Robert Litchfield

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.

A Comparison Of Pain, Strength, Range Of Motion, And Functional Outcomes After Hemiarthroplasty And Total Shoulder Arthroplasty In Patients With Osteoarthritis Of The Shoulder: A Systematic Review And Meta-analysis

BACKGROUND A systematic review of the literature was performed to estimate the impact of hemiarthroplasty compared with total shoulder arthroplasty on function and range of motion in patients suffering from osteoarthritis of the shoulder. METHODS We conducted an electronic search for relevant studies published in any language from 1966 to 2004, a manual search of the proceedings from five major orthopaedic meetings from 1995 to 2003, and a review of the reference lists from potentially relevant studies. Four randomized clinical trials, with similar eligibility criteria and surgical techniques, that compared hemiarthroplasty and total shoulder arthroplasty for the treatment of primary osteoarthritis of the shoulder were found to be eligible. Authors from three of the four studies provided original patient data. Analysis of covariance focused on the two-year outcome and included a comparison of the aggregate University of California at Los Angeles shoulder score, four University of California at Los Angeles domain scores, and range of motion. RESULTS A total of 112 patients (fifty managed with hemiarthroplasty and sixty-two managed with total shoulder arthroplasty), who had a mean age of sixty-eight years, were included in this analysis. A significant moderate effect was detected in the function domain of the University of California at Los Angeles shoulder score (p < 0.001) in favor of total shoulder arthroplasty (mean [and standard deviation], 8.1 +/- 0.3) compared with hemiarthroplasty (mean, 6.6 +/- 0.3). A significant difference in the pain score was found in favor of the total shoulder arthroplasty group (p < 0.0001). However, the large degree of heterogeneity (p = 0.006, I(2) = 80.2%) among the studies decreased our confidence that total shoulder arthroplasty provides a true, consistent benefit with regard to pain. There was a significant difference in the overall change in forward elevation of 13 degrees (95% confidence interval, 0.5 degrees to 26 degrees ) in favor of the total shoulder arthroplasty group (p = 0.008). CONCLUSIONS At a minimum of two years of follow-up, total shoulder arthroplasty provided better functional outcome than hemiarthroplasty for patients with osteoarthritis of the shoulder. Since continuous degeneration of the glenoid after hemiarthroplasty or glenoid loosening after total shoulder arthroplasty may affect the eventual outcome, longer-term (five to ten-year) results are necessary to determine whether these findings remain consistent over time.

A Prospective, Randomized Evaluation of Acellular Human Dermal Matrix Augmentation for Arthroscopic Rotator Cuff Repair

PURPOSE To prospectively evaluate the safety and effectiveness of arthroscopic acellular human dermal matrix augmentation of large rotator cuff tear repairs. METHODS A prospective, institutional review board-approved, multicenter series of patients undergoing arthroscopic repair of 2-tendon rotator cuff tears measuring greater than 3 cm were randomized by sealed envelopes opened at the time of surgery to arthroscopic single-row rotator cuff repair with GraftJacket acellular human dermal matrix (Wright Medical Technology, Arlington, TN) augmentation (group 1) or without augmentation (group 2). Preoperative and postoperative functional outcome assessments were obtained by use of the American Shoulder and Elbow Surgeons (ASES), Constant, and University of California, Los Angeles scales. Gadolinium-enhanced magnetic resonance imaging (MRI) evaluation of these repairs was obtained at a mean of 14.5 months (range, 12 to 24 months). Adverse events were recorded. RESULTS There were 22 patients in group 1 and 20 in group 2 with a mean age of 56 years. The mean follow-up was 24 months (range, 12 to 38 months). The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8 in group 2. The scores in group 1 were statistically better than those in group 2 (P = .035). The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to 85.3 in group 2. The scores in group 1 were statistically better than those in group 2 (P = .008). The University of California, Los Angeles score improved from 13.3 to 28.2 in group 1 and from 15.9 to 28.3 in group 2 (P = .43). Gadolinium-enhanced MRI scans showed intact cuffs in 85% of repairs in group 1 and 40% in group 2 (P < .01). No adverse events were attributed to the presence of the matrix grafts. CONCLUSIONS Acellular human dermal matrix augmentation of large (>3 cm) cuff tears involving 2 tendons showed better ASES and Constant scores and more frequent intact cuffs as determined by gadolinium-enhanced MRI. Intact repairs were found in 85% of the augmented group and 40% of the nonaugmented group (P < .01). No adverse events related to the acellular human dermal matrix were observed. LEVEL OF EVIDENCE Level II, lesser-quality randomized controlled trial.

A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament.

PurposeThe purpose of this study was to verify and characterize the anatomical properties of the anterolateral capsule, with the aim of establishing a more accurate anatomical description of the anterolateral ligament (ALL). Furthermore, microscopic analysis of the tissue was performed to determine whether the ALL can morphologically be classified as ligamentous tissue, as well as reveal any potential functional characteristics.MethodsThree different modalities were used to validate the existence of the ALL: magnetic resonance imagining (MRI), anatomical dissection, and histological analysis. Ten fresh-frozen cadaveric knee specimens underwent MRI, followed by anatomical dissection which allowed comparison of MRI to gross anatomy. Nine additional fresh-frozen cadaveric knees (19 total) were dissected for a further anatomical description. Four specimens underwent H&E staining to look at morphological characteristics, and one specimen was analysed using immunohistochemistry to locate peripheral nervous innervation.ResultsThe ALL was found in all ten knees undergoing MRI and all nineteen knees undergoing anatomical dissection, with MRI being able to predict its corresponding anatomical dissection. The ALL was found to have bone-to-bone attachment points from the lateral femoral epicondyle to the lateral tibia, in addition to a prominent meniscal attachment. Histological sectioning showed ALL morphology to be characteristic of ligamentous tissue, having dense, regularly organized collagenous bundles. Immunohistochemistry revealed a large network of peripheral nervous innervation, indicating a potential proprioceptive role.ConclusionFrom this study, the ALL is an independent structure in the anterolateral compartment of the knee and may serve a proprioceptive role in knee mechanics.

A Prospective, Double-Blind, Randomized Clinical Trial Comparing Subacromial Injection of Betamethasone and Xylocaine to Xylocaine Alone in Chronic Rotator Cuff Tendinosis

Background Rotator cuff tendinosis is a common problem with significant health and economic effects. Nonoperative management includes the widespread use of subacromial steroid injections despite the lack of evidence of its efficacy. Hypothesis A subacromial injection of betamethasone will be more effective than xylocaine alone in improving the quality of life, impingement sign, and range of motion in patients who have chronic rotator cuff tendinosis or partial rotator cuff tears. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Patients with rotator cuff tendinosis or partial cuff tear with symptoms longer than 6 months, with failure of 6 weeks of physical therapy and 2 weeks of nonsteroidal anti-inflammatory drugs, who were older than 30 years of age, and who showed > 50% improvement with the Neer impingement test were stratified for Workplace Safety and Insurance Board status and previous injection. Outcome measures—the Western Ontario Rotator Cuff Index; American Shoulder and Elbow Surgeons standardized form; Disabilities of the Arm, Shoulder and Hand; active forward elevation; active internal rotation; active external rotation; and the Neer impingement sign—were assessed at 2, 6, 12, and 24 weeks after injection. The injection into the subacromial space contained either 5 mL of 2% xylocaine alone or 4 mL of 2% xylocaine and 1 mL (6 mg) of betamethasone in an opaque syringe. Results In 58 patients (betamethasone group, n = 30; xylocaine group, n = 28), the authors found no statistically significant difference between the 2 treatment groups for all outcomes and time intervals. The scores for the Western Ontario Rotator Cuff Index at 3 months were xylocaine = 45.4% ± 13% and betamethasone = 56.3% ± 17% (P=. 13). At 6 months, the scores were xylocaine = 51% ± 32% and betamethasone = 59% ± 26% (P=. 38). All other outcomes showed similar values. As well, similar results were found for 2 and 6 weeks after injection. Both groups showed improvement from baseline in all outcomes. Conclusions With the numbers available for this study, the authors found betamethasone to be no more effective in improving the quality of life, range of motion, or impingement sign than xylocaine alone in patients with chronic rotator cuff tendinosis for all follow-up time intervals evaluated.

An Evaluation of the Apprehension, Relocation, and Surprise Tests for Anterior Shoulder Instability

Background Although there are many studies describing tests for shoulder instability, there are few assessing the validity of these tests in diagnosing anterior shoulder instability. Purpose To assess the validity of the apprehension, relocation, and surprise tests as predictors of anterior shoulder instability. Study Design Retrospective review of prospectively collected data. Methods Forty-six patients with a clear diagnosis of one of the following shoulder disorders were evaluated by four independent, blinded examiners: traumatic anterior instability (18), rotator cuff tendinosis (17), posterior instability (2), glenohumeral osteoarthritis (4), or multidirectional instability (5). Interobserver reliability was also determined. Results In subjects who had a feeling of apprehension on all three tests, the mean positive and negative predictive values were 93.6% and 71.9%, respectively. The surprise test was the single most accurate test (sensitivity = 63.89%; specificity = 98.91%). An improvement in the feeling of apprehension or painwith the relocation test added little to the value of the tests. Interobserver reliability was determined to be 0.83. Conclusions and Clinical Relevance The results of this study suggest that a positive instability exam on all three tests is highly specific and predictive of traumatic anterior glenohumeral instability.

Medial opening wedge high tibial osteotomy: A prospective cohort study of gait, radiographic, and patient-reported outcomes

OBJECTIVE To evaluate the effect of medial opening wedge high tibial osteotomy on gait, radiographic, and patient-reported outcomes over a 2-year postoperative period in patients with varus alignment and medial compartment knee osteoarthritis, and to identify significant predictors of outcome. METHODS We used an observational cohort study design and prospectively administered 3-dimensional quantitative gait analysis, hip to ankle weight-bearing radiographs, and patient-reported outcomes preoperatively and 6, 12, 18, and 24 months postoperatively. Observed changes with 95% confidence intervals (95% CIs) were calculated. Multivariate linear regression and cluster analysis were used to evaluate associations between patient characteristics and 2-year outcomes in dynamic knee joint load (external knee adduction moment during gait) and Knee Injury and Osteoarthritis Outcome Scores (KOOS). RESULTS A total of 126 patients (mean age 47.48 years) were included in the study. Mean changes suggested clinically important improvements in malalignment (change in mechanical axis angle 8.04 degrees [95% CI 7.16 degrees , 8.93 degrees ]), medial compartment load during gait (change in knee adduction moment -1.38 [95% CI -1.53, -1.22] percentage body weight x height), and all KOOS domain scores (change in pain 23.19 [95% CI 19.49, 26.89] KOOS points). A small (13%) increase in knee adduction moment was observed from 6 to 24 months postoperatively. Few preoperative clinical and/or gait characteristics assessed at baseline were significantly associated with 2-year outcomes. CONCLUSION A medial opening wedge high tibial osteotomy with correction to approximately neutral alignment produces substantial and clinically important changes in dynamic knee joint load and patient-reported measures of pain, function, and quality of life 2 years postoperatively. Changes in knee adduction moment observed in the first 2 years postoperatively should be explored as potential predictors of longer-term success and subgroups of patients with poor outcomes.

Isokinetic Evaluation of Internal/External Tibial Rotation Strength After the Use of Hamstring Tendons for Anterior Cruciate Ligament Reconstruction

Background Evaluation of the knee after an anterior cruciate ligament reconstruction with the use of the semitendinosus and gracilis (hamstring) autografts has primarily focused on flexion and extension strength. The semitendinosus and gracilis muscles contribute to internal tibial rotation, and it has been suggested that harvest of these tendons for the purpose of an anterior cruciate ligament reconstruction contributes to internal tibial rotation weakness. Hypothesis Internal tibial rotation strength may be affected by the semitendinosus and gracilis harvest after anterior cruciate ligament reconstruction. Study Design Prospective evaluation of internal and external tibial rotation strength. Methods Inclusion criteria for subjects (N = 30): unilateral anterior cruciate ligament reconstruction at least 2 years previously, a stable anterior cruciate ligament (<5-mm side-to-side difference) at time of testing confirmed by surgeon and KT-1000 arthrometer, no history of knee problems after initial knee reconstruction, a normal contralateral knee, and the ability to comply with the testing protocol. In an attempt to minimize unwanted subtalar joint motion, subjects were immobilized using an ankle brace and tested at angular velocities of 60°/s, 120°/s, and 180°/s at a knee flexion angle of 90°. Results The mean peak torque measurements for internal rotation strength of the operative limb (60°/s, 17.4 ± 4.5 ft-lb; 120°/s, 13.9 ± 3.3 ft-lb; 180°/s, 11.6 ± 3.0 ft-lb) were statistically different compared to the nonoperated limb (60°/s, 20.5 ± 4.7 ft-lb; 120°/s, 15.9 ± 3.8 ft-lb; 180°/s, 13.4 ± 3.8 ft-lb) at 60°/s (P = .012), 120°/s (P = .036), and 180°/s (P = .045). The nonoperative limb demonstrated greater strength at all speeds. The mean torque measurements for external rotation were statistically similar when compared to the nonoperated limb at all angular velocities. Conclusions We have shown through our study that patients who undergo surgical intervention to repair a torn anterior cruciate ligament with the use of autogenous hamstring tendons demonstrate with weaker internal tibial rotation postoperatively at 2 years when compared to the contralateral limb.

A Randomized Controlled Trial Comparing the Effectiveness of Functional Knee Brace and Neoprene Sleeve Use After Anterior Cruciate Ligament Reconstruction

Background Despite a lack of evidence for their effectiveness, functional knee braces are commonly prescribed to patients after anterior cruciate ligament (ACL) reconstruction. Purpose This trial was conducted to compare postoperative outcomes in patients using an ACL functional knee brace and patients using a neoprene knee sleeve. Hypothesis Patients using a brace will have superior outcomes than those using a sleeve. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods One hundred fifty patients were randomized to receive a brace (n = 76) or neoprene sleeve (n = 74) at their 6-week postoperative visit after primary ACL reconstruction with hamstring autograft. Patients were assessed preoperatively, then 6 weeks and 6, 12, and 24 months postoperatively. Outcome measures included disease-specific quality of life (Anterior Cruciate Ligament–Quality of Life [ACL-QOL] Questionnaire), anterior tibial translation (KT-1000 arthrometer side-to-side difference), the single-limb forward hop test (limb symmetry index), and Tegner Activity Scale. Outcomes at 1 and 2 years were compared after adjusting for baseline scores. Subjective ratings of how patients felt while using the brace/sleeve were also collected for descriptive purposes using a questionnaire. Four a priori directional subgroup hypotheses were evaluated using tests for interactions. Results There were no significant differences between brace (n = 62) and sleeve (n = 65) groups for any of the outcomes at 1- and 2-year follow-ups. Adjusted mean differences at 2 years were as follows: −0.94 (95% confidence interval [CI], −7.52 to 5.64) for the ACL-QOL Questionnaire, −0.10 mm (95% CI, −0.99 to 0.81) for KT-1000 arthrometer side-to-side difference, −0.87% (95% CI, −8.89 to 7.12) for hop limb symmetry index, and −0.05 (95% CI, −0.72 to 0.62) for the Tegner Activity Scale. Subjective ratings of confidence in the knee provided by the brace/sleeve were higher for the brace group than the sleeve group. Subgroup findings were minimal. Adverse events were few and similar between groups. Conclusions A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction.