The Smoking Gun

A cognitive bias backfires in the worst possible way......

A 32-year-old entertainment industry technician presents to an Orthopaedic Surgeon for a second opinion. He describes an injury after a night of celebration where he fell and suffered a closed transverse fracture to his right patella 9 months prior.

He was taken by ambulance to the emergency department of his local public hospital and the next day open reduction and internal fixation of his fractured patella was undertaken with a tension band. Intraoperative imaging was undertaken and this confirmed that the surgeon had achieved an anatomic reduction of the fracture with a tension band wire. 

The patient was initially managed in a splint, touch weight-bearing on crutches and then range of motion exercises were started after two weeks. 

Initial radiographs at 8 weeks suggested anatomic reduction was maintained. By 3 months a delayed union was diagnosed, and by 7 months a non-union was noted, with fixation wire breakage, and displacement of the fracture fragments. 

The patient complains of severe pain and states he is "extremely disappointed" with the care received at the hospital. 

The surgeon notes that the patient is an active smoker consuming 1.5 packets per day since he was 16 years old. The outpatient notes from the public hospital contain multiple references to advice given to the patient to not smoke peri-operatively, advice which was not followed.

The surgeon recommends revision fixation with bone grafting, but only if the patient stops smoking. Due to recurrent failure to smoking in the past, the patient was referred to a psychologist, and once the smoking cessation was confirmed, the revision surgery was completed successfully.

Take Home Messages: 

1 Patient's and sometimes medical staff have a cognitive bias to downplay the effects of smoking on postoperative complications.

2 Smoking increases infection risk, thromboembolism risk and non-union risk 300-500%

4 Nicotine patches still increase risk of complications, particularly non-union 

5 Elective surgery should not be undertaken until smoking has ceased

6 Patients who smoke are more at risk of musculoskeletal trauma, and hence complication with accidental bony injury

7 Many patients require psychological support to alter behaviour.

Stem Cells Gone Wrong

A 64-year male presents to the Emergency department on a Sunday morning. He is an obese diabetic who describes himself as an occasional smoker. In his 20’s he underwent an open Lateral Meniscectomy and now has severe lateral compartment osteoarthritis. His BMI is 38. Two years prior he was seen by an orthopaedic surgeon and was recommended to lose weight , take improved analgesia and exercise. He was advised the knee replacement was likely but was told that he really should maximise his non-operative options. 

Earlier this year he attended a stem cell clinic in Melbourne, had liposuction, and the fractionated adipose Pericytes were then injected into both of knees as “stem cell” therapy. Some of the Pericytes were then frozen. Due to ongoing pain he went back 5 days ago and had more of the now defrosted Pericytes injected into both of his knees. On Friday he noted increasing pain and swelling in the right knee. On Saturday he saw his GP who diagnosed a possible septic right knee and prescribed oral Cefuroxime. His GP suggested if he didn’t settle, then to attend the EmergencyDepartment. Over the next 24 hours, his knee pain worsened, he developed low-grade fevers and an increasing effusion. 

On examination in the Emergency Department, he had a low-grade temperature of 38.4 degrees Celsius and a moderate effusion. His CRP was 87, knee synovial fluid white cell count was 13,600 and he had a mild neutrophilia. He denied a history of gout, but gout crystals were visible on microscopy. No bacteria were visible and the fluid was cultured, but culture results will take 2- 7 days. 

What is the diagnosis ? 

It could be either an acute attack of gout on a background of chronic gout, or a septic knee. Both could have occurred from the injection. The rate of infection is quite low after knee injection, but it remains the most common cause of a septic native knee joint. Because he was started on antibiotics prior to a synovial specimen being taken, he could have a culture negative infection. Bacteria are rarely visible in septic synovial fluid. 

What is the management ? 

Because of the high CRP and synovial cell count, a presumptive diagnosis of sepsis was made. The patient was taken to the Operating Theatre and an arthroscopic lavage and synovectomy was performed. Severe synovitis was noted and severe osteoarthritis in the lateral compartment. The synovial fluid was very turbid with gout crystals visible throughout the knee. Intravenous broad-spectrum antibiotics were commenced and the patient was kept in hospital for 1 week. No culture had occurred by day 7. RNA testing of the tissue biopsy was undertaken, but this was equivocal. The patient made a slow recovery over the next weeks, with resolution of the pain and swelling. Oral broad spectrum antibiotics were continued for 4 weeks, 

Total knee replacement was delayed for at least 6 months due to the possible infection in the the joint being a contra-indication. 

What is the take-home message ? 

1 Adipose-derived stem cells have no current role in the management of Osteoarthritis. No controlled study has shown improved symptoms over placebo.

2 If a possible diagnosis of a septic joint is made, antibiotics must not be commenced until a tissue sample is obtained. 

3 Weight loss, exercise and appropriate analgesia remain the primarymanagement of uncomplicated Osteoarthritis 

Osteoarthritis in the Young Active Male : Knee Preservation or Replacement ?

Left Medial Joint Space Narrowing in Moderate - Severe Medial Osteoarthritis

Osteoarthritis in the Young Active Male : Knee Preservation or Replacement ? A 52-year-old male carpenter is referred by his GP after failingnon- operative rehabilitation with his physio for Left medial knee osteoarthritic pain. His pain on a VAS is between 4 - 6/10, with a fair score on a Lysholm Knee Score of 60/100.  He stopped running sports 5 years prior due to medial pain. He stopped pivoting sports over 15 years earlier. At age 25 years he tore his Anterior Cruciate Ligament, however, this was never reconstructed, and he underwent a partial medial meniscectomy 10 years ago. 

On examination, his BMI is 27, walks with a varus thrust and his alignment is in varus (bow-legged). His Anterior Cruciate Ligament is incompetent with a Grade III Lachman test and a marked Pivot shift. He indicates medial pain.  He has a full range of motion and intact distal pulses. 

Plain radiographs show severe medial compartment osteoarthritis, and the MRI confirms a partially absent medial meniscus with extrusion. The Patellofemoral compartment and lateral compartment are normal on MRI. He is in 5 degrees of mechanical axis varus on alignment X-Rays. 

Opening Wedge HTO with ACLR

What are his operative options ? 

Always using joint preserving approach in young patients, particularly in males is the ideal approach.  An arthroscopy is not going to help him as his problem as is a combination of medial osteoarthritis and instability. Multiple randomized controlled trials suggest Arthroscopy does not help osteoarthritis symptoms.  A Unicompartmental Replacement (UKR) is contraindicated due to theAnterior Cruciate Ligament deficiency and while some surgeons undertake combined ACLR and UKR, that is a very controversial procedure in any age group, particularly in young males. 

A Total Knee Replacement would be a possible option, but at 52 he is very young for this. The AOA National Joint Replacement Registry would suggest a male under 55 years would have a failure rate of about 8-10 % by the 10 th year post implantation. As an option especially given, his lateral and patellofemoral compartments are well preserved, TKR would be a reasonable option if he was over 60 - 65, and happy to not run or jump ever again. 

Atraumatic Knee Pain in a Middle Aged Tennis Player

Dr Christopher Vertullo MBBS FRACS Orth

A 62-year-old tennis player presents to you complaining of an atraumatic onset of knee pain over the last few weeks. The pain is associated with a clicking sensation at the front of the knee and is worse after playing. She has never had this type of problem before and is concerned about a meniscal tear.

When you examine her knee, you note that she has a BMI of 31, a full range of active knee motion, no effusion, some wasting of her quads and some patellofemoral crepitus. The medial side of her knee is not tender.

Your next management step should be:

A To arrange an MRI and urgent review

B To reassure that no investigations are needed at this stage as the most likely diagnosis is Patellofemoral Osteoarthritis, and that quadriceps strengthening with her physiotherapist is all that is required. 

C To suggest to stop playing tennis and start some NSAID.

D To arrange an MRI and urgent orthopaedic surgical review

The correct answer is obviously B. An atraumatic onset of knee pain in a middle-aged patient will be degenerative change, in this case of the Patellofemoral joint. The initial management should be to avoid investigations at this stage, lose some weight, strengthen the quadriceps with her physio and consider NSAID prior to playing if no contraindication.

The patient then returns 6 weeks later, the pain is much better, but she wants to get an MRI to "see what is happening". 

Should you order an MRI ?

The answer is "not really", as a plain radiograph, particularly looking at the Patellofemoral joint is much more helpful as the initial test. If you initial diagnosis is incorrect, and she has a meniscal tear, arthroscopy will not be indicated, unless her knee is locked or she has a repairable meniscal root tear. The place for MRI in these situations is rather limited, and only when non-operative management has failed or the diagnosis is uncertain from the history and examination. Finally, reassurance that it is safe to continue exercising is vital as it helps the patient lose weight. Patellofeomoral pain really responds to weight loss dramatically.

Which Investigation for the Painful Knee ?

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Dr Christopher Vertullo MBBS FRACS

It is always difficult knowing which investigation to order when a patient presents with a painful knee. Often the most expensive test is not the best, and in many situations some radiological modalities have no place at all. A 70-year-old male patient presents to you with increasing right medial knee pain and aching. It had an atraumatic onset, and is worse with activity.  He had pain which was 1-3 / 10 previously , but since helping his daughter move house 3 weeks ago it has become much worse, and is interfering with his sleep. You examine him and notice he walks with a limp, has a reduced range of motion to 5- 100 degrees with no effusion. His hip is not stiff to rotation and he has a good distal vascular perfusion to his feet.  He then asks for an MRI, “like all the footballers get”.   

Investigation of atraumatic  onset knee pain should always start with a plain radiograph. A series of four XRs, is the Gold Standard. These include an Erect Antero-Posterior (AP) Radiograph, a Lateral, a Patellofemoral view and an erect flexion AP, known as a Rosenberg. Oblique X-Rays are rarely useful. 

What about the MRI ? Well in these situations, middle-aged or older patients with atraumatic onset of their pain, MRI is only a secondary investigation as the diagnosis is an exacerbation of osteoarthritis and degeneration . In fact, often the XR is all that is needed. The only reason to get an MRI is if the XR shows very little osteoarthritis and the patient fails to settle with a few weeks of rest. In these situations, a stress fracture can present with a similar history but fails to settle with rest. 

The Australian Knee Society recently combined with the Australian MusculoSkeletal Imaging Group to produce a position statement for the investigation of the degenerative knee. It is a handy reference for all musculoskeletal primary care practitioners.