Geoffrey A. Bernas

Effect of Graft Choice on the Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation

BACKGROUND Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. METHODS As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45° of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. RESULTS Overall, 45° posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass correlation coefficient = 0.55; 95% confidence interval, 0.53 to 0.56). Similarly, the 45° posteroanterior flexion weight-bearing radiographs had higher correlation with arthroscopic findings of chondral disease (Spearman rho = 0.36; 95% confidence interval, 0.32 to 0.39) compared with anteroposterior radiographs (Spearman rho = 0.29; 95% confidence interval, 0.26 to 0.32). With respect to standards for the magnitude of the reliability coefficient and correlation coefficient (Spearman rho), the International Knee Documentation Committee classification demonstrated the best combination of good interobserver reliability and medium correlation with arthroscopic findings. CONCLUSIONS The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. The International Knee Documentation Committee classification assessed with use of 45° posteroanterior flexion weight-bearing radiographs had the most favorable combination of reliability and correlation. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Purpose/Hypothesis: The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. Conclusion: Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. Registration: NCT00625885

Defining Safe Rehabilitation for Ulnar Collateral Ligament Reconstruction of the Elbow A Biomechanical Study

Background Ulnar collateral ligament reconstruction of the elbow using a variety of techniques has been successful in enabling overhead athletes with ulnar collateral ligament insufficiency to return to competition. Most current postoperative rehabilitation programs begin with a period of motion restriction, including limiting elbow extension, that is followed by a transition from elbow strengthening to an interval throwing program, to competition. Motion restrictions early in the postoperative period may increase the risk for contractures. There is limited information to support current motion restrictions. Purpose (1) To determine strain on the reconstructed ulnar collateral ligament during a rehabilitation protocol that includes passive range of motion, isometric muscle contraction, and varus and valgus torques. (2) To develop guidelines for a safe initial rehabilitation protocol. Study Design Controlled laboratory study. Methods Eight cadaveric elbows underwent ulnar collateral ligament reconstruction with the docking technique using a gracilis tendon graft. Differential variable reluctance transducers on the anterior and posterior bands of the reconstructed anterior bundle of the ulnar collateral ligament were used to measure strain, while an optical motion tracking system monitored elbow motion. Strain was measured in the following 3 settings: passive range of motion, 22.2 N isometric flexion and extension contractions, and 3.34 N·m varus and valgus torques with the arm at 90° of flexion. Results Range of motion from maximum extension to 50° of flexion produced 3% or less strain in both bands of the reconstructed ligament. Forearm rotation did not significantly affect strain in the anterior or posterior bands (P = .336 and P = .357). Strain at 90° approached 7% in the posterior band (upper 95% confidence interval). Isometric muscle contractions had no measurable effect on strain. Varus torques decreased and valgus torques increased strain significantly (P < .05). Conclusion In the immediate postoperative period, full extension is safe, while flexion beyond 50° may place deleterious strain on the reconstruction. Isometric flexion and extension exercises do not increase ligament strain but may be unsafe at 90° of flexion, while valgus exercises (internal rotation at the shoulder) can increase strain in the reconstructed ligament. Clinical Relevance The results have implications for the development of appropriate rehabilitation protocols after ulnar collateral ligament reconstructive surgery.

Sex-Specific Predictors of Intra-articular Injuries Observed During Anterior Cruciate Ligament Reconstruction.

Background: Male patients tend to have more meniscal and chondral injuries at the time of anterior cruciate ligament (ACL) reconstruction than females. No studies have examined sex-specific predictors of meniscal and chondral lesions in ACL-injured patients. Purpose: To identify sex-specific predictors of meniscal and chondral lesions, as well as meniscal tear management, in patients undergoing ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected prospectively from 689 patients (56.2% males) undergoing ACL reconstruction between 2005 and 2014. Predictors of meniscal tears, meniscal tear management, and chondral injuries were determined using multivariate logistic regression models stratified by sex. Predictors were age, body mass index (BMI; 25-29.99 and ≥30 vs ≤24.99 kg/m2), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports-related) of injury, interval from injury to surgery (≤6 vs >6 weeks), and instability episodes (vs none). Odds ratios and 95% CIs were reported. Results: Males had more lateral (46% vs 27.8%; P < .0001) and medial (40.2% vs 31.5%; P = .01) meniscal tears, as well as more lateral (72.1% vs 27.9%; P < .0001) and medial (61.4% vs 38.6%; P = .01) meniscectomies than females. For males, age predicted chondral injuries and medial meniscectomy; BMI ≥30 kg/m2 predicted medial meniscal tears; high-impact and other sports predicted medial meniscal tears, medial meniscectomies, and medial meniscal repairs; injuries ≤6 weeks from surgery predicted lateral meniscal repairs; and instability episodes predicted medial meniscal tears, medial tears left in situ, medial meniscectomies, and medial meniscal repairs. For females, age predicted chondral injuries, BMI ≥30 kg/m2 predicted lateral meniscectomies and repairs, and instability episodes predicted medial meniscectomies. Conclusion: Sex differences were observed. For males, predictors included age, BMI, sports-related injuries, injuries ≤6 weeks from surgery, and instability episodes. For females, predictors included age, BMI, and instability episodes.

Accuracy of a Computer-Based Diagnostic Program for Ambulatory Patients With Knee Pain

Background: Looking up information regarding a medical condition is the third most popular activity online, and there are a variety of web-based symptom-checking programs available to the patient. However, the authors are not aware of any that have been scientifically evaluated as an accurate measure for the cause of one’s knee pain. Purpose/Hypothesis: The purpose of this study was to design and evaluate an Internet-based program that generates a differential diagnosis based on a history of knee pain entered by the patient. The hypothesis was that the program would accurately generate a differential diagnosis for patients presenting with knee pain. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A web-based program was created to collect knee pain history and generate a differential diagnosis for ambulatory patients with knee pain. The program selected from 26 common knee diagnoses. A total of 527 consecutive patients aged ≥18 years, who presented with a knee complaint to 7 different board-certified orthopaedic surgeons during a 3-month period, were asked to complete the questionnaire in the program. Upon completion, patients were examined by a board-certified orthopaedic surgeon. Both the patient and physician were blinded to the differential diagnosis generated by the program. A third party was responsible for comparing the diagnosis(es) generated by the program with that determined by the physician. The level of matching between diagnoses determined the accuracy of the program. Results: A total of 272 male and 255 female patients, with an average age of 47 years (range, 18-84 years), participated in the study. The median number of diagnoses generated by the program was 4.8 (range, 1-10), with this list containing the physician’s diagnosis(es) 89% of the time. The specificity was 27%. Conclusion: Despite a low specificity, the results of this study show the program to be an accurate method for generating a differential diagnosis for knee pain.

Patient Outcomes After Observation Versus Debridement of Unstable Chondral Lesions During Partial Meniscectomy: The Chondral Lesions And Meniscus Procedures (champ) Randomized Controlled Trial

Background: It is unknown whether unstable chondral lesions observed during arthroscopic partial meniscectomy (APM) require treatment. We examined differences at 1 year with respect to knee pain and other outcomes between patients who had debridement (CL-Deb) and those who had observation (CL-noDeb) of unstable chondral lesions encountered during APM. Methods: Patients who were ≥30 years old and undergoing APM were randomized to receive debridement (CL-Deb group; n = 98) or observation (CL-noDeb; n = 92) of unstable Outerbridge grade-II, III, or IV chondral lesions. Outcomes were evaluated preoperatively and at 8 to 12 days, 6 weeks, 3 months, 6 months, and 1 year postoperatively. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) pain score, Short Form-36 (SF-36) health survey, range of motion, quadriceps circumference, and effusion. The primary outcome was the WOMAC pain score at 1 year. T tests were used to examine group differences in outcomes, and the means and standard deviations are reported. Results: There were no significant differences between the groups with respect to any of the 1-year outcome scores. Compared with the CL-Deb group, the CL-noDeb group had improvement in the KOOS quality-of-life (p = 0.04) and SF-36 physical functioning scores (p = 0.01) as well as increased quadriceps circumference at 8 to 12 days (p = 0.02); had improvement in the pain score on the WOMAC (p = 0.02) and KOOS (p = 0.04) at 6 weeks; had improvement in SF-36 physical functioning scores at 3 months (p = 0.01); and had increased quadriceps circumference at 6 months (p = 0.02). Conclusions: Outcomes for the CL-Deb and CL-noDeb groups did not differ at 1 year postoperatively. This suggests that there is no benefit to arthroscopic debridement of unstable chondral lesions encountered during APM, and it is recommended that these lesions be left in situ. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Design of a randomized controlled trial to compare debridement to observation of chondral lesions encountered during partial meniscectomy: The ChAMP (Chondral Lesions And Meniscus Procedures) Trial.

BACKGROUND Few studies have examined whether chondral lesions encountered in patients undergoing meniscectomy should be surgically treated. The primary aim of the ChAMP (Chondral Lesions And Meniscus Procedures) Trial is to determine whether there is a difference in knee pain between patients undergoing debridement versus observation of chondral lesions encountered during arthroscopic meniscectomy. This paper describes the rationale and study design for the ChAMP Trial. METHODS/DESIGN The ChAMP Trial is a randomized controlled trial of patients aged 30 and older undergoing partial meniscectomy and randomly allocated to debridement (CL-Deb, N=98) or observation (CL-Obs, N=92) of chondral lesions identified during surgery and deemed to be significant (Outerbridge Grade II-IV). Patients and data collectors were unaware of treatment allocation until completion of the study. Patients with surgically insignificant (Outerbridge Grade I) chondral lesions or no chondral lesions were included as a third non-randomized comparison group (NoCL, N=76). The primary outcome is the difference in knee pain assessed by WOMAC (Western Ontario and McMaster Universities Arthritis Index) between the CL-Deb and CL-Obs groups at 1-year after surgery. Secondary outcomes include 1-year differences in additional measures of knee pain, function, symptoms, activity, and quality of life assessed by the WOMAC, KOOS (Knee Injury and Osteoarthritis Outcome Score), visual analog pain scale, and physical exam; as well as general health assessed with the SF-36 (Short-form Health Survey). Increased intraoperative costs associated with the addition of chondral debridement will also be assessed. DISCUSSION This study will add to the scant literature regarding management of chondral lesions in patients undergoing meniscectomy and might provide treatment guidance for clinicians and their patients.

A Case-Control Study Comparing Bone Bruising and Intra-articular Injuries in Patients Undergoing Anterior Cruciate Ligament Reconstruction With and Without Medial Collateral Ligament Tears.

Background: Concomitant injuries can occur in patients with combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) tears; however, no studies have compared these injuries in patients undergoing ACL reconstruction with an MCL tear to those with an intact MCL. Purpose: To compare bone bruising, meniscus tears, and chondral lesions in patients undergoing ACL reconstruction with an MCL tear (cases) to those with an intact MCL (controls). Study Design: Case-control study; Level of evidence, 3. Methods: Thirty-two cases and 352 controls were identified from a prospective registry. Bone bruising was confirmed on magnetic resonance imaging, and meniscus tears and chondral lesions were confirmed arthroscopically. Demographics and concomitant injuries were compared between cases and controls using exact chi-square tests. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% CIs adjusted for age, sex, body mass index, and mechanism and type of injury. Results: Cases had significantly more contact injuries than controls (58.1% vs 21.3%, P < .0001). The prevalence and odds of bone bruising of the lateral tibial plateau (89.7% vs 84.6%; P = .59; OR, 3.53; 95% CI, 0.45-27.71), lateral femoral condyle (82.8% vs 72.8%; P = .28; OR, 1.94; 95% CI, 0.64-5.88), medial tibial plateau (20.7% vs 31.7%; P = 0.29; OR, 0.53; 95% CI, 0.19-1.53), and medial femoral condyle (6.9% vs 8.3%; P ≥ .999; OR, 1.07; 95% CI, 0.21-5.40) did not differ significantly between cases and controls. The prevalence and odds of lateral meniscus tears (53.3% vs 43%; P = .34; OR, 1.85; 95% CI, 0.76-4.52), medial meniscus tears (31.3% vs 33.5%; P = .85; OR, 0.90; 95% CI, 0.37-2.21), and chondral lesions (16% vs 10.8%; P = .50; OR, 0.70; 95% CI, 0.15-3.21) also did not significantly differ between cases and controls. Conclusion: ACL-MCL injuries were most often due to a contact mechanism, whereas ACL tears without associated MCL injury were more frequently due to a noncontact mechanism. However, there were no significant differences in concomitant injuries in ACL-MCL knees versus ACL knees.

How Accurate Are Patients at Diagnosing the Cause of Their Knee Pain With the Help of a Web-based Symptom Checker?

Background: Researching medical information is the third most popular activity online, and there are a variety of web-based symptom checker programs available. Purpose: This study evaluated a patient’s ability to self-diagnose their knee pain from a list of possible diagnoses supplied by an accurate symptom checker. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: All patients older than 18 years who presented to the office of 7 different fellowship-trained sports medicine surgeons over an 8-month period with a complaint of knee pain were asked to participate. A web-based symptom checker for knee pain was used; the program has a reported accuracy of 89%. The symptom checker generates a list of potential diagnoses after patients enter symptoms and links each diagnosis to informative content. After exploring the informative content, patients selected all diagnoses they felt could explain their symptoms. Each patient was later examined by a physician who was blinded to the differential generated by the program as well as the patient-selected diagnoses. A blinded third party compared the diagnoses generated by the program with those selected by the patient as well as the diagnoses determined by the physician. The level of matching between the patient-selected diagnoses and the physician’s diagnoses determined the patient’s ability to correctly diagnose their knee pain. Results: There were 163 male and 165 female patients, with a mean age of 48 years (range, 18-76 years). The program generated a mean 6.6 diagnoses (range, 2-15) per patient. Each patient had a mean 1.7 physician diagnoses (range, 1-4). Patients selected a mean 2 diagnoses (range, 1-9). The patient-selected diagnosis matched the physician’s diagnosis 58% of the time. Conclusion: With the aid of an accurate symptom checker, patients were able to correctly identify the cause of their knee pain 58% of the time.