridge grade was negatively correlated with Lysholm (P=0.016, OR=1.589) and Ikeuchi (P=0.017, OR=1.582) scores. Saucerization with repair was a risk factor for poor Ikeuchi scores (P=0.037, OR=4.328) in terms of subtotal/total meniscectomy. Conclusion: Arthroscopic treatment of symptomatic DLM is safe and effective . Female sex, cartilage lesions and saucerization with repair may be related to unfavourable postoperative outcomes. Clinical efficacy may worsen with increasingBMI, work intensity, symptomatic duration, age of onset and Outerbridge grade.

Influence of Glucose Concentration on Colony-Forming Efficiency and Biological Performance of Primary Human Tissue–Derived Progenitor Cells

Objective Glucose concentrations used in current cell culture methods are a significant departure from physiological glucose levels. The study focuses on comparing the effects of glucose concentrations on primary human progenitors (connective tissue progenitors [CTPs]) used for cartilage repair. Design Cartilage- (Outerbridge grade 1, 2, 3; superficial and deep zone cartilage), infrapatellar fatpad-, synovium-, and periosteum-derived cells were obtained from 63 patients undergoing total knee arthroplasty and cultured simultaneously in fresh chondrogenic media containing 25 mM glucose (HGL) or 5 mM glucose (NGL) for pairwise comparison. Automated ASTM-based quantitative image analysis was used to determine colony-forming efficiency (CFE), effective proliferation rates (EPR), and sulfated-proteoglycan (GAG-ECM) staining of the CTPs across tissue sources. Results HGL resulted in increased cell cultures with CFE = 0 compared with NGL in all tissue sources ( P = 0.049). The CFE in NGL was higher than HGL for superficial cartilage ( P < 0.001), and contrary for synovium-derived CTPs ( P = 0.046) when CFE > 0. EPR of the CTPs did not differ between the media in the 6-day assay time period ( P = 0.082). The GAG-ECM area of the CTPs and their progeny was increased in presence of HGL ( P = 0.027). Conclusion Glucose concentration is critical to progenitor’s physiology and should be taken into account in the setting of protocols for clinical or in vitro cell expansion strategies.

Influential factors of postoperative outcomes of symptomatic lateral discoid meniscus

Background: Discoid lateral meniscus (DLM) have a higher rate of tear and degeneration for its abnormal shape and structure. Arthroscopy is the main treatment for symptomatic DLM, however, postoperative clinical outcomes vary widely resulting from effects of diverse factors. Therefore, the present research aims to explore the factors influencing postoperative clinical outcomes of symptomatic DLM. Methods: Patients with discoid meniscus who underwent arthroscopic surgery at our hospital from 9/2008 to 9/2015 were selected according to the inclusion and exclusion criteria. Gender, body mass index (BMI), and 18 other factors were selected as potential predictors that might affect postoperative outcomes. Knee function was assessed by the Lysholm, Tegner, International Knee Documentation Committee (IKDC) and Ikeuchi scales. Univariate analyses (rank-sum test and chi-squared test) and multivariate analyses (ordered logistic regression and logistic regression) were used to detect the risk factors bearing on postoperative outcomes. P<0.05 was considered statistically significant.Results: A total of 502 patients were enrolled. Female gender was an influencing factor for Lysholm (P=0.002, odds ratio (OR)=2.713), Tegner (P=0.001, OR=2.526), IKDC (P=0.022, OR=1.735) and Ikeuchi scores (P=0.010, OR=2.164). BMI was negatively correlated with Lysholm (P=0.007, OR=1.119) and IKDC (P=0.029, OR=1.088) scores. Work intensity was negatively related to IKDC (P=0.038, OR=1.492) and Ikeuchi (P=0.014, OR=1.689) scores. Age of onset was inversely correlated with Tegner (P<0.001, OR=1.109) score. Symptoms duration and IKDC (P=0.002, OR=1.020) had an inverse correlation. Lack of cartilage lesions was a protective factor in terms of Tegner score (P<0.001, OR=0.261). Outerbridge grade was negatively correlated with Lysholm (P=0.016, OR=1.589) and Ikeuchi (P=0.017, OR=1.582) scores. Saucerization with repair was a risk factor for poor Ikeuchi scores (P=0.037, OR=4.328) in terms of subtotal/total meniscectomy.Conclusion: Arthroscopic treatment of symptomatic DLM is safe and effective. Female sex, cartilage lesions and saucerization with repair may be related to unfavourable postoperative outcomes. Clinical efficacy may worsen with increasing BMI, work intensity, symptomatic duration, age of onset and Outerbridge grade.

Acetabular Morphologic Characteristics Predict Early Conversion to Arthroplasty After Isolated Hip Arthroscopy for Femoroacetabular Impingement

Background: Hip arthroscopy in the setting of dysplasia and borderline dysplasia is controversial. Dysplasia severity is most often defined by the lateral center edge angle (LCEA) but can also be evaluated radiographically by the acetabular inclination (AI). Purpose/Hypothesis: The purpose was to determine the effect of AI on outcomes after isolated hip arthroscopy for femoroacetabular impingement (FAI). We hypothesized that patients with dysplasia would have higher rates of arthroplasty as well as inferior clinical and functional outcomes compared with patients who did not have dysplasia. Study Design: Cohort study; Level of evidence, 3. Methods: A hip arthroscopy registry was reviewed for participants undergoing arthroscopic correction of FAI from February 28, 2008, to June 10, 2013. Participants required a clinical diagnosis and isolated arthroscopic correction of FAI with preoperative imaging and intraoperative cartilage status recorded. AI dysplasia was defined as an AI greater than 10°, LCEA dysplasia as LCEA less than 18°, and borderline LCEA dysplasia as LCEA 18° to 25°. Patients without an acetabular deformity (LCEA 25°-40°; AI <10°) served as a control population. Postoperative variables included patient-reported outcome surveys with conversion to arthroplasty as the primary endpoint. Minimum 5-year outcome scores were obtained for 337 of 419 patients (80.4%) with an average follow-up of 75.2 ± 12.7 months. Results: This study included 419 patients: 9 (2%) with LCEA dysplasia, 42 (10%) with AI dysplasia, and 51 (12%) with borderline dysplasia. The AI but not LCEA was significantly correlated with lower outcome scores on the modified Harris Hip Score ( r = 0.13; P = .01), Non-Arthritic Hip Score ( r = 0.10; P = .04), and Hip Outcome Score–Sports Subscale ( r = 0.11; P = .04). A total of 58 patients (14%) underwent arthroplasty at 31 ± 20 months postoperatively. Patients with LCEA dysplasia had an arthroplasty rate of 56% (odds ratio, 8.4), whereas patients with AI dysplasia had an arthroplasty rate of 31% (odds ratio, 3.3), which was significantly greater than the rate for the nondysplastic cohort (13.5%; P < .0001). Patients with borderline LCEA dysplasia did not have increased rates of arthroplasty. A multivariate analysis found increasing age, increasing AI, Tönnis grade higher than 1, and femoral Outerbridge grade higher than 2 to be most predictive of conversion to arthroplasty. Conclusion: We found that an elevated AI, along with increasing age, Tönnis grade, and femoral Outerbridge grade significantly predict early conversion to arthroplasty after isolated hip arthroscopy. We recommend using the AI, in addition to the LCEA, in evaluating hip dysplasia before hip arthroscopy.

Primary labral reconstruction in patients with femoroacetabular impingement, irreparable labral tears and severe acetabular chondral defects decreases the risk of conversion to total hip arthroplasty: a pair-matched study

In the presence of severe acetabular cartilage defects, the benefits of labral reconstruction (RECON) versus labral resection (RESEC) have not been determined. Prospectively collected data between October 2008 and December 2016 were retrospectively reviewed. Inclusion criteria were hip arthroscopy, acetabular Outerbridge grade III/IV, irreparable labral tears that underwent RECON or RESEC, and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, International Hip Outcome Tool, Patient Satisfaction and Visual Analogue Scale for pain. Exclusion criteria included Tönnis grade &gt;1, previous hip conditions or previous ipsilateral hip surgeries. A 1:1 matched-pair analysis was performed based on age ±5 years, sex, body mass index ±5 kg/m2, Tönnis grade, acetabular microfracture, femoral Outerbridge grade (0 or I compared with II, III or IV). Relative risk (RR) and conversion rate to total hip arthroplasty (THA) were calculated. A total of 38 RECON hips were successfully matched. Both groups demonstrated significant improvements in patient-reported outcomes (PROs). THA conversion was 5.3% and 21.1% for the RECON and RESEC groups, respectively (P = 0.04). RECON was four times less likely to require THA conversion than the RESEC group (RR=4.0; 95% CI 0.91–17.63). In the setting of primary arthroscopic management of femoroacetabular impingement, irreparable labral tears and acetabular chondral lesions of Outerbridge III/IV, patients that underwent RECON and RESEC experienced significant improvement in PROs at minimum 2-year follow-up, and these functional scores were comparable when groups were matched. However, RR and rate to THA conversion were significantly higher in the RESEC group.

Effect of alcohol consumption on patient-reported outcomes in hip arthroscopy: a matched controlled study with minimum 2-year follow-up

Introduction:There is a paucity of literature examining the effects of alcohol consumption on patient-reported outcomes (PROs) after hip arthroscopy. The purpose of this study was to report 2-year outcomes of hip arthroscopy in patients who consume alcohol compared to patients who abstain.Methods:Registry data were prospectively collected and retrospectively reviewed to identify heavy drinkers at the time of primary hip arthroscopy. Patients were matched 1:1 (heavy drinkers:non-drinkers) based on age, sex, BMI, acetabular Outerbridge grade, and capsular treatment. All patients were assessed with 4 validated PROs: mHHS, NAHS, HOS-SSS, and iHOT-12. Pain was estimated with VAS.Results:42 patients were pair matched in each group (heavy drinkers:non-drinkers). Both groups demonstrated significant improvement for all PROs and VAS. Heavy drinkers reported lesser improvement in HOS-SSS ( p = 0.0169), smaller decrease in VAS ( p = 0.0157), and lower final scores on iHOT-12 ( p = 0.0302), SF-12 mental ( p = 0.0086), and VR-12 mental ( p = 0.0151). Significantly fewer patients in the heavy-drinking group reached PASS for mHHS ( p = 0.0464). Odds of achieving PASS for mHHS was 2.5 times higher for patients who abstain from alcohol. The rates of revision hip arthroscopy and conversion to total hip arthroplasty were not statistically different between groups.Conclusion:While hip arthroscopy may still yield clinical benefit in drinkers, patients who consume heavy amounts of alcohol may ultimately achieve an inferior functional status and should be counselled on drinking cessation to optimise their results.

Effect of Delayed Primary Anterior Cruciate Ligament Reconstruction on Medial Compartment Cartilage and Meniscal Health

Background: The time required to develop a secondary cartilage or meniscal injury in the medial compartment after anterior cruciate ligament (ACL) injury is not well understood. Purpose: To determine the association between time delay until ACL reconstruction and the presence of medial compartment Outerbridge grade 3 or 4 chondral injury or medial meniscal tear requiring treatment. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 609 patients underwent primary ACL reconstruction at a single institution at a median 46 days between injury and surgery (61.4% male; mean age, 26.5 years [SD, 11.1]). Chondral status was graded according to Outerbridge criteria at the time of surgery. Multivariate regression analysis was used to assess the relationship between time delay until surgery and medial compartment chondral injury or meniscal injury requiring treatment. Adjustment was performed as needed for patient demographics, sporting activity, and prior knee injuries. Time until surgery had a nonlinear association with medial compartment health and was more effectively described in discrete intervals rather than as a continuous variable. The optimal time intervals to predict medial compartment health were determined by comparison of Bayes information criterion values between fully adjusted regression models. Results: After controlling for relevant confounders, delay of surgery >8 weeks had an increased likelihood of a medial meniscal tear requiring partial meniscectomy (adjusted odds ratio [aOR], 2.30; 95% CI, 1.04-5.12; P = .04) and a decreased likelihood of a meniscal tear requiring repair (aOR, 0.50; 95% CI, 0.32-0.76; P = .001). Delay of surgery >5 months had an increased likelihood of a medial Outerbridge grade ≥3 chondral defect (aOR, 3.11; 95% CI, 1.64-5.87; P = .001) or a grade 4 defect (aOR, 3.84; 95% CI, 1.75-8.45; P = .001). Conclusion: From the time of ACL injury, risk of an irreparable medial meniscal tear found at the time of ACL reconstruction is significantly increased by 8 weeks, and risk of high-grade medial chondral damage is increased by 5 months.