UHCW publication: Safety and feasibility evaluation of tourniquets for total knee replacement (SAFE-TKR): study protocol

Safety and feasibility evaluation of tourniquets for total knee replacement (SAFE-TKR): study protocol
Wall, Peter Dh; Ahmed, Imran; Metcalfe, Andrew; Price, Andrew J; Seers, Kate; et al. BMJ Open Vol. 8, Iss. 4,  (April 10, 2018): e022067.

This study is designed to determine whether a full randomised controlled trial (RCT) examining the clinical effectiveness and safety of total knee replacement surgery with or without a tourniquet is warranted and feasible.


Get full text at http://bmjopen.bmj.com/content/8/4/e022067

New NICE Technology appraisal guidance TA508: Autologous chondrocyte implantation using chondrosphere for treating symptomatic articular cartilage defects of the knee

Autologous chondrocyte implantation using chondrosphere for treating symptomatic articular cartilage defects of the knee.

Evidence-based recommendations on autologous chondrocyte implantation using chondrosphere (Spherox) for treating symptomatic articular cartilage defects of the knee in adults.Guidance development process.

Published March 2018
Next review March 2021


Full guidance available at https://www.nice.org.uk/guidance/ta508

New NICE Interventional procedures guidance IPG607: Mosaicplasty for symptomatic articular cartilage defects of the knee

Mosaicplasty for symptomatic articular cartilage defects of the knee


Evidence-based recommendations on mosaicplasty in people with symptomatic articular cartilage defects of the knee. This involves taking healthy cartilage from the edge of the joint and inserting it into drilled tunnels in the damaged site.

This guidance replaces NICE interventional procedures guidance on mosaicplasty for knee cartilage defects (IPG162).
Published March 2018
Next review: this guidance will be reviewed if there is new evidence or safety concerns.


Full guidance available at: https://www.nice.org.uk/guidance/ipg607

UHCW publication: pilot randomized trial of meniscal allograft transplantation versus personalized physiotherapy for patients with a symptomatic meniscal deficient knee compartment

A pilot randomized trial of meniscal allograft transplantation versus personalized physiotherapy for patients with a symptomatic meniscal deficient knee compartment.
Smith, N. A.; Parsons, N.; Wright, D.; Hutchinson, C.; Metcalfe, A.; Thompson, P.; Costa, M. L.; Spalding, T.
The Bone & Joint Journal 2018 January 100B(1):56–63
Abstract

Aims: Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months.

Patients and Methods: A single-centre assessor-blinded, comprehensive cohort study, incorporating a pilot randomized controlled trial (RCT) was performed on patients with a symptomatic compartment of the knee in which a (sub)total meniscectomy had previously been performed. They were randomized to be treated either with a meniscal allograft transplantation or personalized physiotherapy, and stratified for malalignment of the limb. They entered the preference groups if they were not willing to be randomized. The Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Lysholm score and complications were collected at baseline and at four, eight and 12 months following the interventions.

Results: A total of 36 patients entered the study; 21 were randomized and 15 chose their treatments. Their mean age was 28 years (range 17 to 46). The outcomes were similar in the randomized and preference groups, allowing pooling of data. At 12 months, the KOOS4 composite score (mean difference 12, p = 0.03) and KOOS subscales of pain (mean difference 15, p = 0.02) and activities of daily living (mean difference 18, p = 0.005) were significantly superior in the meniscal transplantation group. Other PROMs also favoured this group without reaching statistical significance. There were five complications in the meniscal transplantation and one in the physiotherapy groups.

Conclusion: This is the first study to compare meniscal allograft transplantation to non-operative treatment. The results provide the best quality evidence to date of the symptomatic benefits of meniscal allograft transplantation in the short term, but a multicentre RCT is required to investigate this question further. Full text PDF available at http://ovidsp.ovid.com/athens/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=01714648-201801000-00010&D=ovft&PDF=y (UHCW Athens login required)

UHCW publication: Meniscal transplantation is beneficial at one year

Infographic: Meniscal transplantation is beneficial at one year.
Smith, N. A.; Parsons, N.; Wright, D.; Hutchinson, C.; Metcalfe, A.; Thompson, P.; Costa, M. L.; Spalding, T.
The Bone & Joint Journal 2018 January 100B(1): 64–65


Menisci protect the knee joint from wear by distributing load, providing stability, and improving congruency. Partial and complete meniscectomies are widely performed for patients with meniscal tears that are not repairable, but meniscal loss increases contact pressures and predisposes patients to degenerative change. Meniscal allograft transplantation (MAT) aims to improve symptoms, increase function, and reduce the development of osteoarthritis in patients with a symptomatic, meniscal deficient knee. However, outcomes following MAT have never been definitively tested. We performed a comprehensive cohort study with a pilot randomized controlled trial (RCT) designed to assess the benefits of MAT over a programme of personalised physiotherapy. In this small study, we demonstrate that patients undergoing meniscal allograft transplantation using a ‘soft-tissue’ technique show better patient-reported outcome measures at one year. A long-term multicentre RCT is now required to confirm these promising early findings and to evaluate whether MAT can slow the progression to osteoarthritis and improve function in the long term.


Full text PDF available at http://ovidsp.ovid.com/athens/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=01714648-201801000-00011&D=ovft&PDF=y (UHCW Athens login required)

Infographic: Meniscal transplantation is beneficial at one year

Bone Joint J. 2018 Jan;100-B(1):64-65. doi: 10.1302/0301-620X.100B1.BJJ-2017-1478.
UHCW Research: Smith NA, Wright, D, Spalding, T, Hutchinson, C and Thompson, P

A pilot randomized trial of meniscal allograft transplantation versus personalized physiotherapy for patients with a symptomatic meniscal deficient knee compartment

Bone Joint J. 2018 Jan;100-B(1):56-63. doi: 10.1302/0301-620X.100B1.BJJ-2017-0918.R1.

Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months.

UHCW Research: Smith NA, Wright, D, Spalding, T and Thompson, P

Tonogenchoncel-L (Invossa) Gene Therapy for Regeneration of Cartilage in Patients with Degenerative Arthritis or Osteoarthritis of the Knee

Tonogenchoncel-L is a type of treatment which involves taking cells which make up the cartilage and altering them genetically to help stimulate the growth of the cartilage. These modified cells are injected directly into the knee joint with the intention of helping the lost cartilage regrow. If tonogenchoncel-L was licenced in the UK it could provide a unique treatment for people with knee osteoarthritis which has the potential to help cartilage regrow and improve symptoms.

From NIHR Innovation Observatory

Greater pre-operative anxiety, pain and poorer function predict a worse outcome of a total knee arthroplasty

Knee Surg Sports Traumatol Arthrosc (2017) 25: 3403. https://doi.org/10.1007/s00167-016-4314-8

Around 10–30 % of patients are dissatisfied with the results of their total knee arthroplasty (TKA). This review aimed to identify and evaluate the predictors of outcome measured by the three domains of health-related quality of life (pain, stiffness and function). The focus was on pre-operative psychological factors as related to other patient-related variables.

UHCW Research: Daniel Wilson-Nunn

Autologous chondrocyte implantation for treating symptomatic articular cartilage defects of the knee

New Technology Appraisal Guidance from NICE

Autologous chondrocyte implantation (ACI) is recommended as an option for treating symptomatic articular cartilage defects of the knee, only if:

• the person has not had previous surgery to repair articular cartilage defects 
• there is minimal osteoarthritic damage to the knee (as assessed by clinicians experienced in investigating knee cartilage damage using a validated measure for knee osteoarthritis) 
• the defect is over 2 cm2 and 
• the procedure is done at a tertiary referral centre.

Knee Replacement; New study recommends alternative pain relief for knee replacement patients

Biotech Week; Atlanta (Aug 9, 2017): 200.

A new study led by researchers at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust and the University of Warwick has recommended an alternative method of pain relief for patients undergoing knee replacement surgery.

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty

Bone Joint J. 2017 Jul;99-B(7):904-911. doi: 10.1302/0301-620X.99B7.BJJ-2016-0767.R2. Epub 2017 Jun 29.

The aim of this study was to compare the effectiveness of a femoral nerve block and a periarticular infiltration in the management of early post-operative pain after total knee arthroplasty (TKA).

Periarticular infiltration is a viable and safe alternative to femoral nerve block for the early post-operative relief of pain following TKA. Cite this article: Bone Joint J 2017;99-B:904-11.

UHCW Research: Wall, P. D. H., Balasubramanian S. and Thompson P.

Royal College of Surgeons respond to new research on the effectiveness of knee arthroscopy surgery

Knee arthroscopy should not be performed in almost all patients with degenerative knee disease, a panel of international experts have said in The BMJ today. The experts say that the surgery does not, on average, result in a lasting improvement in pain or function - and they say further research is unlikely to alter this advice.

In response to the research, Mrs Scarlett McNally, council member for the Royal College of Surgeons said:

“This review applies to a particular type of knee surgery which orthopaedic surgeons are already moving away from for people with arthritis. Following the Cochrane review in 2008, and the subsequent revision of NICE guidance, surgeons now only consider knee arthroscopy as a suitable course of action for patients that have issues with their knee unexpectedly catching or giving way. Surgeons also only offer it to patients that have not responded well to non-surgical treatment, particularly weight loss and strengthening exercises, after at least 3 months. That said, any new research is always welcome and it is important that surgeons use this as an opportunity to remind themselves that they should only offer this procedure in very particular circumstances.

Can Tibial Cementation Be Enhanced in Knee Arthroplasty Surgery?

J Knee Surg. 2016 Jul;29(5):391-5. doi: 10.1055/s-0035-1564595. Epub 2015 Sep 26.

Aseptic loosening of the tibial component continues to be a significant mode of failure in total knee arthroplasty surgery. Surface cemented components preserve tibial bone stock, but are reliant on a strong bone-cement interface. This study compares standard surface cemented tibial component design to a tibial component with the addition of an undersurface cement containment skirt. The hypothesis was that the addition of a 2-mm underside skirt would allow cement containment and pressurization during implantation, which might improve the overall survival. Two identical tibial components were used, out of which one had the 2-mm underside skirt removed for the purposes of this study. Overall, 12 tibial Sawbones were prepared identically and transducers placed in the medial and lateral plateau. Each component was implanted six times, according to the manufacturer's operative technique. The series of implantation experiments showed no difference in cement pressurization (p = 0.86) regardless of the tibial component design used, with a wide variation in pressure measurements occurring in both groups. The tibial component skirt has not demonstrated any enhancement in cement pressurization. The cement containment skirt might still be advantageous by increasing the cement mantle thickness without causing excessive bone penetration; however, the biological effects cannot be predicted without further clinical evaluation.

UHCW Research: Westerman RW.

The importance of early diagnosis in spontaneous osteonecrosis of the knee — A case series with six year follow-up

The Knee (23(4), August 2016 pp. 702-7. http://dx.doi.org/10.1016/j.knee.2016.04.005

Spontaneous osteonecrosis of the knee has an unknown aetiology. Management options include conservative, surgical and pharmacological interventions. The aim of this study was to report the experience of the authors in conservative management of SONK using non-operative measures by analysing the functional outcome and need for surgical intervention.

UHCW Research: Robert W. Jordan

Protein oxidation, nitration and glycation biomarkers for early-stage diagnosis of osteoarthritis of the knee and typing and progression of arthritic disease

Arthritis Research & Therapy201618:250. DOI: 10.1186/s13075-016-1154-3

There is currently no blood-based test for detection of early-stage osteoarthritis (OA) and the anti-cyclic citrullinated peptide (CCP) antibody test for rheumatoid arthritis (RA) has relatively low sensitivity for early-stage disease. Morbidity in arthritis could be markedly decreased if early-stage arthritis could be routinely detected and classified by clinical chemistry test. We hypothesised that damage to proteins of the joint by oxidation, nitration and glycation, and with signatures released in plasma as oxidized, nitrated and glycated amino acids may facilitate early-stage diagnosis and typing of arthritis.

UHCW Research: Usman Ahmed, Attia Anwar, Paul J. Thornalley and Naila Rabbani

Patients’ decision making in total knee arthroplasty: a systematic review of qualitative research

Bone and Joint Research DOI: 10.1302/2046-3758.410.2000420 Published 8 October 2015 

A patient-centred approach, usually achieved through shared decision making, has the potential to help improve decision making around knee arthroplasty surgery. However, such an approach requires an understanding of the factors involved in patient decision making. This review’s objective is to systematically examine the qualitative literature surrounding patients’ decision making in knee arthroplasty.

UHCW Research: T. Barlow and A Realpe

Adult native knee extensor mechanism ruptures

Injury (INJURY), Oct2016; 47(10): 2065-2070.

Extensor mechanism rupture is a serious event requiring prompt diagnosis and treatment. Patella fractures are reportedly six times more frequent than soft tissue injuries such as quadriceps or patella tendon ruptures. Classically quadriceps and patella tendon ruptures are seen more in males, with those over 40 predominantly suffering from quadriceps tendon ruptures, often associated with an underlying condition, whereas patella tendon ruptures are mostly associated with sport injuries and are commonly seen in the under 40s. Almost all types of extensor mechanism ruptures benefit from early management which typically involves surgery.

UHCW Research: I.P. Pengas and T. Spalding

Sub-sartorial block for post-operative pain relief following knee surgeries

Regional Anesthesia and Pain Medicine. Conference: 35th Annual European Society of Regional Anaesthesia and Pain Therapy Congress, ESRA 2016. Netherlands. Conference Start: 20160907. Conference End: 20160910. 41 (5 Supplement 1) (pp e97), 2016. Date of Publication: September - October 2016.

Pain relief following knee surgery is vital as the severity of pain is extremely high and it does often impede functional recovery of the patient. Methods: We performed a prospective audit on postoperative pain relief following knee surgeries. All our patients received a sub-sartorial block with 30mls of 0.5% chirocaine following a GA or a spinal anaesthetic. All the patients were randomly selected. They were followed up at six hours & 24 hours after their discharge from recovery. Their knee movements, VAS pain scores, analgesia received, time when the first dose of morphine was administered as well as total morphine requirement in the first 24 hours were noted. Results: Knee movements were possible with mild to moderate pain. The average first dose of morphine was administered seven hours after discharge from recovery and the total morphine consumption in the first 24 hours was 30mg. This is much less than the dosage used for standard enhanced care programs for knee replacement surgeries where a BD dose of 20mg MST morphine is used. Conclusions: Our audit shows that there was no incidence of severe pain on movement. The morphine consumption is comparable to other nerve blocks for knee surgeries based on meta-analysis available in literature with an added advantage of sparing of quadriceps that aids in knee movement and physiotherapy along with pain relief

UHCW Research: Vaidyanath C. and Sadasivan R.

Microstructural scaffold (patch) insertion without autologous cell implantation for repairing symptomatic chondral knee defects

New NICE Interventional Procedure guidance:

Evidence-based recommendations on microstructural scaffold (patch) insertion without autologous cell implantation for repairing symptomatic chondral knee defects in adults and young people. This involves stimulating growth of new cartilage in the knee.