Marc S. Fineberg

Current trends in anterior cruciate ligament reconstruction.

In 2006, a survey regarding anterior cruciate ligament (ACL) reconstruction was mailed to physician members of the American Orthopaedic Society for Sports Medicine. A total of 993 responses were received from 1747 possible respondents (57%). The number of ACL reconstructions per year ranged from 1 to 275 (mean=55). The most important factors in the timing of surgery were knee range of motion and effusion. Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively). A single-incision arthroscopic technique was used by 90%. Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision. There was limited experience (4%) with double-bundle and computer-assisted ACL reconstruction. Arthroscopic-assisted, single-incision reconstruction using a BPTB autograft fixed with metal interference screws remains the most common technique used for primary ACL reconstruction. In the past 5 years, the use of alternative graft sources and methods of fixation has increased. Consensus regarding the best graft type, fixation method, and postoperative protocol is still lacking.

Emerging Trends in Anterior Cruciate Ligament Reconstruction.

Abstract Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed and researched orthopedic procedures. As technology and comparative research have advanced, surgical practices have changed to achieve a superior outcome. Our group performed a survey of orthopedic surgeons to evaluate current practice trends and techniques as a follow‐up to similar surveys performed in 1999 and 2006. In a survey between 2013 and 2014 consisting of 35 questions regarding the surgical technique, graft choice, fixation method, and perioperative care in ACL reconstruction was sent electronically to the members of the American Orthopaedic Society of Sports Medicine and the Arthroscopy Association of North America. Responses were recorded and compared with previous results. Survey responses were received from 824 active surgeons. Of the respondents, 89.4% are subspecialty trained, 98% of which in sports medicine. Preoperatively, full‐knee extension was the only “very significant” factor in surgical timing. Approach preference via an arthroscopic‐assisted single‐incision approach predominated (89%)—similar to earlier results. Bone‐patellar‐tendon‐bone use decreased relative to hamstring allograft at 45 and 41%, respectively. Tibial tunnel placement shifted anteriorly and femoral tunnel placement shifted posterosuperiorly as compared with the results obtained 5 years ago. Femoral drilling through a low medial portal was preferred in 47% of responses, increased from 15%. Preferred fixation on both the tibial and femoral sides was either metal or bioabsorbable interference screws. The use of transfixation pins and other devices decreased. Postoperative rehab protocols did not significantly change, 68.7% preferred full‐weight bearing, 55% using a range of motion knee brace locked in extension, 66.4% starting physical therapy 1 week postoperatively, with unrestricted activity at 6 to 9 months. Overall, an increasing trend toward using hamstring autograft and drilling the femoral tunnel through an accessory portal in primary ACL reconstruction was observed. This may reflect recent literature supporting more anatomic reconstruction of the ACL. Considerations including deep venous thrombosis prophylaxis, brace use, timing of surgery, weight‐bearing restrictions, physical therapy, graft choice in athletes, and return to activity remained largely unchanged.

Arthroscopic Visualization of the Popliteus Tendon

PURPOSE This study was conducted to define what portion of the normal popliteus musculotendinous unit can be visualized during standard diagnostic arthroscopy. METHODS Knee arthroscopy was performed on 5 fresh-frozen cadaveric human knees by use of standard anterolateral and anteromedial portals. The most proximal and distal portions of the popliteus that could be visualized were tagged with arthroscopic sutures. The knees were subsequently dissected, and 4 measurements were made per specimen: the total length of the popliteus tendon; the length of the popliteus tendon that was able to be visualized; the extrasynovial segment at the femoral attachment, which was unable to be visualized; and the distance from the distal-most visible point of the tendon to the musculotendinous junction of the popliteus. RESULTS The mean total length of the popliteus tendon was 42.0 mm. The arthroscopically tagged portion of the popliteus tendon that was able to be visualized averaged 18.2 mm, or 43.8% of the tendon length. The mean distance from the musculotendinous junction to the visualized portion was 15.1 mm, or 35.8% of the total tendon length. The mean distance from the most proximal visualized portion of the tendon to the femoral attachment was 8.7 mm, or 20.4% of the total tendon length. The musculotendinous junction was not arthroscopically visible in any specimen. CONCLUSIONS On standard knee arthroscopy, less than half of the normal popliteus tendon is visible, and the femoral insertion and musculotendinous junction are not visualized. Because most reported popliteus injuries have occurred here, reliance on arthroscopic visualization alone is inadequate. CLINICAL RELEVANCE The limitations of arthroscopic visualization of the normal popliteus tendon have implications for the diagnosis and treatment of posterolateral corner injuries.

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.

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.

How Does the Presence of Unstable Chondral Lesions Affect Patient Outcomes After Partial Meniscectomy? The ChAMP Randomized Controlled Trial:

Background: Chondral lesions are commonly encountered during arthroscopic partial meniscectomy (APM); however, it is unknown how these lesions affect postoperative outcomes. Purpose: The authors compared postoperative outcomes among patients with and without unstable chondral lesions 1 year after APM. Study Design: Cohort study; Level of evidence, 3. Methods: The authors conducted a secondary analysis of data from the ChAMP (Chondral Lesions and Meniscus Procedures) randomized controlled trial. They compared the following outcomes for patients with unstable chondral lesions that were left in situ and observed (CL-noDeb) versus patients without unstable chondral lesions (NoCL) at 1 year after APM: Western Ontario and McMaster Universities Osteoarthritis Index, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain, the Short Form Health Survey, range of motion, quadriceps circumference, and effusion. Multivariate linear regression was used to obtain mean differences (MDs) with corresponding 95% CIs adjusted for age, body mass index, and preoperative score (for postoperative scores). Results: Compared with the CL-noDeb group, the NoCL group had greater improvement in Western Ontario and McMaster Universities Osteoarthritis Index for pain (MD, 7.9, 95% CI: 2.7-13.1), stiffness (MD, 9.1, 95% CI: 1.9-16.3), and physical function (MD, 4.6, 95% CI: 0.1-9.0) and Knee injury and Osteoarthritis Outcome Score for pain (MD, 8.4, 95% CI: 2.7-14.0), function in sport and recreation (MD, 11, 95% CI: 3.0-19.1), and quality of life (MD, 10.4, 95% CI: 2.3-18.5). The NoCL group was less likely than the CL-noDeb group to have an effusion (P = .02) 1 year after surgery. Conclusion: Patients undergoing APM without unstable chondral lesions had better outcomes than patients with unstable chondral lesions.

Glenoid Superior Labrum Anterior to Posterior (SLAP) Lesions

Glenoid superior labrum anterior to posterior (SLAP) lesions are a potential source of shoulder pain which may occur due to repetitive stress in overhead/throwing athletes or secondary to acute trauma. SLAP lesions are commonly associated with other shoulder pathology. Clinical examination includes evaluation for potential internal rotation deficits, glenohumeral instability, biceps-specific tests, dynamic shear tests, and evaluation for potential suprascapular neuropathy. MRI with contrast is the preferred diagnostic test, but accuracy is variable. Nonsurgical efforts may be attempted initially with arthroscopic examination of the superior labral/biceps complex being diagnostically definitive. Surgical treatment of SLAP tears depends on the type of tear present and patient-related factors.

Biceps Brachii Tendon Injuries: Biceps Tendon Rupture

Biceps tendon injuries can be a significant source of pain, loss of function, and upper arm deformity in either the acute or chronic setting. Evaluation and treatments differ depending on whether the proximal or distal tendon is affected. A thorough history and physical examination is crucial in making the correct diagnosis. MRI is often a useful ancillary test to confirm and delineate the extent of the injury. Treatment options vary depending on the location of the injury as well as patient and surgeon preference.

Fixation strength of tibial inlay graft with one versus two screws: a cadaveric study.

Various modes of fixation have been advocated for posterior cruciate ligament reconstruction. This study compared pullout forces and modes of failure for 2 commonly used techniques. Ten Achilles tendon-bone plug grafts were fixed to tibial troughs using either one 6.5-mm or two 4-mm cancellous screws positioned anatomically and tested to failure. The constructs did not differ statistically in mean pullout forces (385.2 and 358.8 N for the 6.5-mm and 4-mm screw constructs, respectively). The 2-screw construct failed by pullout, whereas the single-screw fixation failed through fracture. This study provides insight into the fixation used for posterior cruciate ligament reconstruction.