Timothy N. Taft

Dislocation of the acromioclavicular joint. An end-result study.

The cases of 127 patients who had an acute dislocation of the acromioclavicular joint were studied. Fifty-two patients, with an average follow-up of 10.8 years, were managed operatively, and seventy-five patients, with an average follow-up of 9.5 years, were managed non-operatively. Using a rating system that included subjective, objective, and roentgenographic criteria, it did not appear that reduction of the acromioclavicular joint was necessary to obtain consistently good results. Operative management, using either coracoclavicular or acromioclavicular fixation, was associated with a higher rate of complications than non-operative treatment. The use of a sling for four weeks without reduction of the joint, followed by a graduated exercise program, led to acceptable clinical results. In patients who had persistent pain and stiffness of the acromioclavicular joint, or in whom symptomatic post-traumatic arthritis developed, resection of the distal part of the clavicle reliably produced significant improvement.

Intramedullary Screw Fixation of Jones Fractures Analysis of Failure

Treatment failures after screw fixation of Jones fractures are reported to be infrequent. Between 1993 and 1999, 15 patients (mean age, 21.7 years) underwent cannulated screw fixation of a Jones fracture at our institution. There were six treatment failures: four re-fractures and two symptomatic nonunions. The mean time to full activity was 6.8 weeks for the patients with failure compared with 9 weeks for patients who did not have complications. Although all patients were asymptomatic and radiographically progressing to union before return to full activity, only one of six patients with failures had complete radiographic union, compared with six of seven patients with no complications. There was a higher proportion of elite athletes (division I or professional level) among the failure group (83%) compared with those without complications (11%). There were no significant differences in age, sex, screw diameter, use of bone graft, or age of fracture between patients with failures and those without complications. Return to full activity, especially among elite athletes, before complete radiographic union was predictive of failure. Even though intramedullary screw fixation offers advantages over nonoperative treatment, a significant risk of postoperative complications exists.

Postarthroscopy analgesia with bupivacaine A prospective, randomized, blinded evaluation

The analgesic effect of intraarticular bupivacaine in jected at the conclusion of knee arthroscopy done under general anesthesia was investigated in a pro spective, randomized, and blinded fashion. Pain scores, the use of analgesic medications, crutch use, weight bearing, activity level, and difficulty sleeping the night after surgery were all unaffected by the use of bupiva caine. The apparent lack of effect is most likely due to rapid clearance from the knee, leaving only a transient, 1 to 2 hours of potential benefit. In this study, the patients were already quite comfortable during this time period due to the routine use of intraoperative narcotics. The preoperative level of knee discomfort was found to be a major determinant of postoperative discomfort. Other much less important factors were synovial and chondral shaving, sex of the patient, and experience of the surgeon.

The effect of a nonsteroidal antiinflammatory drug on the healing of ligaments

Because of the increasing number of ligament sprains being treated with nonsteroidal antiinflammatory drugs (NSAIDs), this study was undertaken to document the effects of one such drug on ligament healing in an experimental setting. Male Sprague-Dawley rats weigh ing between 400 and 500 g were used to evaluate the effect of the NSAID piroxicam on the healing of an experimental injury to the medial collateral ligament (MCL). The following factors were varied in the experi ments: dosage, days of treatment, and the day postin jury when treatment was begun. Piroxicam-treated rats were compared to placebo-treated rats in terms of the drugs effect on the mechanical strength of the healing ligament. The ligaments were mechanically tested in tension to failure at a constant deformation rate of 0.25 mm/sec on a materials testing machine. Administration of piroxicam on Days 1 to 6 postinjury resulted in a 42% increase in strength at Day 14 postinjury for the piroxicam-treated ligaments (P < 0.01) when compared with the placebo-treated controls. Neither doubling nor halving the standard piroxicam dose significantly al tered this increased healing strength. Biochemical analysis of collagen synthesis demonstrated a sugges tive, although not statistically significant, increase in collagen synthesis and collagen content in the piroxi cam-treated healing ligament. In separate experiments, piroxicam had no effect on the healed ligament at 21 days or on the strength of uninjured ligaments. In conclusion, piroxicam increased the early strength of healing ligaments in the rat when the drug was admin istered for short periods of time after injury. It did not affect the final strength when healing was complete, nor did it alter the strength of uninjured ligaments.

Effect of Graft Choice on the Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Post-operative problems following anterior cruciate ligament reconstruction

Seventy adult patients were studied during the postoperative rehabilitation period following anterior cruciate ligament reconstruction in order to investigate the role of pre-, intra-, and postoperative factors in range of motion and graft problems. A standard bone-patellar tendon-bone autograft was used for the reconstruction. Pre-and intraoperative factors such as concomitant injuries, time from injury to surgery, age, sex, and tunnel placement were recorded. Tunnel placement was recorded on intraoperative radiographs of the final guide pin placement and compared to pin placement on cadaver knees. The results indicated a significant relation between early reconstruction (<1 month) following the injury and range of motion problems during the early rehabilitation period (P<0.001). This relation disappeared by the end of the first postoperative year. Prolonged surgery was also associated with early motion problems (P<0.05). Graft laxity or failure was correlated with an earlier return of range of motion (P<0.05). We hypothesized that graft failure can have a biologic cause rather than a mechanical one since intraoperative X-rays indicated a near-anatomic tunnel placement in this patient group when compared to ideal placement in the cadaver knees.

Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete Analysis of an NCAA Division I Cohort

Background: Graft survivorship, reinjury rates, and career length are poorly understood after anterior cruciate ligament (ACL) reconstruction in the elite collegiate athlete. The purpose of this study was to examine the outcomes of ACL reconstruction in a National Collegiate Athletic Association (NCAA) Division I athlete cohort. Study Design: Case series; Level of evidence, 4. Methods: A retrospective chart review was performed of all Division I athletes at a single public university from 2000 to 2009 until completion of eligibility. Athletes were separated into 2 cohorts: those who underwent precollegiate ACL reconstruction (PC group) and those who underwent intracollegiate reconstruction (IC group). Graft survivorship, reoperation rates, and career length information were collected. Results: Thirty-five athletes were identified with precollegiate reconstruction and 54 with intracollegiate reconstruction. The PC group had a 17.1% injury rate with the original graft, with a 20.0% rate of a contralateral ACL injury. For the IC group, the reinjury rates were 1.9% with an ACL graft, with an 11.1% rate of a contralateral ACL injury after intracollegiate ACL reconstruction. The athletes in the PC group used 78% of their total eligibility (average, 3.11 years). The athletes in the IC group used an average of 77% of their remaining NCAA eligibility; 88.3% of those in the IC group played an additional non-redshirt year after their injury. The reoperation rate for the PC group was 51.4% and was 20.4% for the IC group. Conclusion: Reoperation and reinjury rates are high after ACL reconstruction in the Division I athlete. Precollegiate ACL reconstruction is associated with a very high (37.1%) rate of repeat ACL reinjuries to the graft or opposite knee. The majority of athletes are able to return to play after successful reconstruction.

Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation

BACKGROUND Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. METHODS As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45° of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. RESULTS Overall, 45° posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass correlation coefficient = 0.55; 95% confidence interval, 0.53 to 0.56). Similarly, the 45° posteroanterior flexion weight-bearing radiographs had higher correlation with arthroscopic findings of chondral disease (Spearman rho = 0.36; 95% confidence interval, 0.32 to 0.39) compared with anteroposterior radiographs (Spearman rho = 0.29; 95% confidence interval, 0.26 to 0.32). With respect to standards for the magnitude of the reliability coefficient and correlation coefficient (Spearman rho), the International Knee Documentation Committee classification demonstrated the best combination of good interobserver reliability and medium correlation with arthroscopic findings. CONCLUSIONS The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. The International Knee Documentation Committee classification assessed with use of 45° posteroanterior flexion weight-bearing radiographs had the most favorable combination of reliability and correlation. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Multirater Agreement of the Causes of Anterior Cruciate Ligament Reconstruction Failure A Radiographic and Video Analysis of the MARS Cohort

Background: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement. Hypothesis: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient’s history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon’s training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon’s opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK). Results: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17). Conclusion: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.

Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Purpose/Hypothesis: The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. Conclusion: Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. Registration: NCT00625885