Melissa A. Kluczynski

Factors Associated With Meniscal Tears and Chondral Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction A Prospective Study

Background: Increased time from anterior cruciate ligament (ACL) injury to surgery is known to be associated with increased medial meniscal tears. Few studies have examined the predictors of meniscal tears and chondral lesions, including instability episodes. Purpose: To examine the predictors of meniscal tears and chondral injuries in patients undergoing ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Data were collected prospectively from 541 patients undergoing ACL reconstruction. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals for predictors of meniscal tears, tear management, and chondral injuries. Predictors included age, sex, body mass index (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 ≤12 vs >12 weeks), and instability episodes (vs none). Results: A total of 211 lateral meniscal tears (35.3% untreated, 48.3% meniscectomized, 16.4% repaired), 197 medial meniscal tears (25% untreated, 52% meniscectomized, 23% repaired), and 82 chondral injuries occurred. Age predicted chondral injuries. Male sex predicted more lateral meniscal tears overall, untreated lateral tears, and lateral meniscectomies as well as predicting medial meniscal tears overall and medial meniscectomies. Obesity predicted more chondral injuries. Sports-related injuries predicted fewer medial meniscal tears overall and medial meniscectomies. Injuries ≤6 weeks from surgery predicted more lateral meniscal repairs but fewer medial meniscectomies. Injuries ≤12 weeks from surgery predicted more chondral injuries. More instability episodes predicted medial meniscal tears overall, untreated medial tears, medial meniscectomies, and medial repairs. Conclusion: Male sex predicted lateral meniscal tears and management. Male sex, sports, injuries ≤6 weeks from surgery, and preoperative episodes of instability predicted medial meniscal tears and management. Age predicted chondral injuries. This was one of the first studies to examine the number of instability episodes as a predictor of an intra-articular injury.

Plasma 25-hydroxyvitamin D concentrations and periodontal disease in postmenopausal women.

BACKGROUND Vitamin D has anti-inflammatory and antimicrobial properties that, together with its influence on bone health, may confer periodontal benefit. METHODS Cross-sectional associations (years 1997-2000) between plasma 25-hydroxyvitamin D concentration [25(OH)D] and periodontal measure were investigated among 920 postmenopausal women. Measures of chronic disease were defined based on: 1) alveolar crestal height (ACH) measures from intraoral radiographs and tooth loss and 2) Centers for Disease Control and Prevention (CDC)/American Academy of Periodontology (AAP) criteria using measures of clinical attachment level and probing depth (PD). Acute oral inflammation was assessed by the percentage of gingival sites that bled upon assessment with a probe. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for periodontal disease among participants with adequate [25(OH)D ≥50 nmol/L] compared with deficient/inadequate [25(OH)D <50 nmol/L] vitamin D status adjusted for age, dental visit frequency, and body mass index. RESULTS No association was observed between vitamin D status and periodontal disease defined by ACH and tooth loss (adjusted OR = 0.96, 95% CI = 0.68 to 1.35). In contrast, women with adequate compared with deficient/inadequate vitamin D status had 33% lower odds (95% CI = 5% to 53%) of periodontal disease according to the CDC/AAP definition and 42% lower odds (95% CI = 21% to 58%) of having ≥50% of gingival sites that bled. CONCLUSIONS Vitamin D status was inversely associated with gingival bleeding, an acute measure of oral health and inflammation, and inversely associated with clinical categories of chronic periodontal disease that incorporated PD, an indicator of oral inflammation. However, vitamin D was not associated with chronic periodontal disease based on measures of ACH in combination with tooth loss.

A Prospective Study of the Association Between Bone Contusion and Intra-articular Injuries Associated With Acute Anterior Cruciate Ligament Tear

Background: Bone bruising, commonly found on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury, may be associated with intra-articular injuries, but little is known about this association. Purpose: To examine demographic factors and intra-articular injuries associated with bone bruising in patients undergoing ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Patients with ACL injury who had an MRI within 6 weeks and arthroscopy within 3 months of injury were included in this prospective study (N = 171). Presence and severity of bone bruising were determined from preoperative MRIs for each anatomic site: lateral femoral condyle (LFC), lateral tibial plateau (LTP), medial femoral condyle (MFC), and medial tibial plateau (MTP). Multiple logistic regression was used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for predictors of bruising and associations between bruising and intra-articular injuries found during arthroscopy. Outcomes included the presence of bruising and severity of lateral bruising (mild, moderate, severe vs none/minimal bruising). Results: Frequencies of bone bruising were as follows: 85% LTP, 77% LFC, 26% MTP, and 6% MFC. Patient age between 18 and 28 years (OR, 0.27; 95% CI, 0.09-0.82) and 29 years and older (OR, 0.18; 95% CI, 0.05-0.61) predicted less LFC bruising compared with patients aged 17 years and younger. Age (18-28 years: OR, 0.15; 95% CI, 0.03-0.66; ≥29 years: OR, 0.10; 95% CI, 0.02-0.68) and contact injuries (OR, 0.17; 95% CI, 0.04-0.78) predicted less moderate LFC bruising. Male sex predicted mild (OR, 6.16; 95% CI, 1.44-26.43), moderate (OR, 8.98; 95% CI, 1.96-41.19), and severe (OR, 15.66; 95% CI, 3.19-76.92) LFC bruising. Male sex also predicted mild LTP bruising (OR, 0.19; 95% CI, 0.05-0.83), and contact injuries predicted severe LTP bruising (OR, 5.01; 95% CI, 1.21-20.67). LFC bruising (OR, 2.57; 95% CI, 1.04-6.32) and LTP bruising (OR, 3.13; 95% CI, 1.06-9.23) were associated with lateral meniscal tears. Moderate (OR, 8.14; 95% CI, 1.93-34.27) and severe (OR, 15.30; 95% CI, 2.34-100.10) LTP bruising was associated with medial meniscal tears. MFC bruising and MTP bruising were not associated with any predictors or intra-articular injuries. Conclusion: Bone bruising is more common and severe in young men, and lateral bone bruising is associated with lateral meniscal tears. Medial meniscal tears are associated with increased severity of LTP bruising.

Duration of Physical Activity and Serum 25-hydroxyvitamin D Status of Postmenopausal Women

PURPOSE To investigate whether the association between physical activity and serum 25-hydroxyvitamin D (25(OH)D) concentrations is independent of sun exposure, body size, and other potential explanatory variables. METHODS By using data from a sample of 1343 postmenopausal women from the Womens Health Initiative, we used linear regression to examine the associations of duration (minutes/week) of recreational activity and of yard work with 25(OH)D concentrations (nmol/L). RESULTS In age-adjusted analyses, positive associations were observed between 25(OH)D concentrations and both duration of recreational physical activity (β = 0.71, SE [0.09], p <.001) and yard work (β = 0.36, SE [0.10], p = .004). After further adjustment for vitamin D intake, self-reported sunlight exposure, waist circumference, and season of blood draw, 25(OH)D was significantly associated with recreational activity (β = 0.21, SE [0.09], p = .014) but not with yard work (β = 0.18, SE [0.09], p = .061). Interactions were observed between season and both recreational activity (P(interaction) = .082) and yard work (P(interaction) = .038) such that these activity-25(OH)D associations were greater during summer/fall compared with winter/spring. Self-reported sunlight exposure and measures of body size did not modify the associations. CONCLUSIONS The observed age-adjusted activity-25(OH)D associations were attenuated after adjusting for explanatory variables and were modified by season of blood draw. Adopting a lifestyle that incorporates outdoor physical activity during summer/fall, consuming recommended amounts of vitamin D, and maintaining a healthy weight may improve or maintain vitamin D status in postmenopausal women.

A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament

Background: There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL). Purpose: To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded. Results: A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous. Conclusion: A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.

Does Suture Technique Affect Re-Rupture in Arthroscopic Rotator Cuff Repair? A Meta-analysis

PURPOSE To evaluate the effects of suture configuration, repair method, and tear size on rotator cuff (RC) repair healing. METHODS We conducted a literature search of articles that examined surgical treatment of RC tears published between January 2003 and September 2014. For single-row (SR) repairs, we calculated rerupture rates for simple, mattress, and modified Mason-Allen sutures while stratifying by tear size. All double-row repairs-those using 2 rows of suture anchors (DA) and those using a suture bridge (SB)--were performed using mattress sutures, and we compared rerupture rates by repair method while stratifying by tear size. A random-effects model with pooled estimates for between-study variance was used to estimate the overall rerupture proportion and corresponding 95% confidence interval for each group. Statistical significance was defined as P < .05. RESULTS A total of 682 RC repairs from 13 studies were included. For SR repairs of tears measuring less than 3 cm, there was no significant difference in rerupture rates for modified Mason-Allen sutures versus simple sutures (P = .18). For SR repairs of tears measuring 3 cm or more, there was no significant difference in rerupture rates for mattress sutures versus simple sutures (P = .23). The rates of rerupture did not differ between SB and DA repairs for tears measuring less than 3 cm (P = .29) and 3 cm or more (P = .50). CONCLUSIONS For SR repairs, there were no significant differences in rerupture rates between suture techniques for any repair method or tear size. All DA and SB repairs were secured with mattress sutures, and there were no differences in the rates of rerupture between these methods for either size category. These findings suggest that suture technique may not affect rerupture rates after RC repair. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.

Does Body Mass Index Affect Outcomes of Ambulatory Knee and Shoulder Surgery

PURPOSE Obesity is highly prevalent among patients with knee and shoulder injuries and is associated with greater odds of surgical treatment for these injuries. The purpose of this systematic review was to summarize the literature that has examined the association between body mass index (BMI) and outcomes of ambulatory knee and shoulder surgery. METHODS A literature search of PubMed and Medline was conducted up to December 2013. Studies that examined the association between BMI and outcomes after ambulatory knee and shoulder surgery (arthroscopy, repairs, and reconstructions) were included. Outcomes included postoperative functional scores, clinical scores, and complications. RESULTS Eighteen studies were included in this review; 13 involved knee surgery and 5 involved shoulder surgery. Seven knee studies and 2 shoulder studies found increased BMI to be associated with worse postoperative outcomes, whereas the remaining 9 studies did not find an association. Increased BMI was associated with worse clinical scores and less patient satisfaction after arthroscopic meniscectomy or debridement, and with worse clinical scores and lower activity levels after anterior cruciate ligament (ACL) reconstruction. It was also associated with worse clinical scores and a longer hospital stay after rotator cuff repair and with longer time to return to work after subacromial decompression. Six studies examined the association between BMI and complications, but all reported null findings. CONCLUSIONS There is a lack of consensus in the literature regarding the association between BMI and ambulatory knee and shoulder surgery. Several factors may have contributed to contradictory findings, including variation in measuring and classifying anthropometry, postoperative outcomes, and follow-up time. LEVEL OF EVIDENCE Level IV, systematic review of Level I, III, and IV studies.

Early Versus Delayed Passive Range of Motion After Rotator Cuff Repair A Systematic Review and Meta-analysis

Background: Postoperative rehabilitation has been shown to affect healing of the rotator cuff after surgical repair. However, it is unknown whether an early or delayed rehabilitation protocol is most beneficial for healing. Purpose: To determine whether early versus delayed passive range of motion (PROM) affects rotator cuff (RC) retear rates after surgery. Study Design: Systematic review and meta-analysis. Methods: A systematic review of the literature published between January 2003 and February 2014 was conducted. Retear rates were compared for early (within 1 week after surgery) versus delayed (3-6 weeks after surgery) PROM using χ2 or Fisher exact tests as well as relative risks (RR) and 95% CIs. In the first analysis, data from evidence level 1 studies that directly compared early versus delayed PROM were pooled; and in the second analysis, data from level 1 to 4 studies that did not directly compare early versus delayed PROM were pooled. The second analysis was stratified by tear size and repair method. Results: Twenty-eight studies (1729 repairs) were included. The first analysis of level 1 studies did not reveal a significant difference in retear rates for early (13.7%) versus delayed (10.5%) PROM (P = .36; RR = 1.30 [95% CI, 0.74-2.30]). The second analysis revealed that for ≤3 cm tears, the risk of retear was lower for early versus delayed PROM for transosseous (TO) plus single-row anchor (SA) repairs (18.7% vs 28.2%, P = .02; RR = 0.66 [95% CI, 0.47-0.95]). For >5 cm tears, the risk of retear was greater for early versus delayed PROM for double-row anchor (DA) repairs (56.4% vs 20%, P = .002; RR = 2.82 [95% CI, 1.31-6.07]) and for all repair methods combined (52.2% vs 22.6%, P = .01; RR = 2.31 [95% CI, 1.16-4.61]). There were no statistically significant associations for tears measuring <1 cm, 1 to 3 cm, 3 to 5 cm, and >3 cm. Conclusion: Evidence is lacking with regard to the optimal timing of PROM after RC repair; however, this study suggests that tear size may be influential.

Does Early Versus Delayed Active Range of Motion Affect Rotator Cuff Healing After Surgical Repair? A Systematic Review and Meta-analysis

Background: The timing of passive range of motion (ROM) after surgical repair of the rotator cuff (RC) has been shown to affect healing. However, it is unknown if early or delayed active ROM affects healing. Purpose: To determine whether early versus delayed active ROM affects structural results of RC repair surgery. Study Design: Systematic review and meta-analysis. Methods: A systematic review of articles published between January 2004 and April 2014 was conducted. Structural results were compared for early (<6 weeks after surgery) versus delayed (≥6 weeks after surgery) active ROM using chi-square and Fisher exact tests, as well as relative risks (RRs) and 95% CIs. The analyses were stratified by tear size and repair method. Results: A total of 37 studies (2251 repairs) were included in the analysis, with 10 (649 repairs) in the early group and 27 (1602 repairs) in the delayed group. For tears ≤3 cm, the risk of a structural tendon defect was higher in the early versus delayed group for transosseous plus single-row suture anchor repairs (39.7% vs 24.3%; RR, 1.63 [95% CI, 1.28-2.08]). For tears >3 cm, the risk of a structural tendon defect was higher in the early versus delayed group for suture bridge repairs (48% vs 17.5%; RR, 2.74 [95% CI, 1.59-4.73]) and all repair methods combined (40.5% vs 26.7%; RR, 1.52 [95% CI, 1.17-1.97]). For tears >5 cm, the risk of structural tendon defect was higher in the early versus delayed group for suture bridge repairs (100% vs 16.7%; RR, 6.00 [95% CI, 1.69-21.26]). There were no statistically significant associations for tears measuring ≤1, 1-3, or 3-5 cm. Conclusion: Early active ROM was associated with increased risk of a structural defect for small and large RC tears, and thus might not be advisable after RC repair.

Biomechanical Effects of a Horizontal Medial Meniscal Tear and Subsequent Leaflet Resection

Background: Horizontal, degenerative tears of the medial meniscus and subsequent meniscectomy can compromise the biomechanical function of the meniscus in load transmission and weightbearing, leading to the development of radiographic and symptomatic tibiofemoral arthritis. Hypothesis: Resection of both leaflets of a horizontal medial meniscal tear will increase peak contact pressures and decrease contact areas in comparison with resection of only the inferior leaflet. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen human cadaveric knees had tibiofemoral peak contact pressures and contact areas under an 1800-N axial load measured by Tekscan in the control state. A horizontal tear was created in the posterior horn of the medial meniscus, and the knees were retested. The knees were tested a third time after resection of the inferior leaflet (single leaflet) and a final time after resection of the superior leaflet (both leaflets). The Friedman test was used to test for group differences in peak pressure (psi) and contact area (mm2) between test conditions (native, tear, inferior leaflet resection, and resection of both leaflets). Results: For the medial compartment, there was a statistically significant difference in peak pressure (P = .03) but not in contact area (P = .70) between testing conditions. Median peak pressure in the medial compartment was significantly greater for resection of both leaflets compared with the tear (406.5 vs 294.7 psi, respectively; P = .002). Median contact area in the medial compartment was greatest for resection of both leaflets (602.7 mm2), but there were no statistically significant differences between test conditions (P = .70). For the lateral compartment, there were no statistically significant differences in peak pressure (P = .99) or contact area (P = .77) between test conditions. Conclusion: Resection of a single inferior leaflet after a horizontal medial meniscal tear preserves much of the original biomechanical function of the meniscus. Resection of both leaflets leads to a significant increase in contact pressure dispersed over the same contact area, which results in an undesirable biomechanical environment. Clinical Relevance: Arthroscopic inferior leaflet resection is a viable option for providing symptomatic relief of horizontal medial meniscal tears and preserves the ability of the meniscus to absorb axial loading on the knee joint, theoretically decreasing the risk of subsequent osteoarthritis.