J. Robert Giffin

A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

BACKGROUND The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown. METHODS We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life). RESULTS Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (+/-SD) WOMAC score for the surgery group was 874+/-624, as compared with 897+/-583 for the control group (absolute difference [surgery-group score minus control-group score], -23+/-605; 95% confidence interval [CI], -208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0+/-11.4 and 37.2+/-10.6, respectively (absolute difference, -0.2+/-11.1; 95% CI, -3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery. CONCLUSIONS Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy. (ClinicalTrials.gov number, NCT00158431.)

Effects of Increasing Tibial Slope on the Biomechanics of the Knee

Purpose To determine the effects of increasing anterior-posterior (A-P) tibial slope on knee kinematics and in situ forces in the cruciate ligaments. Methods Ten cadaveric knees were studied using a robotic testing system using three loading conditions: (1) 200 N axial compression; (2) 134 N A-P tibial load; and (3) combined 200 N axial and 134 N A-P loads. Resulting knee kinematics were determined before and after a 5-mm anterior opening wedge osteotomy. Resulting in situ forces in each cruciate ligament were determined. Results Tibial slope was increased from 8.8 ± 1.8 ° to 13.2 ± 2.1 °, causing an anterior shift in the resting position of the tibia relative to the femur up to 3.6 ± 1.4 mm. Under axial compression, the osteotomy caused a significant anterior tibial translation up to 1.9 ± 2.5 mm (90 °). Under A-P and combined loads, no differences were detected in A-P translation or in situ forces in the cruciates (intact versus osteotomy). Conclusions Results suggest that small increases in tibial slope do not affect A-P translations or in situ forces in the cruciate ligaments. However, increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that increasing tibial slope may be beneficial in reducing tibial sag in a PCL-deficient knee, whereas decreasing slope may be protective in an ACL-deficient knee.

Hop Testing Provides a Reliable and Valid Outcome Measure During Rehabilitation After Anterior Cruciate Ligament Reconstruction

Background and Purpose Although various hop tests have been proposed as performance-based outcome measures following anterior cruciate ligament (ACL) reconstruction, limited reports of their measurement properties exist. The purpose of this study was to investigate the reliability and longitudinal validity of data obtained from hop tests during rehabilitation after ACL reconstruction. Subjects Forty-two patients, 15 to 45 years of age, who had undergone ACL reconstruction participated in the study. Methods and Measures The study design was prospective and observational with repeated measures. The subjects performed a series of 4 hop tests on 3 separate occasions within the 16th week following surgery and on a fourth occasion 6 weeks later. The tests were a single hop for distance, a 6-m timed hop, a triple hop for distance, and crossover hops for distance. Performance on the ACL-reconstructed limb was expressed as a percentage of the performance on the nonoperative limb, termed the “limb symmetry index.” Subjects also completed the Lower Extremity Functional Scale and a global rating of change questionnaire. Results Intraclass correlation coefficients for limb symmetry index values ranged from .82 to .93. Standard errors of measurement were 3.04% to 5.59%. Minimal detectable changes, at the 90% confidence level, were 7.05% to 12.96%. Changes in hop test scores on the operative limb were statistically greater than changes on the nonoperative limb. Pearson correlations (r) between change in hop performances and self-reported measures ranged from .26 to .58. Discussion and Conclusion The results show that the described series of hop tests provide a reliable and valid performance-based outcome measure for patients undergoing rehabilitation following ACL reconstruction. These findings support the use and facilitate the interpretation of hop tests for research and clinical practice.

Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation

BACKGROUND To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In all but one study, the limb was immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone. METHODS Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupture rate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength. Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury. RESULTS A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were 118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group. CONCLUSIONS This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. All measured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.

Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction

Revision ACL surgery has become increasingly common. Successful revision surgery requires a thorough preoperative evaluation, including a detailed history and a physical and radiographic examination. Preoperative planning is imperative for a successful outcome, as it limits the potential for repeating the errors that led to the failure of the primary procedure. This begins with a determination of the mechanism of failure. Often, a primary as well as a secondary cause of failure can be identified. Determination of the etiology of failure is the first step in a carefully constructed treatment plan, which includes the type of revision and skin incision, graft and hardware removal, tunnel placement, graft selection and fixation, and the rehabilitation protocol. The preoperative plan should have enough flexibility to accommodate unanticipated findings in the operating room. Finally, the importance of counseling the patient preoperatively regarding potential results must be emphasized. Given the complexity of revision ACL reconstruction, the patients expectations must be adjusted to realistically match the potential for success. The goal of successful revision surgery may be only to return the patient to activities of daily living or work, especially if there is evidence of degenerative joint disease. With proper planning and attention to detail, revision ACL surgery can provide a satisfying solution to difficult cases of knee instability.

Revision anterior cruciate ligament reconstruction

Revision ACL surgery is indicated in patients who present with pathologic anterior laxity on clinical examination that reproduces their symptoms of instability during activities of daily living or athletic activities. The goals of the revision ACL surgery are to stabilize the knee, prevent further injury to the articular cartilage and menisci, and maximize the patients function. Successful revision ACL surgery requires a thorough preoperative evaluation, including a detailed history, physical examination, and radiographic evaluation. Preoperative planning begins with a determination of the mechanisms of failure for the initial ACL reconstruction. Often a primary, as well as secondary cause, for failure can be identified. The determination of the cause of failure is the first step in a carefully-constructed treatment plan, which includes consideration of skin incisions to be used, method of graft removal, hardware removal, the need for a staged procedure or concomitant surgery, graft material selection, tunnel placement, graft fixation, and postoperative rehabilitation protocol. Despite the most meticulous planning, unanticipated findings may be encountered in the operating room, and the preoperative plan should have enough flexibility to accommodate these developments. Finally, it is crucial to counsel the patient preoperatively to limit his or her expectations regarding their surgical outcome. Given the complexity of revision ACL reconstruction, patient expectations must be adjusted to realistically match the potential for success. With proper planning, attention to detail, and appropriate patient expectations, revision ACL surgery can result in a beneficial and satisfying patient outcome.

Importance of Tibial Slope for Stability of the Posterior Cruciate Ligament—Deficient Knee

Background Previous studies have shown that increasing tibial slope can shift the resting position of the tibia anteriorly. As a result, sagittal osteotomies that alter slope have recently been proposed for treatment of posterior cruciate ligament (PCL) injuries. Hypotheses Increasing tibial slope with an osteotomy shifts the resting position anteriorly in a PCL-deficient knee, thereby partially reducing the posterior tibial “sag” associated with PCL injury. This shift in resting position from the increased slope causes a decrease in posterior tibial translation compared with the PCL-deficient knee in response to posterior tibial and axial compressive loads. Study Design Controlled laboratory study. Methods Three knee conditions were tested with a robotic universal force-moment sensor testing system: intact, PCL-deficient, and PCL-deficient with increased tibial slope. Tibial slope was increased via a 5-mm anterior opening wedge osteotomy. Three external loading conditions were applied to each knee condition at 0°, 30°, 60°, 90°, and 120° of knee flexion: (1) 134-N anterior-posterior (A-P) tibial load, (2) 200-N axial compressive load, and (3) combined 134-N A-P and 200-N axial loads. For each loading condition, kinematics of the intact knee were recorded for the remaining 5 degrees of freedom (ie, A-P, medial-lateral, and proximal-distal translations, internal-external and varus-valgus rotations). Results Posterior cruciate ligament deficiency resulted in a posterior shift of the tibial resting position to 8.4 ± 2.6 mm at 90° compared with the intact knee. After osteotomy, tibial slope increased from 9.2° ± 1.0° in the intact knee to 13.8° ± 0.9°. This increase in slope reduced the posterior sag of the PCL-deficient knee, shifting the resting position anteriorly to 4.0 ± 2.0 mm at 90°. Under a 200-N axial compressive load with the osteotomy, an additional increase in anterior tibial translation to 2.7 ± 1.7 mm at 30° was observed. Under a 134-N A-P load, the osteotomy did not significantly affect total A-P translation when compared with the PCL-deficient knee. However, because of the anterior shift in resting position, there was a relative decrease in posterior tibial translation and increase in anterior tibial translation. Conclusion Increasing tibial slope in a PCL-deficient knee reduces tibial sag by shifting the resting position of the tibia anteriorly. This sag is even further reduced when the knee is subjected to axial compressive loads. Clinical Relevance These data suggest that increasing tibial slope may be beneficial for patients with PCL-deficient knees.

Radiographic Measures of Knee Alignment in Patients With Varus Gonarthrosis Effect of Weightbearing Status and Associations With Dynamic Joint Load

Background Radiographic measures of lower limb malalignment are used to indicate abnormal loading of the knee and to plan corrective procedures. Hypotheses Weightbearing status during hip-to-ankle radiographs will significantly affect malalignment measures; malalignment in single-limb standing will be most highly correlated to the external knee adduction moment during gait, a proposed dynamic measure of functional knee joint load. Study Design Controlled laboratory study. Methods Mechanical axis angle was measured in 40 patients with varus gonarthrosis from hip-to-ankle radiographs taken with patients in single-limb standing, double-limb standing, and supine positions. Kinematic and kinetic data were collected during walking and used to calculate the peak adduction moment about the knee. Results Repeated-measures analysis of variance and Scheffé post hoc tests indicated that mechanical axis angle measured on single-limb standing radiographs (-8.7°± 4.0°) was significantly greater than on double-limb standing radiographs (-7.1°± 3.8°), which was significantly greater than on supine radiographs (-5.5°± 2.8°). The peak knee adduction moment (2.8 ± 0.8 percentage body weight × height) was only moderately correlated with mechanical axis angle on single-limb standing (r = -0.46), double-limb standing (r = -0.45), and supine (r = -0.43) radiographs. Conclusion Patient position significantly affects frontal plane knee alignment. However, the peak knee adduction moment is only moderately correlated to mechanical axis angle, regardless of weightbearing status. Clinical Relevance These findings are inconsistent with the hypothesis that mechanical axis angle measured in single-limb standing is more representative of dynamic joint load and further highlight the differences between static and dynamic measures. Results also underscore the importance of reporting patient position during radiographs and keeping positions consistent when evaluating patients over time.

Medial opening wedge high tibial osteotomy: A prospective cohort study of gait, radiographic, and patient-reported outcomes

OBJECTIVE To evaluate the effect of medial opening wedge high tibial osteotomy on gait, radiographic, and patient-reported outcomes over a 2-year postoperative period in patients with varus alignment and medial compartment knee osteoarthritis, and to identify significant predictors of outcome. METHODS We used an observational cohort study design and prospectively administered 3-dimensional quantitative gait analysis, hip to ankle weight-bearing radiographs, and patient-reported outcomes preoperatively and 6, 12, 18, and 24 months postoperatively. Observed changes with 95% confidence intervals (95% CIs) were calculated. Multivariate linear regression and cluster analysis were used to evaluate associations between patient characteristics and 2-year outcomes in dynamic knee joint load (external knee adduction moment during gait) and Knee Injury and Osteoarthritis Outcome Scores (KOOS). RESULTS A total of 126 patients (mean age 47.48 years) were included in the study. Mean changes suggested clinically important improvements in malalignment (change in mechanical axis angle 8.04 degrees [95% CI 7.16 degrees , 8.93 degrees ]), medial compartment load during gait (change in knee adduction moment -1.38 [95% CI -1.53, -1.22] percentage body weight x height), and all KOOS domain scores (change in pain 23.19 [95% CI 19.49, 26.89] KOOS points). A small (13%) increase in knee adduction moment was observed from 6 to 24 months postoperatively. Few preoperative clinical and/or gait characteristics assessed at baseline were significantly associated with 2-year outcomes. CONCLUSION A medial opening wedge high tibial osteotomy with correction to approximately neutral alignment produces substantial and clinically important changes in dynamic knee joint load and patient-reported measures of pain, function, and quality of life 2 years postoperatively. Changes in knee adduction moment observed in the first 2 years postoperatively should be explored as potential predictors of longer-term success and subgroups of patients with poor outcomes.

Outcome of Posterior Ankle Arthroscopy for Hindfoot Impingement

PURPOSE To provide short-term clinical results of posterior ankle arthroscopy in the treatment of posterior ankle impingement. METHODS This was a retrospective evaluation of the clinical outcomes of posterior ankle arthroscopy in a series of patients with posterior ankle pain. RESULTS Of 23 patients who underwent 24 posterior ankle arthroscopies between July 1998 and February 2004, 15 patients (mean age, 25 years) with 16 posterior ankle arthroscopies were evaluated at a mean follow-up time of 32 months (range, 6 to 74). Procedures carried out were: excision of os trigonum (11); decompression of prominent posterior talar process (5); tenolysis of flexor hallucis longus (5); removal of loose body (1); osteochondritis dissecans lesion debridement (1); and arthrotomy (1). The average time to return to work was 1 month (range, 0 to 3) and to sports, 5.8 months (range, 1 to 24). Fourteen patients returned to their preinjury level of athletics. Mean Health Survey Short Form (SF-12) scores were 51.80 for the mental component (range, 30.77 to 60.53) and 55.80 for the physical component (range, 44.26 to 63.33). Mean score on the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale was 91 (range, 77 to 100) and on the Lower Extremity Functional Scale was 75 (range, 65 to 80). Documented complications included temporary numbness in the region of the scar in 5 patients and temporary ankle stiffness in 1 patient. There were no permanent neurovascular injuries. All subjects reported significant improvement and indicated that they would undergo the surgery again if needed. CONCLUSIONS Functional and clinical evaluations following posterior ankle arthroscopy revealed that all patients were very satisfied. They reported good to excellent health-related quality of life scores, satisfactory functional outcomes, and a high rate of return to sporting activities. Most importantly, no significant complications were encountered. This review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement. LEVEL OF EVIDENCE Level IV, therapeutic case series.