Background

Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA.

Objectives: To compare the results of various surgical approaches to the knee in primary total knee arthroplasty (TKA) surgery.

Design: Systematic review with meta-analysis.

Data Sources: Cochrane Bone, Joint, and Muscle Trauma group trials register (2007), Cochrane central register of controlled trials (Cochrane Library issue 2, 2007), Medline (1950–2007), Embase (1974–2007), CINAHL (1982–2007), Pubmed, SCOPUS and ZETOC.

Review Methods: Randomised and quasi-randomised controlled trials comparing surgical approaches in patients undergoing primary TKA. Relative risks and 95% CIs were calculated for dichotomous outcomes, and weighted mean differences and 95% CIs calculated for continuous outcomes. Individually randomised trials were pooled whenever possible with the use of the fixed-effects model of Mantel-Haenszel.

Results: 53 articles were identified using our search strategy; of these, 32 were excluded from the systematic review. 21 trials involving 1082 patients (1170 TKAs) were included.

Midvastus (MV) vs Medial Parapatellar (MPP) approach:

Quadriceps function in the early post operative period was better preserved in the MV group. Post operative pain, blood loss and the need for LRR tended to be lower in the MV group.

Conclusions: Approaches preserving the quadriceps tendon improve the early extensor mechanism function and tend to decrease the need for LRR. Combined with a decrease in blood loss and postoperative pain, these approaches improve early rehabilitation and allow for a more rapid recovery of knee function. However, these early improvements fail to provide any long term benefit, do not improve knee scores, or decrease the length of hospital stay.

MIS tends to result in an improved early quadriceps function and decreased blood loss. However, these approaches are technically more demanding, result in longer operative times and provide no long-term benefit. There is concern that they result in a greater number of major complications and risk implant mal-alignment. Eversion of the patella seems to correlate with poor quadriceps function.

Objectives: To compare the results of various surgical approaches to the knee in primary arthroplasty surgery.

Design: Systematic review with meta-analysis

Data Sources: Cochrane Bone, Joint, and Muscle Trauma group trials register (2007), Cochrane central register of controlled trials (Cochrane Library issue 2, 2007), Medline (1950 to February 2007), Embase (1974 to February 2007), CINAHL (1982 to February 2007), Pubmed, SCOPUS and ZETOC. If data was insufficient trialists were contacted via telephone, email or letter.

Review methods: Randomised and quasi-randomised controlled trials comparing surgical approaches to the knee in patients undergoing primary arthroplasty surgery.

Results: Twenty-three randomised, controlled trials (1282 patients, 1490 TKAs) were included.

Midvastus vs Medial Parapatellar approach: Quadriceps function in the early post operative period was better preserved in the MV group. Post operative pain, blood loss and the need for LRR tended to be lower in the MV group. There was no difference in ROM, hospital stay, knee scores, complications or radiological alignment.

Conclusions: Approaches preserving the quadriceps tendon improve the early extensor mechanism function and tend to decrease the need for LRR. Combined with a decrease blood loss and postoperative pain, these approaches improve early rehabilitation and allow for a more rapid recovery of knee function. However, these early improvements fail to provide any long term benefit, do not improve knee scores, or decrease the length of hospital stay.

Introduction and Aims: Conventional histology requires the traumatic removal of tissue from its native environment. This is not only a destructive process but also leads to tissue preparation artefact. We report on a novel arthroscopic instrument, the laser scanning confocal arthroscope (LSCA), which can image tissues of the knee at depth without the need for a damaging tissue biopsy.

Method: The new confocal arthroscope contains 4.4mm diameter with a 90-degree lens. Using three knee joints from two adult Merino sheep we imaged muscle, cartilage, ligament, tendon, synovium, meniscus and loose connective tissue. The knees were separately injected with three fluorophores (Acridine Orange, Acriflavine/Calcein-AM or Fluorescein) prior to imaging. Using a medial para-patellar incision, the contents of the knee were exposed and the confocal arthroscope was held directly on the tissue of interest. A second operator captured the images on a computer.

Results: We were able to demonstrate the common histological features of normal sheep articular cartilage, meniscus, synovium, ligament, tendon and muscle. Tissues were imaged to depths of 200 microns. Articular cartilage was characterised by a layer of dense superficial cells surrounded by extracellular matrix. There was no visible orderly arrangement of cells in this layer. Meniscus was characterised by closely packed circumferential collagen fibres. Synovium demonstrated a dense collection of cells in a thin membrane, typical of this secretory tissue. Ligament and tendon were characterised by bundles of parallel collagen fibres interspersed by scattered cells. Muscle revealed a typical arrangement of muscle fibres surrounded by a loose connective tissue and separated by capillaries and nerves. Eccentric nuclei were seen, however striations were beyond the imaging resolution of the arthroscope.

Conclusion: This study demonstrates the use of a novel arthroscopic instrument for the non-destructive examination of the components of the sheep knee joint. We foresee that the laser scanning confocal arthroscope will have future application in the assessment of cartilage grafting techniques and arthritis modifying drugs.