Matthew J. Matava

Correlation Between Magnetic Resonance Imaging and Clinical Outcomes After Cartilage Repair Surgery in the Knee A Systematic Review and Meta-analysis

Background: Magnetic resonance imaging (MRI) is often used to assess cartilage after surgical repair. The correlation between MRI and clinical outcomes is not well understood. Hypothesis: Postoperative MRI findings correlate with clinical outcome measures in patients after articular cartilage surgery of the knee. Study Design: Meta-analysis. Methods: A systematic review of the literature was performed to identify studies in which MRI and clinical outcomes were correlated after autologous chondrocyte implantation (ACI), osteochondral autograft transfer system (OATS), or microfracture. Studies that reported correlation coefficients (r) for different MRI parameters were then included in a meta-analysis. Results: A total of 26 studies were identified for inclusion in this systematic review, 15 of which were included in the meta-analysis. Most of the studies (n = 19) involved ACI, although studies were available for OATS (n = 5) and microfracture (n = 4). The strongest MRI correlates with clinical outcomes after ACI were graft hypertrophy (r = 0.72) and repair tissue signal (r = 0.71). After microfracture, the strongest MRI correlates were the Henderson score (r = 0.97), subchondral edema (r = 0.77), and repair tissue signal (r = 0.76). Correlations after OATS were not as strong, with defect fill (r = 0.53) and repair tissue structure (r = 0.51) being the strongest. Conclusion: The MRI findings do correlate with clinical outcomes after cartilage repair surgery in the knee, although the specific parameters that correlate best vary by the type of procedure performed. No current MRI classification system has been shown to correlate with clinical outcomes after all types of cartilage repair surgery.

Magnetic Resonance Imaging as a Tool to Predict Meniscal Reparability

One hundred six patients who underwent high field strength magnetic resonance imaging and subsequent arthroscopy of the knee were evaluated to determine the accuracy of magnetic resonance imaging in predicting meniscal tear reparability. Each scan was independently read by three examiners with varying degrees of expertise: a musculoskeletal radiologist, a senior orthopaedic surgeon, and a general radiologist. Each suspected tear was characterized by its morphologic type, maximum length, and minimum distance from the meniscosynovial junction. A prediction was then made of whether the tear was reparable. There were 115 meniscal tears noted in the 106 patients studied. The examiners ability to correctly estimate tear type was only fair, with correct estimates made only 14% to 67% of the time. The overall correlation of the three examiners to correctly predict the method of treatment was fair. The average accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of magnetic resonance imaging in predicting meniscal reparability were 74%, 29%, 89%, 50%, and 80%, respectively; for predicting meniscectomy, these values were 69%, 68%, 75%, 90%, and 43%, respectively. There were no significant differences between the three examiners in the accuracy of their treatment predictions. The results of this study suggest that magnetic resonance imaging is only moderately reliable for the prediction of meniscus reparability. In addition, the training of the reader does not appear to significantly influence the results.

Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review.

Shoulder arthroscopy is currently one of the more common orthopaedic procedures, with an estimated 1.4 million procedures performed per year worldwide1. Many of these procedures are being performed on an outpatient basis and present substantial postoperative pain control challenges to the surgeon and anesthesiologist. An integral component of successful ambulatory surgical treatment is achieving and maintaining adequate pain management during the early postoperative course.nnThe pain during the first twenty-four to forty-eight hours after arthroscopic shoulder surgery is often equivalent to that after open surgery, with 30% of patients reporting severe pain on the first postoperative day2. In a study of more than 15,000 outpatient surgical procedures from nine different surgical specialties, pain was responsible for 12% of the unplanned postoperative hospital admissions3. A retrospective review of 222 shoulder arthroscopy cases revealed a 2% rate of unplanned overnight admission because of pain symptoms4. Additionally, postoperative pain may instigate endocrine and metabolic responses, autonomic reflexes, nausea, and constipation that potentially lead to delayed postoperative rehabilitation, adhesive capsulitis, hospital admission, and loss of work days5-7. As a result, many different modalities have been described in both the orthopaedic and anesthesiology literature to minimize postoperative pain following ambulatory surgery8.nnTraditionally, these surgical procedures were performed under general anesthesia with infiltration of local anesthetic and parenteral administration of opioids to achieve early postoperative pain relief. Over forty years ago, Winnie reported the results of an interscalene brachial plexus block involving a single anesthetic injection for pain control following shoulder surgery9. Nearly two decades later, Tuominen et al. described an interscalene block technique involving the placement of an indwelling catheter to provide continuous infusion of anesthetic for two to three days of pain relief10. A third modality …

Public Perception Regarding Anterior Cruciate Ligament Reconstruction

BACKGROUNDnRelatively little information exists regarding the publics perception of anterior cruciate ligament (ACL) injuries and their treatment. The objective of this study was to test the hypothesis that the publics understanding of ACL surgery may be incorrect with regard to various aspects of this procedure and to identify issues to emphasize in patient education.nnnMETHODSnThis study utilized a forty-three-question survey designed to measure an individuals knowledge base and perception of ACL reconstruction with regard to the anatomy, function, indications, operative technique, risks, recovery time, and overall benefits of the procedure. Eligible individuals were between fifteen and sixty years of age. Study participants were recruited from an academic orthopaedic sports medicine clinic, a collegiate athletic training room, and various public venues.nnnRESULTSnA total of 210 individuals (106 men and 104 women) with a mean age of thirty were surveyed. Educational level of the respondents varied widely. Twenty-seven percent of the respondents were employed in a health-care setting. Sixty-five percent of the respondents rated their ACL knowledge level as little or none. Participants self-perception of ACL knowledge was highly correlated with their survey scores on questions with a specific correct answer (p < 0.001). Almost one-third thought that surgical treatment involved repair of the torn ligament rather than reconstruction. Over half (56%) of the respondents preferred an autograft for ligament reconstruction, compared with 4% who preferred an allograft. The ability to return to sports after ACL surgery was the most important concern, followed by the risk of developing osteoarthritis.nnnCONCLUSIONSnThere is wide variability in the lay publics knowledge level of ACL injuries; a substantial number of misguided perceptions were identified. Return to sports and risk for future osteoarthritis following ACL surgery appear to be the most important factors to the lay public. Focusing educational efforts on areas of knowledge deficits may be particularly important for patients of physicians who treat ACL injuries.

Discussing treatment options with a minor: the conflicts related to autonomy, beneficence, and paternalism.

A seventeen-year-old male, high-school football player presents to an orthopaedic surgeon because of recurrent right knee pain after having undergone an arthroscopic meniscal repair one year previously. The patient did well initially but now has recurrent medial joint-line pain in the knee, which developed when he planted the right leg to throw a pass during summer training camp. He was evaluated by the teams athletic trainer and by an orthopaedic surgeon, both of whom, on the basis of their physical examination of the boy, believe that he may have sustained a recurrent meniscal tear. A magnetic resonance arthrogram is acquired, which confirms the presence of a large longitudinal tear of the medial meniscus in the red-red zone, with no signs of degenerative change, articular cartilage damage, or other ligamentous pathology. The patient had just started summer training camp before his senior year of high-school football, and he is considered to be a potential high-level candidate for a Division-I football scholarship.The orthopaedic surgeon presents the patient and his mother with three treatment options: nonoperative management, arthroscopic partial meniscectomy, and arthroscopic meniscal repair. He also presents the relevant risks and benefits of each choice, including, for meniscectomy, the risk of the future development of osteoarthritis if a large portion of the meniscus were to be excised and, for meniscal repair, the need for an extended (four to six-month) rehabilitation period. Both the patient and his mother are apprised of the limitations of preoperative magnetic resonance imaging (MRI) in determining if a meniscal tear can be repaired1-3. The patient states that, on the basis of his symptoms of pain, intermittent locking, and swelling, he does not believe that he would be able to play football if nonoperative management was chosen. He voices a strong preference for meniscectomy, as this would allow him the most rapid return to play. He states that he is not concerned with the future risk of osteoarthritis but is fearful that missing his senior football season will place his scholarship in jeopardy. His mother states that her son would likely not attend college without a scholarship, considering the familys financial situation. The patient states that he therefore wishes to have a meniscectomy, given the likely quicker recovery and faster return to play.The patients mother was initially in favor of a meniscal repair, if possible. However, over the course of the patients visit with the surgeon, she is persuaded by her son to favor a meniscectomy. The surgeon again discusses in detail the risks involved with meniscectomy in an adolescent-primarily the higher risk of future knee osteoarthritis. The patient remains persistent in his choice, mainly due to his desire to avoid the prolonged postoperative course of limited weight-bearing and physical therapy and thus the loss of his final high-school season. The mother, who is the patients legal guardian for consent, ultimately follows her sons wishes and elects to consent to only an arthroscopic meniscectomy.

Magnetic Resonance Imaging of the Knee

AbstractMagnetic resonance imaging (MRI) has revolutionised diagnostic imaging of the knee. It has evolved significantly since Kean described healthy and pathologic knee anatomy in 1983. This innovative technology allows superior soft-tissue detail with multiplanar imaging capability that provides accurate evaluation of intra and extra-articular structures of the knee not demonstrated with other imaging modalities. The development and advancements in MRI and the introduction of high-resolution coils have provided a noninvasive, nonoperator dependent, cost effective means to diagnose knee pathology. MRI is well tolerated by patients, widely accepted by evaluating physicians, and assists in distinguishing pathologic knee conditions that may have similar clinical signs and symptoms (i.e. meniscal tears, osteochondral lesions). This paper presents an overview of MRI of the knee and focuses on the MRI findings in a number of common pathologic conditions.n

Platelet-rich plasma: the next big thing?: commentary on an article by Ujash Sheth, BHSc, et al.: "Efficacy of autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis".

Autologous blood concentrates, one of which is platelet-rich plasma, have been becoming more popular as a result of the increasing attention that these products have received in the mainstream media following their use by high-profile athletes. Platelet-rich plasma has been utilized for a number of musculoskeletal conditions despite a relative lack of rigorous supportive data. Thus, there is a growing debate regarding the clinical efficacy of this treatment regimen. Several uncontrolled studies have shown beneficial effects for a variety of indications. However, the results of controlled trials comparing platelet-rich plasma with standard therapies have not been as definitive. Despite this relative lack of robust evidence, the market for platelet-rich plasma is expected to be worth

The university of the National Football League: how technology, injury surveillance, and health care have improved the safety of America's game

126 million by 20161.nnIt is against this backdrop that Sheth et al. provided a timely meta-analysis and systematic review of twenty-three randomized controlled trials and ten prospective cohort studies to assess the clinical results of autologous blood concentrates compared with those of control therapy, such as a placebo, corticosteroid injection, or …

Natural history of ACL tears: From rupture to osteoarthritis

American football has become one of the most popular sports in the United States. Despite the millions of players at all levels of competition who gain the physical, social, and psychological rewards that football provides, many interested stakeholders continue to ask, Is football safe? Although there are only approximately 1,700 players on National Football League (NFL) rosters, the injuries they sustain have garnered the most attention-and criticism-from the national media. Increased public awareness of the injury potential football possesses has led to an open debate and a major shift in public sentiment over the past 5 years. Although no sport is perfectly safe, the question is whether it can be made relatively safe and if the long-term consequences are worth the risk. This article reviews the methods by which one sports league-the NFL-has used advances in medical technology and injury surveillance to improve the health and safety of its players.

Editorial Commentary: Your Surgical “Tool Box” Just Got a Little Bit Bigger

The anterior cruciate ligament (ACL) was originally identifi ed and described as far back as the time of Galen (1). However, a description of an ACL injury did not occur for over a millennium, as the fi rst report of this injury can be traced to the 1850s when Stark described two patients with this condition (2). While attempts to surgically repair this ligament date back to the early 20th century (3, 4), the routine treatment of ACL tears did not become mainstream until the genesis of sports medicine as a medical discipline in the 1970s. Many of the early surgeons treating ACL injuries recognized the relevance of this ligament to knee stability — primarily for activities that involve cutting, twisting, or pivoting. Correspondingly, it has been well documented that chronic knee instability is associated with meniscal damage and chondral injury (5–13).