William M. Wind

Current trends in anterior cruciate ligament reconstruction.

In 2006, a survey regarding anterior cruciate ligament (ACL) reconstruction was mailed to physician members of the American Orthopaedic Society for Sports Medicine. A total of 993 responses were received from 1747 possible respondents (57%). The number of ACL reconstructions per year ranged from 1 to 275 (mean=55). The most important factors in the timing of surgery were knee range of motion and effusion. Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively). A single-incision arthroscopic technique was used by 90%. Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision. There was limited experience (4%) with double-bundle and computer-assisted ACL reconstruction. Arthroscopic-assisted, single-incision reconstruction using a BPTB autograft fixed with metal interference screws remains the most common technique used for primary ACL reconstruction. In the past 5 years, the use of alternative graft sources and methods of fixation has increased. Consensus regarding the best graft type, fixation method, and postoperative protocol is still lacking.

Evaluation and Treatment of Posterior Cruciate Ligament Injuries Revisited

Current knowledge and treatment of posterior cruciate ligament injuries continue to lag behind that of anterior cruciate ligament injuries. This is the result of the relative infrequency of posterior cruciate ligament injuries and the lack of consensus with respect to its natural history, surgical indications, technique, and postoperative rehabilitation. Recent anatomical and biomechanical studies have improved our understanding of the posterior cruciate ligament in an attempt to reproduce its anatomy and function during reconstruction. The following is a comprehensive review on the evaluation and treatment of posterior cruciate ligament injuries with special focus on the current surgical techniques.

Predicting ulnar nerve location in pinning of supracondylar humerus fractures

Thirty-four consecutive patients with displaced supracondylar humerus fractures were treated with reduction and percutaneous pinning. The precise location of the ulnar nerve to the medial pin was determined by intraoperative nerve stimulation. In 22 of the 34 patients, the authors attempted to predict the location of the ulnar nerve by palpation and placing a mark on the skin. They also recorded the ability to feel the anatomic landmarks for pin fixation, including the medial epicondyle and ulnar nerve. The average distance from the medial pin to the predicted location was 9.3 mm, whereas the actual distance measured 7.6 mm, for a significant difference of 1.7 mm. Statistically, the authors could not accurately predict the location of the ulnar nerve prior to blind percutaneous crossed K-wire fixation of supracondylar humerus fractures. However, clinically they were fairly close in their prediction and documented safe insertion and distance from the nerve. Intraoperative nerve stimulation may assist in localizing the nerve prior to placement of the medial pin. Stimulation of the pin itself following insertion is another technique to ensure safe pin placement and decrease the risk of injury.

Sports for the Physically Challenged Child

Abstract Participation in sports is important for the physical and emotional health of the physically challenged child. Sports can improve strength, endurance, and cardiopulmonary fitness while providing companionship, a sense of achievement, and heightened self‐esteem. With interest in such participation increasing, it is necessary for the physicians, therapists, and families of children with special needs to understand the preparticipation evaluation, athletic options, specialized equipment, and sportspecific risks. Recommendations that provide guidelines for safe, effective participation in sports are currently available for common congenital and developmental disabilities such as Down syndrome, cerebral palsy, myelodysplasia, hemophilia, congenital amputations, and arthritic disorders.

Infection following knee arthroscopy

Arthroscopy of the knee is not a risk-free procedure. Although rare, numerous complications have been reported in the literature. Fortunately, infection is a rare complication following arthroscopy, which, when treated, usually results in a benign outcome. We present the first reported case of Candida albicans infection following routine arthroscopy of the knee, which eventually resulted in a knee fusion. A review of infections that can occur after knee arthroscopy and their treatment is also presented. This and other potential complications should be considered when performing knee arthroscopy.

Accuracy of a Computer-Based Diagnostic Program for Ambulatory Patients With Knee Pain

Background: Looking up information regarding a medical condition is the third most popular activity online, and there are a variety of web-based symptom-checking programs available to the patient. However, the authors are not aware of any that have been scientifically evaluated as an accurate measure for the cause of one’s knee pain. Purpose/Hypothesis: The purpose of this study was to design and evaluate an Internet-based program that generates a differential diagnosis based on a history of knee pain entered by the patient. The hypothesis was that the program would accurately generate a differential diagnosis for patients presenting with knee pain. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A web-based program was created to collect knee pain history and generate a differential diagnosis for ambulatory patients with knee pain. The program selected from 26 common knee diagnoses. A total of 527 consecutive patients aged ≥18 years, who presented with a knee complaint to 7 different board-certified orthopaedic surgeons during a 3-month period, were asked to complete the questionnaire in the program. Upon completion, patients were examined by a board-certified orthopaedic surgeon. Both the patient and physician were blinded to the differential diagnosis generated by the program. A third party was responsible for comparing the diagnosis(es) generated by the program with that determined by the physician. The level of matching between diagnoses determined the accuracy of the program. Results: A total of 272 male and 255 female patients, with an average age of 47 years (range, 18-84 years), participated in the study. The median number of diagnoses generated by the program was 4.8 (range, 1-10), with this list containing the physician’s diagnosis(es) 89% of the time. The specificity was 27%. Conclusion: Despite a low specificity, the results of this study show the program to be an accurate method for generating a differential diagnosis for knee pain.

Patient Outcomes After Observation Versus Debridement of Unstable Chondral Lesions During Partial Meniscectomy: The Chondral Lesions And Meniscus Procedures (champ) Randomized Controlled Trial

Background: It is unknown whether unstable chondral lesions observed during arthroscopic partial meniscectomy (APM) require treatment. We examined differences at 1 year with respect to knee pain and other outcomes between patients who had debridement (CL-Deb) and those who had observation (CL-noDeb) of unstable chondral lesions encountered during APM. Methods: Patients who were ≥30 years old and undergoing APM were randomized to receive debridement (CL-Deb group; n = 98) or observation (CL-noDeb; n = 92) of unstable Outerbridge grade-II, III, or IV chondral lesions. Outcomes were evaluated preoperatively and at 8 to 12 days, 6 weeks, 3 months, 6 months, and 1 year postoperatively. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) pain score, Short Form-36 (SF-36) health survey, range of motion, quadriceps circumference, and effusion. The primary outcome was the WOMAC pain score at 1 year. T tests were used to examine group differences in outcomes, and the means and standard deviations are reported. Results: There were no significant differences between the groups with respect to any of the 1-year outcome scores. Compared with the CL-Deb group, the CL-noDeb group had improvement in the KOOS quality-of-life (p = 0.04) and SF-36 physical functioning scores (p = 0.01) as well as increased quadriceps circumference at 8 to 12 days (p = 0.02); had improvement in the pain score on the WOMAC (p = 0.02) and KOOS (p = 0.04) at 6 weeks; had improvement in SF-36 physical functioning scores at 3 months (p = 0.01); and had increased quadriceps circumference at 6 months (p = 0.02). Conclusions: Outcomes for the CL-Deb and CL-noDeb groups did not differ at 1 year postoperatively. This suggests that there is no benefit to arthroscopic debridement of unstable chondral lesions encountered during APM, and it is recommended that these lesions be left in situ. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

How Accurate Are Patients at Diagnosing the Cause of Their Knee Pain With the Help of a Web-based Symptom Checker?

Background: Researching medical information is the third most popular activity online, and there are a variety of web-based symptom checker programs available. Purpose: This study evaluated a patient’s ability to self-diagnose their knee pain from a list of possible diagnoses supplied by an accurate symptom checker. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: All patients older than 18 years who presented to the office of 7 different fellowship-trained sports medicine surgeons over an 8-month period with a complaint of knee pain were asked to participate. A web-based symptom checker for knee pain was used; the program has a reported accuracy of 89%. The symptom checker generates a list of potential diagnoses after patients enter symptoms and links each diagnosis to informative content. After exploring the informative content, patients selected all diagnoses they felt could explain their symptoms. Each patient was later examined by a physician who was blinded to the differential generated by the program as well as the patient-selected diagnoses. A blinded third party compared the diagnoses generated by the program with those selected by the patient as well as the diagnoses determined by the physician. The level of matching between the patient-selected diagnoses and the physician’s diagnoses determined the patient’s ability to correctly diagnose their knee pain. Results: There were 163 male and 165 female patients, with a mean age of 48 years (range, 18-76 years). The program generated a mean 6.6 diagnoses (range, 2-15) per patient. Each patient had a mean 1.7 physician diagnoses (range, 1-4). Patients selected a mean 2 diagnoses (range, 1-9). The patient-selected diagnosis matched the physician’s diagnosis 58% of the time. Conclusion: With the aid of an accurate symptom checker, patients were able to correctly identify the cause of their knee pain 58% of the time.

Evaluation and Treatment of Isolated and Combined PCL Injuries

There has been a renewed interest in the management of PCL injuries in an attempt to duplicate the success of ACL surgery. Physical examination is the keystone to diagnosis and management of PCL injuries.In this chapter we review the physical examination of PCL injury and differentiate between isolated and combined injury patterns. The tibial inlay technique of PCL reconstruction is outlined in detail as well as the clinical resultsof PCL reconstruction using the inlay technique.

How Does the Presence of Unstable Chondral Lesions Affect Patient Outcomes After Partial Meniscectomy? The ChAMP Randomized Controlled Trial:

Background: Chondral lesions are commonly encountered during arthroscopic partial meniscectomy (APM); however, it is unknown how these lesions affect postoperative outcomes. Purpose: The authors compared postoperative outcomes among patients with and without unstable chondral lesions 1 year after APM. Study Design: Cohort study; Level of evidence, 3. Methods: The authors conducted a secondary analysis of data from the ChAMP (Chondral Lesions and Meniscus Procedures) randomized controlled trial. They compared the following outcomes for patients with unstable chondral lesions that were left in situ and observed (CL-noDeb) versus patients without unstable chondral lesions (NoCL) at 1 year after APM: Western Ontario and McMaster Universities Osteoarthritis Index, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain, the Short Form Health Survey, range of motion, quadriceps circumference, and effusion. Multivariate linear regression was used to obtain mean differences (MDs) with corresponding 95% CIs adjusted for age, body mass index, and preoperative score (for postoperative scores). Results: Compared with the CL-noDeb group, the NoCL group had greater improvement in Western Ontario and McMaster Universities Osteoarthritis Index for pain (MD, 7.9, 95% CI: 2.7-13.1), stiffness (MD, 9.1, 95% CI: 1.9-16.3), and physical function (MD, 4.6, 95% CI: 0.1-9.0) and Knee injury and Osteoarthritis Outcome Score for pain (MD, 8.4, 95% CI: 2.7-14.0), function in sport and recreation (MD, 11, 95% CI: 3.0-19.1), and quality of life (MD, 10.4, 95% CI: 2.3-18.5). The NoCL group was less likely than the CL-noDeb group to have an effusion (P = .02) 1 year after surgery. Conclusion: Patients undergoing APM without unstable chondral lesions had better outcomes than patients with unstable chondral lesions.