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Cole B.J.,Rush University Medical Center | Farr J.,OrthoIndy | Winalski C.S.,Cleveland Clinic | Hosea T.,The New School | And 3 more authors.
American Journal of Sports Medicine | Year: 2011

Background: There are currently several approaches being pursued to treat focal defects of articular cartilage, each having specific advantages or challenges. A single-stage procedure that uses autologous cartilage fragments, Cartilage Autograft Implantation System (CAIS), is being evaluated in patients and may offer a clinically effective option. Purpose: To establish the safety of CAIS and to test whether CAIS improves quality of life by using standardized outcomes assessment tools. Study Design: Randomized controlled trial; Level of evidence, 2.Methods: Patients (n = 29) were randomized (1:2) with the intent to treat with either a control (microfracture [MFX]) or an experimental (CAIS) procedure. Patients were followed at predetermined time points for 2 years using several standardized outcomes assessment tools (SF-36, International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS]). Magnetic resonance imaging was performed at baseline, 3 weeks, and 6, 12, and 24 months. Results: Lesion size and International Cartilage Repair Society (ICRS) grade were similar in both groups. General outcome measures (eg, physical component score of the SF-36) indicated an overall improvement in both groups, and no differences in the number of adverse effects were noted in comparisons between the CAIS and MFX groups. The IKDC score of the CAIS group was significantly higher (73.9 ± 14.72 at 12 months and 82.95 ± 14.88 at 24 months) compared with the MFX group (57.78 ± 18.31 at 12 months and 59.5 ± 13.44 at 24 months). Select subdomains (4/5) in the KOOS instrument were significantly different at 12 and 18 months, and all subdomains (Symptoms and Stiffness, Pain, Activities of Daily Living, Sports and Recreation, Knee-related Quality of Life) were significantly increased at 24 months in CAIS with scores of 88.47 ± 11.68, 90.64 ± 7.87, 97.29 ± 3.8, 78.16 ± 22.06, and 69 ± 23.15 compared with 75 ± 9.31, 78.94 ± 13.73, 89.46 ± 8.13, 51.67 ± 26.01, and 37.15 ± 21.67 in the MFX group. These significant improvements were maintained at 24 months in both IKDC and KOOS. Qualitative analysis of the imaging data did not note differences between the 2 groups in fill of the graft bed, tissue integration, or presence of subchondral cysts. Patients treated with MFX had a significantly higher incidence of intralesional osteophyte formation (54% and 70% of total number of lesions treated) at 6 and 12 months when compared with CAIS (8% and 25% of total number of lesions treated).Conclusion: The first clinical experience in using CAIS for treating patients with focal chondral defects indicates that it is a safe, feasible, and effective method that may improve long-term clinical outcomes. © 2011 The Author(s).

Gilmore M.L.,New England Baptist Hospital | Wolfe D.J.,Brigham and Womens Hospital | Wolfe D.J.,Harvard University
General Hospital Psychiatry | Year: 2013

Objective: The objective was to examine whether prophylactic treatment with antipsychotics can decrease the incidence and severity of postsurgical delirium. Method: A meta-analysis of existing trials comparing delirium incidence between patients given prophylactic antipsychotic and placebo was performed. Secondary outcomes were total hospital days, total days of delirium and severity. Pooled odds ratios (ORs) and mean differences were calculated using a random-effects model. Results: Five randomized placebo-controlled trials comprising a total of 1491 patients were included. In the pooled analysis, prophylactic antipsychotic administration showed a reduction in delirium incidence (OR: 0.42; 95% confidence interval (CI): 0.24, 0.74). Among the studies reporting other outcomes, patients receiving antipsychotics prophylactically showed no differences in total hospital days (0.1; 95% CI: - 0.73, 0.94), days of delirium (- 1.17; 95% CI: - 5.22, 2.88) or delirium severity (- 1.02; 95% CI: - 6.81, 4.76). Conclusions: Prophylactic antipsychotic treatment in surgical patients modestly decreases the incidence of delirium, but not the length of hospital stay, duration of delirium or its severity. Given the modest protective effect of antipsychotics and their potential adverse reactions, there is insufficient evidence to support its universal use as a preventive agent, though potential benefit may be seen in populations at high risk of developing delirium. © 2013 Elsevier Inc.

Gardiner A.,New England Baptist Hospital
The American journal of sports medicine | Year: 2010

Osteotomies have a role in the active patient with degenerative joint disease of the medial or lateral knee who, for reasons of age or activity level, is not yet a good candidate for prosthetic arthroplasty. Recognition and treatment of malalignment associated with ligamentous instability is essential if long-term good outcomes are to be expected from ligamentous reconstruction. Also, treatment of concomitant malalignment and the unloading of the operative site is now recognized as an important adjunct to any cartilage-preserving surgery. This review examines the use of osteotomies about the knee in the athletic patient. Indications, contraindications, preoperative planning, surgical techniques, and complications are reviewed.

Suri P.,Harvard University | Rainville J.,Harvard University | Kalichman L.,New England Baptist Hospital | Kalichman L.,Ben - Gurion University of the Negev | Katz J.N.,Harvard University
JAMA - Journal of the American Medical Association | Year: 2010

Context: The clinical syndrome of lumbar spinal stenosis (LSS) is a common diagnosis in older adults presenting with lower extremity pain. Objective: To systematically review the accuracy of the clinical examination for the diagnosis of the clinical syndrome of LSS. Data Sources: MEDLINE, EMBASE, and CINAHL searches of articles published from January 1966 to September 2010. Study Selection: Studies were included if they contained adequate data on the accuracy of the history and physical examination for diagnosing the clinical syndrome of LSS, using a reference standard of expert opinion with radiographic or anatomic confirmation. Data Extraction: Two authors independently reviewed each study to determine eligibility, extract data, and appraise levels of evidence. Data Synthesis: Four studies evaluating 741 patients were identified. Among patients with lower extremity pain, the likelihood of the clinical syndrome of LSS was increased for individuals older than 70 years (likelihood ratio [LR], 2.0; 95% confidence interval [CI], 1.6-2.5), and was decreased for those younger than 60 years (LR, 0.40; 95% CI, 0.29-0.57). The most useful symptoms for increasing the likelihood of the clinical syndrome of LSS were having no pain when seated (LR, 7.4; 95% CI, 1.9-30), improvement of symptoms when bending forward (LR, 6.4; 95% CI, 4.1-9.9), the presence of bilateral buttock or leg pain (LR, 6.3; 95% CI, 3.1-13), and neurogenic claudication (LR, 3.7; 95% CI, 2.9-4.8). Absence of neurogenic claudication (LR, 0.23; 95% CI, 0.17-0.31) decreased the likelihood of the diagnosis. A wide-based gait (LR, 13; 95% CI, 1.9-95) and abnormal Romberg test result (LR, 4.2; 95% CI, 1.4-13) increased the likelihood of the clinical syndrome of LSS. A score of 7 or higher on a diagnostic support tool including history and examination findings increased the likelihood of the clinical syndrome of LSS (LR, 3.3; 95% CI, 2.7-4.0), while a score lower than 7 made the diagnosis much less likely (LR, 0.10; 95% CI, 0.06-0.16). Conclusions: The diagnosis of the clinical syndrome of LSS requires the appropriate clinical picture and radiographic findings. Absence of pain when seated and improvement of symptoms when bending forward are the most useful individual findings. Combinations of findings are most useful for identifying patients who are unlikely to have the diagnosis. ©2010 American Medical Association. All rights reserved.

Nandi S.,New England Baptist Hospital
The journal of knee surgery | Year: 2012

We report herein deep medial collateral ligament (MCL) tear of the knee with application of valgus stress during arthroscopic partial medial meniscectomy. With symptomatic treatment only, the patient went on to heal this injury without incident and recovered in an expected fashion from arthroscopic surgery. There is no earlier report in the literature of deep MCL tear during knee arthroscopy. Awareness of this entity, its consequences, and optimal management are essential as arthroscopic partial meniscectomy is the most common surgery performed by orthopedic surgeons.

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