Michael J. Stuart

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

BACKGROUND Whether arthroscopic partial meniscectomy for symptomatic patients with a meniscal tear and knee osteoarthritis results in better functional outcomes than nonoperative therapy is uncertain. METHODS We conducted a multicenter, randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. We randomly assigned 351 patients to surgery and postoperative physical therapy or to a standardized physical-therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months. The primary outcome was the difference between the groups with respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization. RESULTS In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, -1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ significantly between the groups. CONCLUSIONS In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases; METEOR ClinicalTrials.gov number, NCT00597012.).

Flexion instability after primary posterior cruciate retaining total knee arthroplasty

Between 1990 and 1995, 25 painful primary posterior cruciate ligament retaining total knee arthroplasties were revised for flexion instability. These patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90° flexion, and above average motion of their total knee arthroplasty. The primary total knee arthroplasty was performed for osteoarthritis in 23 patients and rheumatoid arthritis in two patients. There were 13 male and 12 female patients and their mean age was 65 years (range, 35-77 years). Before the revision operation, Knee Society knee scores averaged 45 points (range, 17-68 points) and function scores averaged 42 points (range, 0-60 points). Twenty-two of the knee replacements were revised to posterior stabilized implants and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant were improved markedly after the revision surgery. Only one of three knee replacements that underwent tibial polyethylene exchange was improved. After the revision for flexion instability, Knee Society knee scores averaged 90 points (range, 82-99 points) and function scores averaged 75 points (range, 45-100 points) for the 20 knees with a successful outcome. This study suggests that flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate ligament retaining total knee arthroplasty. A revision operation that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate retaining total knee arthroplasty.

Periprosthetic fractures of the tibia associated with total knee arthroplasty

One hundred two periprosthetic tibial fractures associated with total knee arthroplasty were identified in 29 men and 73 women. Eighty-three fractures occurred postoperatively, and 19 occurred intraoperatively. Fractures were classified into four types based on location and proximity to the prosthesis. There were 61 Type I fractures, occurring at the tibial plateau; 22 Type II fractures, occurring adjacent to the prosthetic stem; 17 Type III fractures, occurring distal to the prosthetic stem; and two Type IV fractures, involving the tibial tubercle. Fracture types were additionally classified by whether the prosthesis appeared to be radiographically well fixed (A) or loose (B) at the time of fracture, or whether the fracture occurred intraoperatively (C). The majority of postoperative Types I and II fractures were Types IB and IIB, and these were treated most successfully with revision surgery. Types IIA, IIIA, and IVA fractures were managed successfully by the usual principles of tibial fracture treatment. Type IC fractures usually were managed by intraoperative fixation, Type IIC by bone grafting or external immobilization and weightbearing restrictions, and Type IIIC by conventional fracture management. This classification system provides a guide for determining the appropriate treatment for tibial fractures associated with total knee arthroplasty.

Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort.

Background Revision anterior cruciate ligament (ACL) reconstruction has worse outcomes than primary reconstructions. Predictors for these worse outcomes are not known. The Multicenter ACL Revision Study (MARS) Group was developed to perform a multisurgeon, multicenter prospective longitudinal study to obtain sufficient subjects to allow multivariable analysis to determine predictors of clinical outcome. Purpose To describe the formation of MARS and provide descriptive analysis of patient demographics and clinical features for the initial 460 enrolled patients to date in this prospective cohort. Study Design Cross-sectional study; Level of evidence, 2. Methods After training and institutional review board approval, surgeons began enrolling patients undergoing revision ACL reconstruction, recording patient demographics, previous ACL reconstruction methods, intra-articular injuries, and current revision techniques. Enrolled subjects completed a questionnaire consisting of validated patient-based outcome measures. Results As of April 1, 2009, 87 surgeons have enrolled a total of 460 patients (57% men; median age, 26 years). For 89%, the reconstruction was the first revision. Mode of failure as deemed by the revising surgeon was traumatic (32%), technical (24%), biologic (7%), combination (37%), infection (<1%), and no response (<1%). Previous graft present at the time of injury was 70% autograft, 27% allograft, 2% combination, and 1% unknown. Sixty-two percent were more than 2 years removed from their last reconstruction. Graft choice for revision ACL reconstruction was 45% autograft, 54% allograft, and more than 1% both allograft and autograft. Meniscus and/or chondral damage was found in 90% of patients. Conclusion The MARS Group has been able to quickly accumulate the largest revision ACL reconstruction cohort reported to date. Traumatic reinjury is deemed by surgeons to be the most common single mode of failure, but a combination of factors represents the most common mode of failure. Allograft graft choice is more common in the revision setting than autograft. Concomitant knee injury is extremely common in this population.

Total knee arthroplasty in patients 55 years old or younger. 10- to 17-year results.

Seventy-four consecutive total knee arthroplasties in 54 patients who were 55 years of age or younger (average age 43 years) were reviewed. All patients had a minimum followup of 10 years with an average followup of 13 years (range, 10-17 years). No patients died or were lost to followup. The preoperative diagnosis was rheumatoid arthritis in 47, gonarthrosis in 12, posttraumatic arthritis in six, osteonecrosis in three, hemophilia in two, and one patient each with pigmented villonodular synovitis, tuberculosis, systemic lupus erythematosus, and achondroplasia. The knee score improved from an average of 36 points (range, 10-80 points) preoperatively to 84 points (range, 37-100 points) at latest followup. The functional score improved from 45 points (range, 0-100 points) to 60 points (range, 0-100 points) at latest followup. Two patients had their implants revised: one at 3 years because of ligamentous laxity and one at 13 years because of aseptic loosening of the tibial component. There were no deep infections. There were no radiographically loose implants at latest followup. The implant survival to revision at 10 years was estimated at 99% (confidence limit, 96%-100%). The implant survival to revision at 15 years was estimated at 95% confidence limit, 88%-100%). Cemented total knee arthroplasty in the young patient is a reliable procedure and has excellent results at 13-year followup with an estimated survivorship of 99% at 10 years.

Repair Versus Reconstruction of the Fibular Collateral Ligament and Posterolateral Corner in the Multiligament-Injured Knee

Background Treatment of the multiligament-injured knee remains controversial. Purpose To compare clinical and functional outcomes of a consecutive series of multiligament-injured knees that underwent repair of the fibular collateral ligament (FCL) and posterolateral corner (PLC), followed by delayed cruciate ligament reconstructions, with those that had single-stage multiligament reconstruction. Study Design Cohort study; Level of evidence, 3. Methods Patients with multiligament knee injury treated by a single surgeon were identified in our prospective database. Between February 2004 and May 2005, patients underwent repair of medial- and lateral-sided injuries, followed by delayed cruciate ligament reconstructions. Between May 2005 and February 2007, patients underwent single-stage multiligament knee reconstruction. All patients followed a standard rehabilitation protocol. Inclusion criteria were minimum 2-year follow-up and multiligament knee injury including the FCL/PLC. International Knee Documentation Committee subjective and Lysholm scores and objective clinical data were documented. Results We identified 45 knees (42 patients); 17 knees (14 patients) were excluded, leaving 28 knees (28 patients) in the study. The repair/staged group (10 knees in 10 patients) had a mean follow-up of 34 months (range, 24-49 months). The reconstruction group (18 knees in 18 patients) had a mean follow-up of 28 months (range, 24-41 months). Four of the 10 FCL/PLC repairs (40%) and 1 of the 18 FCL/PLC reconstructions (6%) failed (P = .04). After revision reconstructions, there were no statistically significant differences between mean International Knee Documentation Committee subjective scores (79 vs. 77, P = .92) and mean Lysholm scores (85 vs 88, P = .92). Regression analysis showed no effect on failure based on age, sex, injury mechanism, time to surgery, interval between stages, total number of ligaments injured, or location of tear. Conclusion Our series demonstrated a statistically significant higher rate of failure for repair compared with reconstruction of the FCL/PLC. Reconstruction of the FCL/PLC structures is a more reliable option than repair alone in the setting of a multiligament knee injury.

A longitudinal examination of athletes' emotional and cognitive responses to anterior cruciate ligament injury

OBJECTIVE To determine the emotional and cognitive impact of injury and surgery on physical recovery in injured athletes. DESIGN A prospective longitudinal study comparing the psychosocial and physical recovery of competitive and recreational athletes. SETTING Tertiary-care sports medicine center. PARTICIPANTS Twenty-seven athletes (15 men and 12 women) who required anterior cruciate ligament (ACL) reconstruction surgery. INTERVENTIONS A repeated-measures design used to compare the psychosocial and physical changes for 6 months after ACL surgery. MAIN OUTCOME MEASURES Emotional (mood) and cognitive (coping) functions and physical recovery (range of motion, physician-rated level of recovery, and physician permission to return to sport). RESULTS There was a significant time-effect difference in mood, with a greater mood disturbance and recovery rate for competitive athletes than recreational athletes. Differences in mood and pain coping were significant at 2 weeks and 2 months after surgery. CONCLUSION Athletes experience significant mood changes throughout rehabilitation, which may hinder rehabilitation early in the process. Longer-term rehabilitation was not impacted by mood or pain coping. Future studies might focus on examining the process over a longer time period (1-2 years after surgery). Physicians should be aware of these findings and appropriately counsel and motivate athletes toward more favorable positive psychological and physical outcomes.

Controversies in the Treatment of Knee Dislocations and Multiligament Reconstruction

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

Comparison of Intersegmental Tibiofemoral Joint Forces and Muscle Activity During Various Closed Kinetic Chain Exercises

The purpose of this study was to analyze intersegmen tal forces at the tibiofemoral joint and muscle activity during three commonly prescribed closed kinetic chain exercises: the power squat, the front squat, and the lunge. Subjects with anterior cruciate ligament-intact knees performed repetitions of each of the three exer cises using a 223-N (50-pound) barbell. The results showed that the mean tibiofemoral shear force was posterior (tibial force on femur) throughout the cycle of all three exercises. The magnitude of the posterior shear forces increased with knee flexion during the descent phase of each exercise. Joint compression forces remained constant throughout the descent and ascent phases of the power squat and the front squat. A net offset in extension for the moment about the knee was present for all three exercises. Increased quadri ceps muscle activity and decreased hamstring muscle activity are required to perform the lunge as compared with the power squat and the front squat. A posterior tibiofemoral shear force throughout the entire cycle of all three exercises in these subjects with anterior cru ciate ligament-intact knees indicates that the potential loading on the injured or reconstructed anterior cruci ate ligament is not significant. The magnitude of the posterior tibiofemoral shear force is not likely to be detrimental to the injured or reconstructed posterior cruciate ligament. These conclusions assume that the resultant anteroposterior shear force corresponds to the anterior and posterior cruciate ligament forces.

Injuries in Junior A Ice Hockey A Three-Year Prospective Study

This 3-year prospective cohort observational analysis of elite amateur hockey players ranging in age from 17 to 20 years on a United States Hockey League team de scribes ice hockey injuries using a strict definition of injury, standardized reporting strategies, and diagnosis by a team physician. One hundred forty-two injuries were recorded for an on-ice injury rate of 9.4 per 1000 player hours. A player was 25 times more likely to be injured in a game (96.1 per 1000 player-game hours) than in practice (3.9 per 1000 player-practice hours). Game-related injuries were more frequent in the third period, and practice-related injuries occurred more of ten in the first third of the season. Collisions represented 51% of the total injuries. The most common types of injuries were strains, lacerations, contusions, and sprains. The face and the shoulder were most fre quently injured. A facial laceration was the most com mon injury; acromioclavicular joint sprain was the sec ond most common injury. Facial lacerations typically occurred in games and were stick related. Further re search is necessary to determine if injuries in Junior A amateur ice hockey can be reduced by mandatory full facial protection, enforcement of existing rules, im provement in shoulder pad design, and by focusing more attention on stretching programs.