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Systematic review

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Authors Winter AR , Collins JE , Katz JN
Journal BMC musculoskeletal disorders
Year 2017
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BACKGROUND: Arthroscopic surgery is a common treatment for knee osteoarthritis (OA), particularly for symptomatic meniscal tear. Many patients with knee OA who have arthroscopies go on to have total knee arthroplasty (TKA). Several individual studies have investigated the interval between knee arthroscopy and TKA. Our objective was to summarize published literature on the risk of TKA following knee arthroscopy, the duration between arthroscopy and TKA, and risk factors for TKA following knee arthroscopy. METHODS: We searched PubMed, Embase, and Web of Science for English language manuscripts reporting TKA following arthroscopy for knee OA. We identified 511 manuscripts, of which 20 met the inclusion criteria and were used for analysis. We compared the cumulative incidence of TKA following arthroscopy in each study arm, stratifying by type of data source (registry vs. clinical), and whether the study was limited to older patients (≥ 50) or those with more severe radiographic OA. We estimated cumulative incidence of TKA following arthroscopy by dividing the number of TKAs among persons who underwent arthroscopy by the number of persons who underwent arthroscopy. Annual incidence was calculated by dividing cumulative incidence by the mean years of follow-up. RESULTS: Overall, the annual incidence of TKA after arthroscopic surgery for OA was 2.62% (95% CI 1.73-3.51%). We calculated the annual incidence of TKA following arthroscopy in four separate groups defined by data source (registry vs. clinical cohort) and whether the sample was selected for disease progression (either age or OA severity). In unselected registry studies the annual TKA incidence was 1.99% (95% CI 1.03-2.96%), compared to 3.89% (95% CI 0.69-7.09%) in registry studies of older patients. In unselected clinical cohorts the annual incidence was 2.02% (95% CI 0.67-3.36%), while in clinical cohorts with more severe OA the annual incidence was 4.13% (95% CI 1.81-6.44%). The mean and median duration between arthroscopy and TKA (years) were 3.4 and 2.0 years. CONCLUSIONS: Clinicians and patients considering knee arthroscopy should discuss the likelihood of subsequent TKA as they weigh risks and benefits of surgery. Patients who are older or have more severe OA are at particularly high risk of TKA.

Systematic review

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Authors Lunn TH , Kehlet H
Journal Acta anaesthesiologica Scandinavica
Year 2013
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Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

Systematic review

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Authors Spahn G , Hofmann GO , Klinger HM
Journal Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA
Year 2013
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PURPOSE: Knee osteoarthritis is one of the most common orthopaedic diseases. Therapeutic options for this disease include conservative treatments and arthroscopic debridement and partial or complete replacement. This meta-analysis aimed to collect and analyse the available information on the effects of arthroscopic joint debridement related to the clinical outcomes, the required conversion to replacement and the factors for patient selection. METHODS: A search for publications was performed in the PubMed, Cochrane and EMBASE medical databases. The primary search resulted in a total of 1,512 citations. The results from 30 papers were included in this study. The extracted dates were listed in a standardised protocol. The statistical evaluation was performed using Comprehensive Meta-analysis software (V2 Biostat, Englewood, NJ, USA). RESULTS: No randomised study that compared conservative and arthroscopic treatments for knee osteoarthritis was found. Most studies reported middle-term results after arthroscopic operations. The results of these studies showed excellent or good outcomes in more than 60 % of all patients. These results were correlated with a significant increase in the knee scores from baseline to follow-up; the standardised difference in means was 2.3 (CI 95 % 1.5-3.0, p < 0.001). The required conversion rate to replacement increased as the follow-up interval increased. The rates were as follows: 1 year-6.1 % (CI 95 %, 2.1-16.6 %), 2 years-16.8 % (CI 95 %, 10.2-26.3 %), 3 years-21.7 % (CI 95 %, 15.5-29.1 %) and 4 years-34.1 % (CI 95 %, 22.8-47.6 %). The mean survival time was 42.7 (CI 95 %, 14.5-71.1) months. Numerous factors influenced the outcome, including the radiological stage of the osteoarthritis and individual patient factors (e.g. time of history of osteoarthritis, weight and smoking). The local knee findings, such as axial dysalignment, missing effusion and massive crepitus, were also correlated with patient outcome. CONCLUSION: Arthroscopic joint debridement is a potential and sufficient treatment for knee osteoarthritis in a middle-term time interval. This procedure results in an excellent or good outcome in approximately 60 % of patients in approximately 5 years. LEVEL OF EVIDENCE: Systematic review of studies, Level III.