Eirik Solheim

Background: Focal cartilage lesions (FCLs) are frequently found during knee arthroscopies and may impair quality of life (QoL) significantly. Several treatment options with good short-term results are available, but the natural history without any treatment is largely unknown. The aim of this study was to evaluate patient-reported outcome measures (PROMs), the need for subsequent cartilage surgery, and the risk of treatment failure 20 years after diagnosis of an FCL in the knee. Methods: Patients undergoing any knee arthroscopy for an FCL between 1999 and 2012 in 6 major Norwegian hospitals were identified. Inclusion criteria were an arthroscopically classified FCL in the knee, patient age of ≥18 years at surgery, and any preoperative PROM. Exclusion criteria were lesions representing knee osteoarthritis or “kissing lesions” at surgery. Demographic data, later knee surgery, and PROMs were collected by questionnaire. Regression models were used to adjust for and evaluate the factors impacting the long-term PROMs and risk factors for treatment failure (defined as knee arthroplasty, osteotomy, or a Knee injury and Osteoarthritis Outcome Score-Quality of Life [KOOS QoL] subscore of 1 FCL (OR, 1.9 [CI, 1.1 to 3.3]), a full-thickness lesion (OR, 2.5 [95% CI, 1.3 to 5.0]), and a lower level of education (OR, 1.8 [95% Cl, 1.1 to 2.8]). Autologous chondrocyte implantation (ACI) was associated with significantly higher KOOS QoL, by 17.5 (95% CI, 3.2 to 31.7) points, and a lower risk of treatment failure compared with no cartilage treatment, microfracture, or mosaicplasty. Conclusions: After a mean follow-up of 19 years, patients with an FCL who did not require a subsequent knee arthroplasty had significantly higher PROM scores than preoperatively. Nonsurgical treatment of FCLs had results equal to those of the surgical FCL treatments except for ACI, which was associated with a better KOOS and lower risk of treatment failure. Full-thickness lesions, >1 FCL, a lower level of education, and a greater BMI were the main risk factors associated with poorer results. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: The hypothesis of the present study assumed that a history of focal cartilage lesions would not affect Knee Injury and Osteoarthritis Outcome scores (KOOSs) following knee arthroplasty compared to a matched national cohort of knee arthroplasty patients.Methods: Fifty‐eight knee arthroplasty patients with previous surgery for focal cartilage lesions (cartilage cohort) were compared to a matched cohort of 116 knee arthroplasty patients from the Norwegian Arthroplasty Register (control group). Age, sex, primary or revision arthroplasty, type of arthroplasty (total, unicondylar or patellofemoral), year of arthroplasty surgery and arthroplasty brand were used as matching criteria. Demographic data and KOOS were obtained through questionnaires. Regression models were employed to adjust for confounding factors.Results: Mean follow‐up post knee arthroplasty surgery was 7.6 years (range 1.2–20.3) in the cartilage cohort and 8.1 (range 1.0–20.9) in the control group. The responding patients were at the time of surgery 54.3 versus 59.0 years in the cartilage and control group, respectively. At follow‐up the control group demonstrated higher adjusted Knee Injury and Osteoarthritis Outcome subscores than the previous focal cartilage patients with a mean adjusted difference (95% confidence interval in parentheses): Symptoms 8.4 (0.3, 16.4), Pain 11.8 (2.2, 21.4), Activities of daily living (ADL) 9.3 (−1.2, 18.6), Sport and recreation 8.9 (−1.6, 19.4) and Quality of Life (QoL) 10.6 (0.2, 21.1). The control group also demonstrated higher odds of reaching the patient‐acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores with odds ratio: Symptoms 2.7 (1.2, 6.4), Pain 3.0 (1.3, 7.0), ADL 2.1 (0.9, 4.6) and QoL 2.4 (1.0, 5.5).Conclusion: Previous cartilage surgery was associated with inferior patient‐reported outcomes after knee arthroplasty. These patients also exhibited significantly lower odds of reaching the patient‐acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores.Level of Evidence: Level III.

Background: Focal cartilage lesions are common in the knee. The risk of later ipsilateral knee arthroplasty remains unknown. The purposes of the present study were to evaluate the long-term cumulative risk of knee arthroplasty after arthroscopic identification of focal cartilage lesions in the knee, to investigate the risk factors for subsequent knee arthroplasty, and to estimate the subsequent cumulative risk of knee arthroplasty compared with that in the general population. Methods: Patients who had undergone surgical treatment of focal cartilage lesions at 6 major Norwegian hospitals between 1999 and 2012 were identified. The inclusion criteria were an arthroscopically classified focal cartilage lesion in the knee, an age of ≥18 years at the time of surgery, and available preoperative patient-reported outcomes (PROMs). The exclusion criteria were osteoarthritis or “kissing lesions” at the time of surgery. Demographic data, later knee surgery, and PROMs were collected with use of a questionnaire. A Cox regression model was used to adjust for and investigate the impact of risk factors, and Kaplan-Meier analysis was performed to estimate cumulative risk. The risk of knee arthroplasty in the present cohort was compared with that in the age-matched general Norwegian population. Results: Of the 516 patients who were eligible, 322 patients (328 knees) consented to participate. The mean age at the time of the index procedure was 36.8 years, and the mean duration of follow-up was 19.8 years. The 20-year cumulative risk of knee arthroplasty in the cartilage cohort was 19.1% (95% CI, 14.6% to 23.6%). Variables that had an impact on the risk of knee arthroplasty included an ICRS grade of 3 to 4 (hazard ratio [HR], 3.1; 95% CI, 1.1 to 8.7), an age of ≥40 years at time of cartilage surgery (HR, 3.7; 95% CI, 1.8 to 7.7), a BMI of 25 to 29 kg/m² (HR, 3.9; 95% CI, 1.7 to 9.0), a BMI of ≥30 kg/m² (HR, 5.9; 95% CI, 2.4 to 14.3) at the time of follow-up, autologous chondrocyte implantation (ACI) at the time of the index procedure (HR, 3.4; 95% CI, 1.0 to 11.4), >1 focal cartilage lesion (HR, 2.1; 95% CI, 1.1 to 3.7), and a high preoperative visual analog scale (VAS) score for pain at the time of the index procedure (HR, 1.1; 95% CI, 1.0 to 1.1). The risk ratio of later knee arthroplasty in the cartilage cohort as compared with the age-matched general Norwegian population was 415.7 (95% CI, 168.8 to 1,023.5) in the 30 to 39-year age group. Conclusions: In the present study, we found that the 20-year cumulative risk of knee arthroplasty after a focal cartilage lesion in the knee was 19%. Deep lesions, higher age at the time of cartilage surgery, high BMI at the time of follow-up, ACI, and >1 cartilage lesion were associated with a higher risk of knee arthroplasty. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: This study aimed to investigate the agreement of patient-assessed and researcher/physician-assessed measurements of the difference in range of motion between the unaffected and affected shoulders in 55 patients undergoing arthroscopic surgery for a unilateral shoulder condition. Methods: The investigation included 55 patients (17 women and 38 men; median age=53 years; range=26–74) with a symptomatic unilateral shoulder condition and a surgically treatable diagnosis. Images of a model/researcher performing active shoulder abduction, flexion, external rotation, and internal rotation were created. Each image was paired with a degree diagram or a level system (for internal rotation) on the back for the patient to accurately self-evaluate and record. Each patient was instructed to attentively examine the figures and perform the movements with the same posture as depicted. On the day of surgery, prior to the procedure, 2 independent researchers who were not involved in the patient's care used a standard goniometer to assess the same active movements that the patient had previously self-assessed. For agreement analyses, the intraclass correlation coefficient and Bland-Altman plots were calculated for continuous data (abduction, flexion, and external rotation), and Cohen’s weighted kappa was calculated for ordinal categorical data (internal rotation). Results: The intraclass correlation coefficient for abduction, flexion, and external rotation was 0.93 (excellent) 95% CI (0.87, 0.96), 0.89 (good) 95% CI (0.81, 0.94), and 0.72 (moderate) 95% CI (0.52, 0.84), respectively. Cohen's kappa for internal rotation (measured as reaching levels on the back) was 0.63 (moderate). Conclusion: We believe that patient-assessed measurements of abduction (intraclass correlation coefficient 0.93) and flexion (intraclass correlation coefficient 0.89) can be used as a valid substitute (for measurements by a clinician or researcher). Patient-assessed measurements for external rotation (intraclass correlation coefficient 0.72) and internal rotation (kappa 0.63) are in moderate agreement and should be used more cautiously as substitutes. Level of Evidence: Level II, Diagnostic Study. Cite this article as: Solheim E, Rosenlund M, Gjørwad Ulsaker K, Parkar AP. Self-assessment of range of motion in patients undergoing surgery for a unilateral shoulder condition. Acta Orthop Traumatol Turc., 2023;57(6):340-347.

Osteochondral autograft transplant (mosaicplasty) is a cartilage repair procedure for patients with knee articular cartilage lesions of a substantial size (>3 cm²). Patient selection is key to a successful result; patients with established osteoarthritis or systematic disorders such as rheumatoid arthritis should not undergo surgery. An exercise program involving neuromuscular training for a minimum of 3 months should be attempted before proceeding to osteochondral autograft transplant. The procedure can, in many cases, be performed arthroscopically. Patients should, however, provide consent for a mini-arthrotomy as this might be needed to achieve optimal access for graft harvesting and insertion. The procedure, in general, consists of 4 major steps. (1) At the initial arthroscopic examination, the size and localization of the defect are assessed after a proper debridement has been performed. The number and size of autografts needed can thereafter be assessed. (2) Graft harvesting is then performed from the periphery of the non-weight-bearing trochlea. (3) To prepare for graft insertion at the recipient site, a drill guide is inserted perpendicular to the joint surface in the defect to allow graft sockets to be reamed. (4) Grafts should be spaced approximately 3 mm apart to avoid confluence of tunnels and weakening of condyles. The orientation and depth of insertion of the grafts are key to mimic the native curvature of the affected joint surface. After an initial phase of non-weight-bearing focusing on range of motion, a gradual increase in neuromuscular exercises is recommended. Patients are typically advised to delay their return to sports until 6 months at the earliest. Results after mosaicplasty have shown that the procedure improves subjective outcomes, compared with baseline function, for up to 10 years after surgery. The additional effect over traditional microfracture treatment is, however, reduced over time. A study evaluating early factors affecting outcomes after cartilage repair procedures (including mosaicplasty) found that a series of factors, such as the time from the onset of symptoms to surgery, number and size of lesions, location and quality of surrounding cartilage, as well as concomitant meniscal injuries, were important ³ .