David Appleby

Outcome of Single-Bundle Versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament A Meta-Analysis

Background The anterior cruciate ligament (ACL) has 2 anatomic bundles. Standard ACL reconstruction is with a single-bundle graft, but double-bundle reconstruction may better control knee rotational torque, a potential cause of failure after single-bundle reconstruction. The authors investigated outcomes of single-bundle versus double-bundle ACL reconstruction. Hypothesis There is no difference in outcomes of single-bundle versus double-bundle reconstruction. Study Design Meta-analysis. Methods The authors systematically identified randomized controlled trials (RCTs) comparing single-bundle versus double-bundle ACL reconstruction (secondary analysis includes nonrandomized trials). Outcomes reported in a majority of included trials were meta-analyzed. Results Four RCTs were included (secondary analysis including 5 additional trials yielded reassuringly similar results). Two outcome measures were reported (in a manner permitting meta-analysis) in at least 3 of 4 trials: KT-1000 arthrometer and pivot-shift testing. On average, KT-1000 arthrometer side-to-side difference was 0.52 mm closer to normal in patients treated with double-bundle reconstruction. This difference is demonstrated to be clinically insignificant. In addition, there was no statistical difference in the odds of having a normal or nearly normal pivot-shift result in patients treated with double-bundle versus single-bundle reconstruction. Conclusion Double-bundle reconstruction does not result in clinically significant differences in KT-1000 arthrometer or pivot-shift testing. The pivot-shift results have particular clinical relevance because the test is designed to evaluate knee rotational instability; the results do not support the theory that double-bundle reconstruction better controls knee rotation. Improved quality of future RCTs would allow meta-analysis of a greater number of outcome measures including measures of symptoms and disabilities most important to patients.

Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction.

PURPOSE The purpose of this study was to determine the cost-effectiveness of knee arthroscopy and anterior cruciate ligament (ACL) reconstruction. METHODS Retrospective analysis of prospectively collected data from a single-surgeon, institutional review board-approved outcomes registry included 2 cohorts: surgically treated knee arthroscopy and ACL reconstruction patients. Our outcome measure is cost-effectiveness (cost of a quality-adjusted life-year [QALY]). The QALY is calculated by multiplying difference in health-related quality of life, before and after treatment, by life expectancy. Health-related quality of life is measured by use of the Quality of Well-Being scale, which has been validated for cost-effectiveness analysis. Costs are facility charges per the facility cost-to-charges ratio plus surgeon fee. Sensitivity analyses are performed to determine the effect of variations in costs or outcomes. RESULTS There were 93 knee arthroscopy and 35 ACL reconstruction patients included at a mean follow-up of 2.1 years. Cost per QALY was

Outcome of Single-Bundle versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament

5,783 for arthroscopy and

Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Rupture in Patients Aged 40 Years or Older : An Expected-Value Decision Analysis

10,326 for ACL reconstruction (2009 US dollars). Sensitivity analysis shows that our results are robust (relatively insensitive) to variations in costs or outcomes. CONCLUSIONS Knee arthroscopy and knee ACL reconstruction are very cost-effective.

The Relationship Between the Outcome of Studies of Autologous Chondrocyte Implantation and the Presence of Commercial Funding

Background The anterior cruciate ligament (ACL) has 2 anatomic bundles. Standard ACL reconstruction is with a single-bundle graft, but double-bundle reconstruction may better control knee rotational torque, a potential cause of failure after single-bundle reconstruction. The authors investigated outcomes of single-bundle versus double-bundle ACL reconstruction. Hypothesis There is no difference in outcomes of single-bundle versus double-bundle reconstruction. Study Design Meta-analysis. Methods The authors systematically identified randomized controlled trials (RCTs) comparing single-bundle versus double-bundle ACL reconstruction (secondary analysis includes nonrandomized trials). Outcomes reported in a majority of included trials were meta-analyzed. Results Four RCTs were included (secondary analysis including 5 additional trials yielded reassuringly similar results). Two outcome measures were reported (in a manner permitting meta-analysis) in at least 3 of 4 trials: KT-1000 arthrometer and pivot-shift testing. On average, KT-1000 arthrometer side-to-side difference was 0.52 mm closer to normal in patients treated with double-bundle reconstruction. This difference is demonstrated to be clinically insignificant. In addition, there was no statistical difference in the odds of having a normal or nearly normal pivot-shift result in patients treated with double-bundle versus single-bundle reconstruction. Conclusion Double-bundle reconstruction does not result in clinically significant differences in KT-1000 arthrometer or pivot-shift testing. The pivot-shift results have particular clinical relevance because the test is designed to evaluate knee rotational instability; the results do not support the theory that double-bundle reconstruction better controls knee rotation. Improved quality of future RCTs would allow meta-analysis of a greater number of outcome measures including measures of symptoms and disabilities most important to patients.

Paper 195: Operative Versus Non-operative Treatment of Anterior Cruciate Ligament Rupture in Patients Greater than 40 Years of Age: An Expected Values Decision Analysis

PURPOSE Our purpose was to determine the optimal treatment of anterior cruciate ligament (ACL) rupture in patients aged 40 years or older. METHODS Our method was expected-value decision analysis with sensitivity analysis, which is a systematic tool for quantitating clinical decisions. We evaluated 100 randomly selected individuals aged 40 years or older with regard to the following variables: age, gender, activity level (International Knee Documentation Committee form), and visual analog scale regarding potential outcome preferences. Patients with prior knee injury or surgery were excluded. A decision tree was constructed (operative v nonoperative potential outcomes). Literature review determined probabilities of outcomes. Statistical fold-back analysis calculated optimal treatment. Sensitivity analysis determined the effect of changing the outcome probabilities on the decision. RESULTS This study included 69 patients (31 with prior knee injury or surgery were excluded). The mean age was 53 years (range, 40 to 80 years), 48% were men, and the activity level was normally distributed (with a slight lower activity skew as anticipated for an older population). The expected value for operative treatment was 7.99 versus 1.86 for nonoperative treatment. Increasing the probability of surgical complications (sensitivity analysis) decreased the expected value of operative treatment but not below the expected value of nonoperative treatment. CONCLUSIONS Decision analysis shows that surgery is the optimal treatment of ACL rupture in patients aged 40 years or older. A limitation is that, by convention, decision analysis does not investigate actual patients with the condition. CLINICAL RELEVANCE Individuals aged 40 years or older are extremely averse to accepting potential knee instability during pivoting and thus prefer ACL surgery despite the risk of surgical complications.

Winner of the 2007 Systematic Review Competition: Outcome of Single-Bundle versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament

Background Autologous chondrocyte implantation (ACI) is an expensive treatment option for focal cartilage defects, and commercial funding of research is associated with a study reaching a positive conclusion. The purpose of this analysis is to compare outcomes (and levels of evidence) between published ACI outcome studies that were commercially funded and studies that were not commercially funded. Hypothesis Commercially funded ACI literature could be commercially biased. Study Design Comparative meta-analysis. Methods MEDLINE was searched for human, knee, ACI, nonmembrane, English language, and clinical outcome studies. Studies were evaluated with regard to funding status (commercially funded or not commercially funded), outcomes, and levels of evidence. Outcomes and levels of evidence were evaluated and compared for commercially funded studies versus those that were not commercially funded. Results Twenty-three studies were included; 16 (70%) were commercially funded. Pooled clinical outcome measures data were not significantly different (Lysholm, Modified Cincinnati, patient-reported Cincinnati, Tegner, pain Visual Analog Scale) when comparing commercially funded studies with those that were not commercially funded. However, distribution of levels of evidence was significantly lower (P = .045) for commercially funded studies. Conclusion Reassuringly, commercial funding of ACI studies did not result in a difference in published clinical outcomes versus those that were not commercially funded. However, the lower levels of evidence of commercially funded studies suggests that commercially funded ACI studies may be of less value to surgeons desiring to practice evidence-based medicine, and, in the future, commercial entities funding medical research could selectively fund studies of the highest levels of evidence.

Meta-Analysis of the Efficacy and Safety of Intradiscal Electrothermal Therapy (IDET)

Purpose: Our purpose is to determine the optimal treatment of ACL rupture in patients over 40 years of age. We hypothesize that there is no difference in the expected value of surgical versus non-surgical treatment. Methods: Our methods are expected values decision analysis with sensitivity analysis which is a systematic tool for quantitating clinical decisions. We evaluated 100 random individuals over 40 for the following variables: age, gender, activity level (IKDC), and visual analog scale regarding potential outcome preferences. Patients with prior knee injury or surgery were excluded. A decision tree was constructed (operative versus nonoperative potential outcomes). Literature review determined probabilities of outcomes. Statistical fold-back analysis calculated optimum treatment. Sensitivity analysis determined effect of changing outcome probabilities on the decision. Results: Sixty-nine patients were included; (31 with prior knee injury or surgery were excluded). Mean age was 53 (range 40-80), 48 % were male, activity level was normally distributed (with a slight lower activity skew as anticipated for an older population). Expected-value for operative treatment was 7.99 versus 1.86 for non-operative treatment. Increasing the probability of surgical complications (sensitivity analysis) decreased the expected value of operative treatment but not below the expected value of non-operative treatment. Conclusion: In contrast to the null hypothesis, decision analysis demonstrates that surgery is the optimal treatment of ACL rupture in patients over 40 years of age. A limitation is that by convention, decision analysis does not investigate actual patients with the condition. It is clinically relevant that individuals over 40 are extremely averse to accepting potential knee instability during pivoting and thus prefer ACL surgery despite risk of surgical complications. Paper 196: ACL Reconstruction in Patients Over 50 Years DIANE LYNN DAHM, MD, USA, PRESENTING AUTHOR KHALED AHMAD DAJANI, MD, USA COREY A WULF, MD, USA RYAN E DOBBS, MD, USA BRUCE LEVY, MD, USA MICHAEL JEROME STUART, MD, USA ABSTRACT Purpose: There is currently a paucity of data in the literature on anterior cruciate ligament (ACL) reconstruction in patients aged 50 years and older. The purpose of this study is to evaluate the results of ACL reconstruction in patients over fifty years of age at the time of surgery. Methods: The records of all patients at our institution at least 50 years of age who underwent ACL reconstruction between 1990 and 2002 were reviewed. Inclusion criteria were age 50, primary ACL reconstruction, and at least 24 months of follow-up. Patients with a history of multiligamentous injury were excluded. Pre-operative and post-operative clinical records were reviewed. Preand post-operative range of motion was recorded. IKDC, Lysholm, UCLA, and Tegner scores were calculated. Results: There were 35 knees in 34 patients that met the inclusion criteria. The mean age of the patients was 57 years (50 to 66) and the mean clinical follow-up was for 72 months (25 to 173). A total of 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The mean pre-operative knee extension was 1° (–5° to 10°) and flexion was 129° (125° to 150°) and at follow-up these values were 0° (–5° to 5°) and 135° (120° to 150°), respectively. Pre-operatively there were 31 knees (89%) with a Lachman grade 2 or 3 . Post-operatively, 33 knees (94%) were Lachman grade 0 or 1 . The mean pre-and post-operative IKDC scores were 39 (range 23-72) and 90 (range 33-100) respectively. UCLA activity scores averaged 8.5 preinjury, 4.3 post-injury and 8.3 post-operatively. Four knees required additional surgery following ACL reconstruction. There were three graft failures (8.6%) requiring revision. No patient was treated for post-operative arthrofibrosis, infection, or deep-vein thrombosis. Conclusions: This study demonstrates satisfactory clinical and functional results in patients over 50 years of age undergoing anterior cruciate ligament reconstruction. Advanced chronologic age alone should not be considered a contraindication to reconstruction.Purpose: There is currently a paucity of data in the literature on anterior cruciate ligament (ACL) reconstruction in patients aged 50 years and older. The purpose of this study is to evaluate the results of ACL reconstruction in patients over fifty years of age at the time of surgery. Methods: The records of all patients at our institution at least 50 years of age who underwent ACL reconstruction between 1990 and 2002 were reviewed. Inclusion criteria were age 50, primary ACL reconstruction, and at least 24 months of follow-up. Patients with a history of multiligamentous injury were excluded. Pre-operative and post-operative clinical records were reviewed. Preand post-operative range of motion was recorded. IKDC, Lysholm, UCLA, and Tegner scores were calculated. Results: There were 35 knees in 34 patients that met the inclusion criteria. The mean age of the patients was 57 years (50 to 66) and the mean clinical follow-up was for 72 months (25 to 173). A total of 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The mean pre-operative knee extension was 1° (–5° to 10°) and flexion was 129° (125° to 150°) and at follow-up these values were 0° (–5° to 5°) and 135° (120° to 150°), respectively. Pre-operatively there were 31 knees (89%) with a Lachman grade 2 or 3 . Post-operatively, 33 knees (94%) were Lachman grade 0 or 1 . The mean pre-and post-operative IKDC scores were 39 (range 23-72) and 90 (range 33-100) respectively. UCLA activity scores averaged 8.5 preinjury, 4.3 post-injury and 8.3 post-operatively. Four knees required additional surgery following ACL reconstruction. There were three graft failures (8.6%) requiring revision. No patient was treated for post-operative arthrofibrosis, infection, or deep-vein thrombosis. Conclusions: This study demonstrates satisfactory clinical and functional results in patients over 50 years of age undergoing anterior cruciate ligament reconstruction. Advanced chronologic age alone should not be considered a contraindication to reconstruction. Paper 197: Long-term Results After ACL Reconstruction Using Hamstring vs. BPT Graft in an Implant Free Pressfit Technique: An 8 Year Follow-up HANS H PAESSLER, MD, GERMANY, PRESENTING AUTHOR BENJAMIN WIPFLER, POSTGRADUATE, GERMANY STEFANIE KLIEM, MD, GERMANY JAN SPRINGER, GERMANY e450 ABSTRACTS

Ex Vivo Comparison of Mechanical Versus Thermal Chondroplasty: Assessment of Tissue Effect at the Surgical Endpoint

Background The anterior cruciate ligament (ACL) has 2 anatomic bundles. Standard ACL reconstruction is with a single-bundle graft, but double-bundle reconstruction may better control knee rotational torque, a potential cause of failure after single-bundle reconstruction. The authors investigated outcomes of single-bundle versus double-bundle ACL reconstruction. Hypothesis There is no difference in outcomes of single-bundle versus double-bundle reconstruction. Study Design Meta-analysis. Methods The authors systematically identified randomized controlled trials (RCTs) comparing single-bundle versus double-bundle ACL reconstruction (secondary analysis includes nonrandomized trials). Outcomes reported in a majority of included trials were meta-analyzed. Results Four RCTs were included (secondary analysis including 5 additional trials yielded reassuringly similar results). Two outcome measures were reported (in a manner permitting meta-analysis) in at least 3 of 4 trials: KT-1000 arthrometer and pivot-shift testing. On average, KT-1000 arthrometer side-to-side difference was 0.52 mm closer to normal in patients treated with double-bundle reconstruction. This difference is demonstrated to be clinically insignificant. In addition, there was no statistical difference in the odds of having a normal or nearly normal pivot-shift result in patients treated with double-bundle versus single-bundle reconstruction. Conclusion Double-bundle reconstruction does not result in clinically significant differences in KT-1000 arthrometer or pivot-shift testing. The pivot-shift results have particular clinical relevance because the test is designed to evaluate knee rotational instability; the results do not support the theory that double-bundle reconstruction better controls knee rotation. Improved quality of future RCTs would allow meta-analysis of a greater number of outcome measures including measures of symptoms and disabilities most important to patients.