Frank R. Noyes

Clinical Healing Rates of Meniscus Repairs of Tears in the Central-Third (Red-White) Zone

PURPOSEnTo determine the clinical healing rate of repairs of meniscus tears that extend into the central one-third region and the factors that affect the outcome.nnnMETHODSnA systematic search of PubMed was conducted to determine the outcome of meniscus repairs in the red-white (R/W) zone. Inclusion criteria were as follows: English language, clinical trials published from 1996 to 2013, R/W tears analyzed separately from tears in other zones, arthroscopic suture-based repairs, and all evidence levels.nnnRESULTSnOf 344 articles identified, 23 met the inclusion criteria. There were 1,232 patients who had 1,326 meniscus repairs, of which 767 were in the R/W zone. Concurrent anterior cruciate ligament reconstruction was performed in 955 patients (78%). The mean age was 25 years, and the mean follow-up was 4 years. Evaluation criteria included clinical examination in 22 studies, follow-up arthroscopy in 15, magnetic resonance imaging in 6, weight-bearing radiographs in 3, and the International Knee Documentation Committee subjective score in 1. Overall, 637 (83%) of the repairs were considered clinically healed because no additional surgery was required and no obvious clinical meniscus symptoms were detected. This included 382 of 470 inside-out suture repairs (81%) and 255 of 297 all-inside suture repairs (86%). Twenty-two factors were assessed in 13 studies to determine their influence on the outcome, with varying results. Authors generally found that patient age, chronicity of injury, involved tibiofemoral compartment, gender, and concurrent anterior cruciate ligament reconstruction did not adversely affect the results. Insufficient data existed to assess the healing rates according to the type of meniscus tear except for single longitudinal tears. Complications were reported in 3% of the patients in this review. Long-term assessment of a chondroprotective effect of the repairs was conducted in only 2 studies.nnnCONCLUSIONSnAn acceptable midterm clinical healing rate was found for R/W meniscus repairs, supporting this procedure when appropriately indicated. Long-term studies assessing the chondroprotective effect in the involved tibiofemoral compartment using magnetic resonance imaging and radiographs are needed.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level I-IV studies.

Neuromuscular Retraining Intervention Programs: Do They Reduce Noncontact Anterior Cruciate Ligament Injury Rates in Adolescent Female Athletes?

PURPOSEnThe purpose of this study was to identify neuromuscular training intervention programs that significantly reduced the incidence of noncontact anterior cruciate ligament (ACL) injury rates in female adolescent athletes.nnnMETHODSnA systematic search of PubMed was conducted to determine the outcome of ACL neuromuscular retraining programs in a specific population. The inclusion criteria were English language, published from 1994-2013, original clinical trials, all evidence levels, female athletes aged 19 years or younger, and noncontact ACL injury incidence rates determined by athlete-exposures.nnnRESULTSnOf 694 articles identified, 8 met the inclusion criteria. Three training programs significantly reduced noncontact ACL injury incidence rates in female adolescent athletes. These were the Sportsmetrics, Prevent Injury and Enhance Performance, and Knee Injury Prevention programs. The estimated number of athletes who needed to train to prevent 1 ACL injury in these 3 studies ranged from 70 to 98, and the relative risk reduction ranged from 75% to 100%. Five programs did not significantly reduce noncontact ACL injury incidence rates. The ACL injury incidence rates for control subjects were lower in these studies (0.03 to 0.08 per 1,000 athlete-exposures) than in those investigations that had a significant effect (0.21 to 0.49 per 1,000 athlete-exposures). There was wide variability among all programs in the frequency, duration, and timing of training; how training was conducted, supervised, or controlled; the components of the program; how exposure data were calculated; noncontact ACL injury incidence rates in the control groups; and compliance with training.nnnCONCLUSIONSnThree ACL intervention programs successfully reduced noncontact ACL injury incidence rates in female adolescent athletes. Pooling of data of all ACL intervention programs is not recommended because of numerous methodologic differences among studies.nnnLEVEL OF EVIDENCEnLevel II, systematic review of Level I and II studies.

A systematic review of the incidence and clinical significance of postoperative meniscus transplant extrusion.

PurposeTo determine the incidence and clinical significance of postoperative meniscus transplant extrusion.MethodsA systematic search was performed using PubMed and Cochrane online databases. Inclusionary criteria were English language, clinical trials of meniscus transplantation published from 1984 to 2014, and meniscus extrusion measured on magnetic resonance imaging (MRI).ResultsTwenty-three studies were included, in which 814 menisci were implanted into 803 patients. MRIs were obtained from 2xa0days to 10xa0years postoperatively. Eighteen studies used fresh-frozen meniscus transplants implanted with bone (nxa0=xa0612) or suture fixation (nxa0=xa0116); four studies, cryopreserved transplants; and one, irradiated transplants. Three measurements assessed extrusion: absolute millimeters of extrusion (0–8.8xa0mm), relative percentage of extrusion (0–100xa0%), and the percent of transplants that were extruded (0–100xa0%). Relationships between transplant extrusion and clinical rating scales, joint space narrowing on standing radiographs, and arthrosis progression were inconclusive. Non-anatomic placement of lateral meniscus transplants and suture fixation of medial and lateral transplants were associated with greater extrusion in two studies.ConclusionsInconsistencies among studies prevent conclusions regarding the incidence and clinical significance of meniscus transplant extrusion. Even so, the short- to mid-term results were encouraging for knee function with daily activities and low rates of failure requiring transplant removal. A postoperative MRI showing more than 3-mm extrusion occurring in some studies suggested technique and/or implant sizing problems that required correction. Future studies should report absolute transplant extrusion, relative percent of extrusion, percent of transplant within the tibiofemoral compartment, and the percent of transplants that are extruded.Level of evidenceIV.

Meniscal Transplantation in Symptomatic Patients Under Fifty Years of Age: Survivorship Analysis.

BACKGROUNDnThe purpose of this study was to prospectively evaluate the long-term results and survivorship of meniscal transplantation in a consecutive series of patients.nnnMETHODSnForty cryopreserved menisci were implanted into thirty-eight patients. Survival end points were transplant removal, revision, or tibiofemoral compartment pain with daily activities. A worst-case scenario was also calculated for patients who did not have symptoms related to the transplant; in this scenario, additional end points were grade-3 signal intensity, extrusion (>50% of meniscal width), or tear on magnetic resonance imaging; signs of meniscal tear on examination; or radiographic loss of joint space. The Cincinnati Knee and International Knee Documentation Committee rating systems were used.nnnRESULTSnAll patients were followed for a mean postoperative time of eleven years. The estimated probabilities of transplant survival were 88% at five years, 63% at ten years, and 40% at fifteen years. Worst-case survival rate estimates were 73% at five years, 68% at seven years, 48% at ten years, and 15% at fifteen years. The mean time to failure was 8.2 years for medial transplants and 7.6 years for lateral transplants. The functional analysis detected significant improvements for pain, swelling, the patients perception of the knee condition, walking, stair-climbing, and squatting (p < 0.05).nnnCONCLUSIONSnThe survivorship analysis showed that, at ten years, 63% had not required subsequent surgery and were asymptomatic with daily activities. However, this percentage decreased to 40% at fifteen years. Although the data indicated that the majority of cryopreserved meniscal transplants may fail in the long term, the resolution of symptoms and improvement in function for several years justifies the procedure in young patients who are symptomatic after meniscectomy. Patients should be advised that the procedure is not curative in the long term and additional surgery will most likely be required.

Sportsmetrics ACL Intervention Training Program: Components, Results

This chapter provides the historical background of the Sportsmetrics ACL intervention training program which was the first knee ligament intervention program for female athletes to be published in the peer-reviewed orthopedic literature. The program focuses on decreasing landing forces and improving lower limb alignment from a valgus position to a neutral position by teaching neuromuscular control of the lower limb and increasing knee and hip flexion angles. The dynamic warm-up, plyometric jump training, strengthening, and flexibility components are described and illustrated in detail. The results of numerous research investigations documenting improvements in neuromuscular indices and ACL injury rates are provided.

Rehabilitation After ACL Reconstruction

This chapter reviews the scientific principles and concepts for the development of an ACL reconstruction postoperative rehabilitation program. The exercises and modalities used in each phase of the program are presented, along with signs and symptoms to recognize and treat to prevent a complication such as loss of knee motion. Criteria are provided to advance the patient through the program in a manner which is safe to the healing graft and responsive to the patient’s final activity level goals. Advanced neuromuscular retraining is advocated for patients who desire to return to high-risk activities such as soccer and basketball. Criteria for final release to unrestricted athletics are provided.

Effect of Intervention Programs on Reducing the Incidence of ACL Injuries, Improving Neuromuscular Deficiencies, and Enhancing Athletic Performance

This chapter reviews the current available data regarding the effectiveness of the ACL intervention programs in reducing injury rates, improving knee kinematic and kinetic factors, and enhancing athletic performance indicators. Three of nine programs published to date that reported ACL injury rates in female athletes according to athlete exposures statistically reduced the injury rate. Over 25 studies have analyzed the effectiveness of knee injury prevention programs in changing kinematic or kinetic factors in female athletes. However, the effectiveness of these programs in altering neuromuscular indices under reactive, unplanned, actual athletic conditions remains largely unknown. While many studies have documented changes in athletic performance indicators following ACL injury prevention training in female athletes, the results remain mixed.

ACL Injuries in the Female Athlete

ACL injuries in the female athlete : , ACL injuries in the female athlete : , کتابخانه دیجیتال جندی شاپور اهواز

Low-impact sports activities are feasible after meniscus transplantation: a systematic review.

PurposeTo determine sports activities achieved after meniscus transplantation and if associations exist between sports activity levels and transplant failure or progression of tibiofemoral osteoarthritis (OA).MethodsA systematic search was performed using PubMed and Cochrane online databases. Inclusionary criteria were English language, clinical trials published from 1996 through May 2017, minimum 2xa0years of follow-up, and sports activity data reported.ResultsTwenty-eight studies were included in which 1521 menisci were implanted into 1497 patients. The mean age was 34.3xa0±xa06.7xa0years, and the mean follow-up was 5.0xa0±xa03.7xa0years. Details on sports activities were provided in 7 studies (285 patients) that reported 70–92% of patients returned to a wide variety of sports activities. Mean Tegner activity scores were reported in 24 investigations. The mean score was <5 in 58% of these studies, indicating many patients were participating in light recreational activities. There was no association between mean Tegner scores and transplant failure rates. A moderate correlation was found between failure rates and mean follow-up time (Rxa0=xa00.63). The effect of sports activity levels on progression of tibiofemoral OA could not be determined because of limited data. Only two studies determined whether symptoms occurred during sports activities; these reported 1/38 (3%) and 5/69 (7%) patients had knee-related problems.ConclusionsIt appeared that the majority of individuals returned to low-impact athletic activities after meniscus transplantation. The short-term follow-up did not allow for an analysis on the effect of return to high-impact activities on transplant failure rates or progression of OA.Level of evidenceIV.

The ACL: Anatomy, Biomechanics, Mechanisms of Injury, and the Gender Disparity

This chapter summarizes the current knowledge regarding ACL anatomy, biomechanics, common injury mechanisms, and the differences in ACL injury rates between male and female athletes. The anatomy of the ACL has been well described; however, disagreement exists regarding its division into two distinct fiber bundles. At least two-thirds of ACL tears occur during noncontact situations such as cutting, pivoting, accelerating, decelerating, and landing from a jump. Reduced knee flexion angles, increased hip flexion angles, valgus collapse at the knee, increased hip internal rotation, and increased internal or external tibial rotation are frequently reported at the time of or just prior to ACL injury. Female athletes are at greater risk for sustaining an ACL injury compared to male athletes participating in soccer, basketball, rugby, and handball. Research has shown that comprehensive training programs can effectively “reprogram” the neuromuscular system to avoid potentially dangerous body mechanics and positions.