Rick P. Csintalan

Prospective Trial of a Treatment Algorithm for the Management of the Anterior Cruciate Ligament–Injured Knee

Background Specific guidelines for operative versus nonoperative management of anterior cruciate ligament injuries do not yet exist. Hypothesis Surgical risk factors can be used to indicate whether reconstruction or conservative management is best for an individual patient. Study Design Prospective nonrandomized controlled clinical trial; Level of evidence, 2. Methods Patients were classified as high, moderate, or low risk using preinjury sports participation and knee laxity measurements. Early anterior cruciate ligament reconstruction (within 3 months of injury) was recommended to high-risk patients and conservative care to low-risk patients. It was recommended that moderate-risk patients have either early reconstruction or conservative care, according to the day of presentation. Assessment of subjective outcomes, activity, physical measurements, and radiographs was performed at mean follow-up of 6.6 years. Results Early phase conservative management resulted in more late phase meniscus surgery than did early phase reconstruction at all risk levels (high risk, 25% vs 6.5%; moderate risk, 37% vs 7.7%, P =. 01; low risk, 16% vs 0%). Early- and late-reconstruction patients’ Tegner scores increased from presurgery to follow-up (P <. 001) but did not return to preinjury levels. Early-reconstruction patients had higher rates of degenerative change on radiographs than did nonreconstruction patients (P <. 05). Conclusions Early phase reconstruction reduced late phase knee laxity, risk of symptomatic instability, and the risk of late meniscus tear and surgery. Moderate- and high-risk patients had similar rates of late phase injury and surgery. Reconstruction did not prevent the appearance of late degenerative changes on radiographs. Relationship between bone contusion on initial magnetic resonance images and the finding of degenerative changes on follow-up radiographs were not detected. The treatment algorithm used in this study was effective in predicting risk of late phase knee surgery.

Gender differences in patellofemoral joint biomechanics

Patellofemoral pain is associated with patellar malalignment and quadriceps weakness which are seen more commonly in women. The objective of the current study was to determine the effects of gender, vastus medialis strength, and tibial rotation on patellofemoral joint biomechanics. Twelve fresh-frozen knees from cadavers were tested using a custom knee jig. Anatomic multiplane loading of the extensor mechanism was used with varying vastus medialis loads. Patellofemoral contact area and pressure were measured using pressure sensitive film at knee flexion angles of 0°, 30°, 60°, and 90° with the tibia in neutral and 15° internal and external tibial rotation. Patellofemoral joint contact areas in specimens from men were larger at knee flexion angles greater than 30°. A significant increase in mean patellofemoral contact pressures was seen for specimens from women when compared with specimens from men at 0° and 30° knee flexion. The knees from women also showed a greater change in contact pressures to varying vastus medialis load at knee flexion angles of 0°, 30°, and 60°. The results of the current study indicate that there are gender differences in patellofemoral contact areas and pressures. These differences may help explain the increased incidence of patellofemoral disorders in women.

Incidence Rate of Anterior Cruciate Ligament Reconstructions

CONTEXT Anterior cruciate ligament (ACL) reconstructions are among the most common sports medicine procedures performed in the US each year. Differences have been reported in the incidence rates (IRs) of ACL tears among male and female national elite athletes. However, there is little information in the published literature that assesses IRs for ACL reconstructions done in the Health Maintenance Organization (HMO) setting specifically. Different populations may show variation in ACL reconstruction IRs. OBJECTIVE This study reports on the IR of ACL reconstructions in a predefined population and compares the differences in age and sex over time. DESIGN A retrospective analysis of 4485 ACL reconstructions performed within Kaiser Permanente Southern California between 2001 and 2005 was completed by a query of an administrative database. Trends in IRs per 100,000 members were calculated and compared across age, sex, and the five-year study period. MAIN OUTCOME MEASURES Linear regression was used to test trends in IR. Sex distribution was compared using the χ(2) test. Analysis of variance was used to compare the mean age from year to year in males and females. The independent sample t-test was used to compare mean age between males and females for each independent year. RESULTS The IR of ACL reconstructions in females rose significantly (p = 0.010) from 14.4 in 2001 (95% confidence interval [CI], 12.6-16.3) to 19.3 in 2005 (95% CI, 17.2-21.5). Within specific age groups, IR increased significantly for females age 14 to 17 (p = 0.013), 18 to 21 (p = 0.017), and 45 to 49 years (p = 0.014). The most dramatic change was seen in the female age category of 14 to 17 years, which increased at a rate of 8.14 cases/100,000 members per year. CONCLUSION Identifying the sex and age groups with most rapidly increasing rates of ACL reconstructions is important in implementing ACL injury-prevention programs.

Are Meniscus and Cartilage Injuries Related to Time to Anterior Cruciate Ligament Reconstruction

Background: Functional instability after anterior cruciate ligament injury can be successfully treated with ligament reconstruction. However, the associated meniscus and cartilage lesions often cannot be repaired and may have long-term detrimental effects on knee function. Purpose: The authors used the large database within the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry to evaluate time to surgery, age, and gender as risk factors for meniscus and cartilage injury and associations with meniscus repair rates in patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry was performed. The associations between time to surgery, age, and gender with meniscus and cartilage lesions and meniscus repair were analyzed using binary logistic regression modeling to calculate odds ratios (ORs) while adjusting for potential confounding variables. Results: A total of 1252 patients met the inclusion criteria. The risk of medial meniscus injury increased only with time to surgery (6–12 months: OR = 1.81, 95% confidence internal [CI] 1.29-2.54, P = .001; and >12 months: OR = 2.19, 95% CI 1.58-3.02, P < .001). The risk of lateral meniscus injury decreased only with female gender (OR = 0.65, 95% CI 0.51-0.83, P = .001). The risk of cartilage injury increased with age (OR = 1.05 per year, 95% CI 1.04-1.07, P < .001) and time to surgery >12 months (OR = 1.57, 95% CI 1.12-2.20, P = .009), but decreased with female gender (OR = 0.71, 95% CI 0.54-0.92, P = .009). Medial meniscus repairs relative to medial meniscus injury decreased with increasing time to surgery (3-6 months: OR = 0.61, 95% CI 0.37-1.00, P = .050; and >12 months: OR = 0.41, 95% CI 0.25-0.67, P < .001) and increasing age (OR = 0.96 per year, 95% CI 0.94-0.98, P < .001). Conclusion: Increased risk of medial meniscus injury and decreased repair rate were strongly associated with increasing time to surgery. Increased risk of cartilage injury was associated with increasing age, increasing time to surgery, and male gender.

Anterior Cruciate Ligament Injuries in Adolescents With Open Physis Effect of Recurrent Injury and Surgical Delay on Meniscal and Cartilage Injuries

Background: Treatment choices for skeletally immature patients sustaining anterior cruciate ligament (ACL) injuries have been controversial. The main dilemma is whether surgical treatment should be provided before patients reach skeletal maturity or whether nonoperative treatment should be provided until the physis has closed. Surgical reconstruction risks physeal damage, while delaying surgery may increase menisci and cartilage damage. Purpose: To identify patients at the onset of ACL injury and follow them longitudinally to surgery or final follow-up to describe differences between nonoperative and operative patients and to analyze the effect of delayed reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of patients enrolled at a large integrated health care system (IHS) between January 1, 2005, and December 31, 2008, was performed. The study sample included all females ≤12 years old and males ≤14 years old who were evaluated with an ACL injury. The incidence of ACL injuries in each age group was calculated using the number of covered lives by the IHS system per age category as the denominator. Each patient was longitudinally followed using an electronic health record that captures all patient encounters. Every encounter was reviewed for symptoms associated with the index knee, and encounters were considered significant if new-onset pain or swelling was reported. Patients were instructed to restrict their activities while awaiting skeletal maturity to undergo reconstruction by not participating in activities that included any cutting or pivoting movements that would risk injury to the knee. Cartilage and meniscal injuries were recorded for patients who underwent reconstruction. Results: A total of 71 patients were identified during the study period (66 males, 4 females). At the completion of this study, 47 (66.2%) patients had undergone ACL reconstruction, and 24 (33.8%) were being treated nonoperatively. While there were no significant associations between time to surgery and meniscal or cartilage injury, there was a positive association between the number of significant encounters and the likelihood of a combined cartilage and meniscal injury (P = .01). Conclusion: This is the first study to measure the incidence of ACL injuries in a skeletally immature population. For patients undergoing ACL reconstruction, an increased number of significant encounters was statistically significantly associated with combined meniscal and cartilage injuries, while increased time from injury to surgery was not significantly associated with additional injuries. In addition, one-third of the patients continued nonoperative treatment without symptoms that warranted surgical interventions during the follow-up period.

Biomechanical and Anatomical Effects of an External Rotational Torque Applied to the Knee A Cadaveric Study

Background External rotational torque is one of the mechanisms that may occur during a pivoting or twisting injury to the knee. Hypothesis Simulated external rotational injury by applying external rotational torque will increase knee laxity and cause soft tissue damage to the knee. Study Design Controlled laboratory study. Methods Six cadaveric knees and a custom testing system were used to produce external rotational torque of 30°, 45°, and 60° with the knee at 30° of flexion. Anterior-posterior, valgus-varus, and rotational knee laxity were quantified. After sequential rotational torque to 60°, the specimens were dissected to identify injured structures. Results External rotational torque of 45° and 60° significantly increased knee joint laxity in all directions (P <. 05). Dissection showed that all posterior cruciate ligaments were intact; all medial collateral and anterior cruciate ligaments revealed either partial or complete tears. The lateral collateral ligaments were torn in all specimens. The popliteus tendon was attenuated in 1 specimen and was completely torn in 1 specimen. The popliteofibular ligament was torn in 3 specimens. Conclusion External rotational torque to 60° increased knee laxity, and dissection revealed a consistent pattern of injury to the medial and lateral collateral and anterior cruciate ligaments and posterolateral corner. Clinical Relevance Because isolated ligament injuries are rare, recognizing these combined ligamentous injuries early is essential for repair in the acute stage.

Medial Patellofemoral Ligament (MPFL) Reconstruction for the Treatment of Patellofemoral Instability

Patellofemoral instability can be a disabling problem. Numerous techniques are employed for its treatment. Medial patellofemoral ligament (MPFL) reconstruction in combination with other procedures has been explored by many orthopedic surgeons. The purpose of the study was to determine the effectiveness of isolated MPFL reconstruction in treating the symptoms associated with patellofemoral instability, preventing recurrence of patella dislocation, and returning patients to preinjury level of activity. This is a case series study. We conducted a clinical follow-up study on 56 knees (49 patients) after MPFL reconstruction for recurrent patellar instability with a mean follow-up of 4.3 years (range, 1.1-6.8). A single MPFL reconstruction technique was performed in all cases. Patient outcomes were evaluated using: International Knee Documentation Committee (IKDC) subjective knee form, Tegner activity score, functional hop test, and radiographs. Mean age at time of surgery was 24 years old (range, 13-49). Females comprised 75% of the sample. Mean interval from injury to surgery was 7.2 ± 8.6 years (range, 51 days-37 years). At follow-up, there were no recurrent dislocations reported, patella subluxation in 6 (11%) cases, and radiographic degenerative changes were none to mild in all patients. The series mean IKDC scores at follow-up was 76.3 ± 19.2 (range, 30-99), and Tegner activity scores were 5.6 ± 2.5. MPFL reconstruction is an option for treating the symptoms of patellar instability, preventing recurrent dislocation, and returning patients near to their preinjury level of activity. The level of evidence is IV.

Quantitative assessment of glenohumeral translation.

Cutaneous electromagnetic position sensors were used to quantify anteroposterior laxity of the shoulder. Forty-three female athletes were tested (27 were soccer players and 16 were swimmers). The athletes had a mean age of 18.8 years (range, 17–24 years), and all were free of shoulder disorders. Dominant and nondominant shoulders were tested. Each shoulder was suspended in 90° abduction and neutral rotation. Serial anteroposterior translations were done manually similar to an anteroposterior drawer examination of the shoulder. The glenohumeral translation for the soccer players was 9.6 mm (range, 5.8–15.1 mm) in the dominant shoulder and 10.7 mm (range, 5.2–16.7 mm) in the nondominant shoulder. The translations in the swimmers were significantly greater at 12.4 mm (range, 8.9–15.9 mm) in the dominant and 13.8 mm (range, 8.8–17.4 mm) in the nondominant shoulders. The mean of the differences between the dominant and nondominant shoulders was 2.1 mm for the swimmers and soccer players. For the soccer players, the range for the side to side differences was 0.1 to 5.3 mm. For the swimmers, the range was 0.1 to 4.3 mm. Finding a clinical device for objective measurement of joint laxity in the shoulder that is accurate, reproducible, noninvasive, and easy to use has been evasive.

Patient and Surgeon Characteristics Associated With Primary Anterior Cruciate Ligament Reconstruction Graft Selection

Background: It has been suggested that a surgeon’s experience and training are the most important factors associated with graft selection, but no studies have qualified this association. Graft usage prevalence has not been described for large anterior cruciate ligament reconstruction (ACLR) populations in the United States. Purpose: To describe the prevalence of graft usage in a large community-based practice and evaluate the association of patient, surgeon, and site characteristics with choice of primary ACLR graft. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Primary ACLRs performed between February 2005 and June 2010 were selected for the study. A community-based ligament registry was used to identify cases and variables used for analysis. Graft choice (any allograft, hamstring autograft, and bone–patellar tendon–bone [BPTB] autograft) was compared by patient characteristics and surgeon and site characteristics. Associations between independent variables and graft choice were evaluated using a polychotomous regression model. Results: Of the 9849 patients included in the study, 64% were male, and overall median age was 28 years. Of these, 2796 (28.4%) received BPTB autografts, 3013 (30.6%) received hamstring autografts, and 4040 (41.0%) received allografts. The prevalence of graft source by patients’ gender, race, age, body mass index (BMI), as well as surgeons’ fellowship training status, average volume, and site volume were significantly different (all P < .001). Adjusted models showed that patients’ gender (P < .001), race (P = .018), age (P < .001), BMI (P < .001), as well as surgeons’ fellowship training status (P < .001), average volume (P < .001), and site volume (P < .001) are associated with graft selection. Older and female patients with lower BMI were more likely to receive allografts and hamstring autografts than BPTB autografts. Cases performed by non–fellowship-trained surgeons, lower volume sites, and/or lower volume surgeons were also more likely to be performed with allografts or hamstring autografts than BPTB autografts. Conclusion: Gender, age, race, as well as facility and surgeon characteristics such as volume and location are associated with ACL graft choices.

Reliability of the International Knee Documentation Committee Radiographic Grading System

Background The International Knee Documentation Committee (IKDC) forms are commonly used to measure outcomes after anterior cruciate ligament (ACL) reconstruction. The knee examination portion of the IKDC forms includes a radiographic grading system to grade degenerative changes. The interrater and intrarater reliability of this radiographic grading system remain unknown. Hypothesis We hypothesize that the IKDC radiographic grading system will have acceptable interrater and intrarater reliability. Study Design Case series (diagnosis); Level of evidence, 4. Methods Radiographs of 205 ACL-reconstructed knees were obtained at 5-year follow-up. Specifically, weightbearing posteroanterior radiographs of the operative knee in 35° to 45° of flexion and a lateral radiograph in 30° of flexion were used. The radiographs were independently graded by 2 sports medicine fellowship—trained orthopaedic surgeons using the IKDC 2000 standard instructions. One surgeon graded the same radiographs 6 months apart, blinded to patient and prior IKDC grades. The percentage agreement was calculated for each of the 5 knee compartments as defined by the IKDC. Interrater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (rs) was applied to evaluate intrarater reliability. Results The interrater agreement between the 2 surgeons was 59% for the medial joint space (ICC = 0.46; 95% confidence interval [CI] = 0.35-0.56), 54% for the lateral joint space (ICC = 0.45; 95% CI = 0.27-0.58), 49% for the patellofemoral joint (ICC = 0.40; 95% CI = 0.26-0.52), 63% for the anterior joint space (ICC = 0.20; 95% CI = 0.05-0.34), and 44% for the posterior joint space (ICC = 0.28; 95% CI = 0.15-0.40). The intrarater agreement was 83% for the medial joint space (rs = .77, P < .001), 86% for the lateral joint space (rs = .76, P < .001), 81% for the patellofemoral joint (rs = .79, P < .001), 91% for the anterior joint space (rs = .48, P < .001), and 69% for the posterior joint space (rs = .64, P < .001). Conclusions While intrarater reliability was acceptable, interrater reliability was poor. These findings suggest that multiple raters may score the same radiographs differently using the IKDC radiographic grading system. The use of a single rater to grade all radiographs when using the IKDC radiographic grading system maximizes reliability.