Peter J. Fowler

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.)

The effect of bracing on varus gonarthrosis.

BACKGROUND The purpose of this study was to compare a custom-made valgus-producing functional knee (unloader) brace, a neoprene sleeve, and medical treatment only (control group) with regard to their ability to improve the disease-specific quality of life and the functional status of patients who had osteoarthritis in association with a varus deformity of the knee (varus gonarthrosis). METHODS The study design was a prospective, parallel-group, randomized clinical trial. Patients who had varus gonarthrosis were screened for eligibility. The criteria for exclusion included arthritides other than osteoarthritis; an operation on the knee within the previous six months; symptomatic disease of the hip, ankle, or foot; a previous fracture of the tibia or femur; morbid obesity (a body-mass index of more than thirty-five kilograms per square meter); skin disease; peripheral vascular disease or varicose veins that would preclude use of a brace; a severe cardiovascular deficit; blindness; poor English-language skills; and an inability to apply a brace because of physical limitations such as arthritis in the hand or an inability to bend over. Treatment was assigned on the basis of a computer-generated block method of randomization with use of sealed envelopes. The patients were stratified according to age (less than fifty years or at least fifty years), deformity (the mechanical axis in less than 5 degrees of varus or in at least 5 degrees of varus), and the status of the anterior cruciate ligament (torn or intact). The patients were randomly assigned to one of three treatment groups: medical treatment only (control group), medical treatment and use of a neoprene sleeve, or medical treatment and use of an unloader brace. The disease-specific quality of life was measured with use of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and function was assessed with use of the six-minute walking and thirty-second stair-climbing tests. The primary outcome measure consisted of an analysis of covariance of the change in scores between the baseline and six-month evaluations. RESULTS One hundred and nineteen patients were randomized. The control group consisted of forty patients (thirty-one men and nine women; mean age, 60.9 years); the neoprene-sleeve group, of thirty-eight patients (twenty-seven men and eleven women; mean age, 58.2 years); and the unloader-brace group, of forty-one patients (twenty-eight men and thirteen women; mean age, 59.5 years). Nine patients withdrew from the study. At the six-month follow-up evaluation, there was a significant improvement in the disease-specific quality of life (p = 0.001) and in function (p< or =0.001) in both the neoprene-sleeve group and the unloader-brace group compared with the control group. There was a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to pain after both the six-minute walking test (p = 0.021) and the thirty-second stair-climbing test (p = 0.016). There was a strong trend toward a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to the change in the WOMAC aggregate (p = 0.062) and WOMAC physical function scores (p = 0.081). CONCLUSIONS The results indicate that patients who have varus gonarthrosis may benefit significantly from use of a knee brace in addition to standard medical treatment. The unloader brace was, on the average, more effective than the neoprene sleeve. The ideal candidates for each of these bracing options remain to be identified.

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.

Medial and Anterior Instability of the Knee: An Anatomical And Clinical Study Using Stress Machines

Our clinical stress machine serves as an additional aid in the detection of isolated or combined damage to ligamentous structures about the knee. The machine has greatly assisted in the classification of chronic ligamentous damage. In the questionable gray area of medial instability, machine evaluation has been a great asset in making critical therapeutic decisions.

Limitation of motion following anterior cruciate ligament reconstruction A case-control study

Limitation of motion following ACL reconstruction is a well-recognized and disturbing complication. The pur poses of this study were to identify and characterize those patients who developed this complication from a series of 527 ACL reconstructions, determine etiologic factors, and make recommendations regarding preven tion and management. The case group included 37 patients who required a manipulation under anesthesia because of failure to gain a satisfactory range of motion after an ACL recon struction. Unsatisfactory motion was defined as a flex ion deformity of 10° or more and/or limitation of flexion to less than 120° by 3 months following ACL recon struction. The control group of patients were selected randomly from the overall series and all had a satisfac tory range of motion. The cases and controls were then compared by analyzing these variables: age, sex, knee, time from injury to reconstruction, type of tissue used, meniscal abnormalities or surgery, repair of the medial collateral ligament, and postoperative immobilization and rehabil itation. The cases were followed up to assess the range of motion compared to the opposite knee at an average of 26 months postmanipulation. Thirty-seven patients (7%) underwent a manipulation under anesthesia, 9 of these (24.3%) also had an arthroscopic arthrolysis. Reconstructions done less than 2 weeks postinjury showed a statistically signifi cant higher rate of knee stiffness. The same trend was also present for those reconstructed 2 to 6 weeks postinjury. All other variables failed to show a significant statistical difference. At followup, the average loss of extension was 4° and loss of flexion 5°. The authors suggest that it is prudent to avoid im mediate reconstructive surgery. The stiff knee requires early aggressive management with a manipulation and or arthroscopic arthrolysis.

Functional postoperative treatment of Achilles tendon repair

Twenty-one patients with surgically repaired Achilles tendon tears that were treated postoperatively with a functional orthosis rather than routine cast immobiliza tion were evaluated. The orthosis allowed unrestricted plantar flexion and limited dorsiflexion to neutral. Toe- touch weightbearing crutch ambulation was allowed immediately and was gradually increased over the 6 to 8 weeks of treatment. Of the 21 patients, 14 were men and 7 were women; the average age at injury was 35.6 years (range, 19 to 65). The minimum followup was 2 years, with an average of 31 months. The repairs were acute in 18 of the patients and chronic in 3. Subjectively, 16 patients felt they returned to their preinjury level of activity and only 1 was not satisfied with his result. Objectively, there were no significant alterations in ankle range of motion when compared to the contralateral limb, with plantar flexion unchanged and dorsiflexion increased an average of only 2°. The average plantar flexion and dorsiflexion strength, power, and endurance of the ankles as measured by isokinetic testing revealed no significant differences when comparing the operated leg to the nonoperated side: strength, 99% and 93%, respectively; power, 98% and 96%, respectively; and endurance, 93% and 91 %, respectively. The angles at which the peak torques occurred were similarly not statistically different. Two patients had superficial wound infections, and 1 had scar adherence of the skin to the tendon. No one had rerupture of the tendon. In conclusion, while the many benefits of postopera tive early motion are well proven, there has been hesi tation to implement this after Achilles tendon surgery due to the concern of compromising the repair. As shown by this study, early controlled motion can safely and effectively be used following Achilles tendon repair in the motivated, reliable patient.

Occult Osteochondral Lesions After Anterior Cruciate Ligament Rupture Six-Year Magnetic Resonance Imaging Follow-up Study

Twenty-three patients with acute anterior cruciate ligament injuries, normal radiographs, and occult osteochondral lesions revealed by magnetic resonance imaging were reviewed 6 years after initial injury and anterior cruciate ligament hamstring autograft reconstruction. Each patient completed the Mohtadi Quality of Life outcome measure for anterior cruciate ligament deficiency, underwent clinical examination, and had a repeat magnetic resonance imaging scan. The index and follow-up magnetic resonance imaging scans were compared with respect to cartilage thinning and marrow signal. A significant number of patients had evidence of cartilage thinning adjacent to the site of the initial osteochondral lesion. Marrow signal changes persisted in 15 (65%) of the patients. Clinical comparison of patients with normal cartilage with those who had cartilage thinning revealed similar results on both KT-1000 arthrometry and on the Mohtadi outcome measure. This suggests that the initial injury resulted in irreversible changes in the knee. Injuries causing marrow signal changes may result in an alteration in the load-bearing properties of subchondral bone, which in turn allow for changes in the overlying cartilage. Further follow-up will determine the clinical significance of changes detected by magnetic resonance imaging.

The Familial Predisposition toward Tearing the Anterior Cruciate Ligament: A Case Control Study

Purpose A study of 171 surgical cases and 171 matched controls was conducted to investigate whether a familial predisposition toward tearing the anterior cruciate ligament of the knee exists. Study Design Case control study; Level of evidence, 3. Methods Patients who were diagnosed with an anterior cruciate ligament tear were matched by age (within 5 years), gender, and primary sport to subjects without an anterior cruciate ligament tear. All 342 subjects completed a questionnaire detailing their family history of anterior cruciate ligament tears. Results When controlling for subject age and number of relatives, participants with an anterior cruciate ligament tear were twice as likely to have a relative (first, second, or third degree) with an anterior cruciate ligament tear compared to participants without an anterior cruciate ligament tear (adjusted odds ratio = 2.00; 95% confidence interval, 1.19-3.33). When the analysis was limited to include only first-degree relatives, participants with an anterior cruciate ligament tear were slightly greater than twice as likely to have a first-degree relative with an anterior cruciate ligament tear compared to participants without an anterior cruciate ligament tear (adjusted odds ratio = 2.24; 95% confidence interval, 1.24-4.00). Conclusions Findings are consistent with a familial predisposition toward tearing the anterior cruciate ligament. Clinical Relevance Future research should concentrate on identifying the potentially modifiable risk factors that may be passed through families and developing strategies for the prevention of anterior cruciate ligament injuries.

Opening Wedge High Tibial Osteotomy for Symptomatic Hyperextension-Varus Thrust

Background The purpose of this study was to assess the functional outcome of opening wedge high tibial osteotomy (HTO) in a young, active group of patients with instability rather than osteoarthritis. Methods The results of 17 opening wedge HTOs in 16 patients with a symptomatic hyperextension-varus thrust were evaluated. Functional results were evaluated according to the activity scoring system of Tegner and Lysholm and using a 5-point visual analogue scale to assess change in knee stability and satisfaction. Radiographs were analyzed to determine changes in femorotibial and mechanical axis alignment, tibial slope, and patellar height. Results Patients were followed for a mean of 56 months. All patients had an increase in their activity score postoperatively. Nine patients rated their symptoms as significantly better and seven as somewhat better. All but one were satisfied with the surgery. Femorotibial axis alignment was changed to a mean of 6 ° valgus, mechanical axis alignment was corrected to a mean of 46% toward the lateral compartment, posterior tibial slope was increased a mean of 8 °, and the ratio of patellar height was decreased a mean of 0.17. Conclusion Opening wedge HTO can produce good functional and radiographic results in selected patients with a symptomatic thrust.

The predictive value of five clinical signs in the evaluation of meniscal pathology

One hundred sixty-one consecutive patients with knee pain of at least 1 years duration were studied on a prospective basis to determine the predictive value of five common clinical tests for the diagnosis of meniscal tears. Each patient had a preoperative examination that evaluated the presence or absence of joint line tenderness, pain on forced flexion, the presence of a positive McMurray test, positive Apley grind and distraction tests, and the presence of a block to extension. The results of these tests were then compared to arthroscopic findings. This study indicates that no one test is predictive for the diagnosis of a meniscal tear; a combination of tests should be used. The presence of anterior cruciate ligament pathology will render these tests less effective for diagnosis of meniscal pathology. Chondromalacia patella is negatively correlated with the presence of joint line tenderness and pain on forced flexion.