[Show abstract][Hide abstract] ABSTRACT: Management of Anterior Cruciate Ligament Injuries: Evidence-Based Guideline is based on a systematic review of the current scientific and clinical research. This guideline has been endorsed by the National Academy of Sports Medicine, the American Orthopaedic Society for Sports Medicine, the National Athletic Trainers' Association, and the American Academy of Physical Medicine and Rehabilitation. The guideline contains 20 recommendations, including both diagnosis and treatment. In addition, the work group highlighted the need for better research in the treatment of anterior cruciate ligament injuries.
Copyright 2015 by the American Academy of Orthopaedic Surgeons.
The Journal of the American Academy of Orthopaedic Surgeons 03/2015; 23(5). DOI:10.5435/JAAOS-D-15-00094 · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
The American Journal of Sports Medicine 10/2014; 42(10):2301-2310. DOI:10.1177/0363546514549005 · 4.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several aetiological theories have been proposed for the development of osteochondritis dissecans. Cartilage toxicity after fluoroquinolone use has been well documented in vitro. We present a case report of a 10-year-old child who underwent a prolonged 18-month course of ciprofloxacin therapy for chronic urinary tract infections. This patient later developed an osteochondritis dissecans lesion of the medial femoral condyle. We hypothesise that the fluoroquinolone therapy disrupted normal endochondral ossification, resulting in development of osteochondritis dissecans. The aetiology of osteochondritis dissecans is still unclear, and this case describes an association between fluoroquinolone use and osteochondritis dissecans development.
Case Reports 09/2014; 2014(sep16 1). DOI:10.1136/bcr-2014-204544
[Show abstract][Hide abstract] ABSTRACT: Objectives: Approximately 30-50% of skeletally immature patients with stable osteochondritis dissecans (OCD) lesions of the knee fail to heal with non-operative treatment, and about 30% of patients who undergo surgery fail to heal radiographically. Unfortunately it is nearly impossible to predict which patients will heal with non-surgical or surgical treatment. We identified multiple OCD features on standard radiographs that may help to predict healing rates. In this study, we test the inter- and intra- rater reliability of orthopaedic surgeons from multiple institutions on classifying these specific OCD radiographic features.
[Show abstract][Hide abstract] ABSTRACT: 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.
The Journal of Bone and Joint Surgery 07/2014; 96(14):1145-1151. DOI:10.2106/JBJS.M.00929 · 4.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypothesis
The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength.
We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12 months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms.
A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures.
There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 07/2014; 23(7). DOI:10.1016/j.jse.2013.10.001 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Research has associated adhesive capsulitis with diabetes mellitus but suggests that glucose-mediated injury may begin before diabetes is diagnosed. The period preceding diabetes is often marked by metabolic syndrome.
We investigated the relationship between metabolic syndrome components (insulin resistance, hypertension, dyslipidemia, and obesity) and the development of adhesive capsulitis using a case-control study. We retrospectively reviewed 150 consecutive adhesive capsulitis patient charts to determine the prevalence of obesity and of medications used for treating metabolic syndrome elements and compared these with previously reported nationwide values.
The prevalence of anti-hyperglycemia medications in the adhesive capsulitis cohort was 18.4% (95% confidence interval [CI], 12.9%-25.7%), twice the national rate of diagnosed diabetes of 7.6% (95% CI, 6.7%-8.5%). In the 20- to 39-year-old group, the prevalence of anti-hyperglycemic medications, 26.3% (95% CI, 11.8%-48.8%), was over 10 times the nationwide rate. The overall prevalence of hypertensive medication use in the adhesive capsulitis group, 33.1% (95% CI, 25.9%-41.2%), was notably higher than the nationwide rate, 21.6% (95% CI, 19.8%-23.4%). In the 40- to 64-year-old group, the prevalence of hypertensive medication use, 36.8% (95% CI, 28.6%-46.0%), was notably higher than the nationwide rate of 24.5% (95% CI, 22.2%-27.0%). The prevalence of anti-lipid medications and obesity was similar between the groups.
The relationship between adhesive capsulitis and metabolic syndrome remains unclear. Our results confirm previous work associating hyperglycemia with adhesive capsulitis. We have also shown a possible association of hypertension, part of metabolic syndrome and a proinflammatory condition, with adhesive capsulitis, which has not been previously described.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 07/2014; DOI:10.1016/j.jse.2013.11.004 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For many orthopaedic disorders, symptoms correlate with disease severity. The objective of this study was to determine if pain level is related to the severity of rotator cuff disorders.
The Journal of Bone and Joint Surgery 05/2014; 96(10):793-800. DOI:10.2106/JBJS.L.01304 · 4.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A recent randomized trial from the Finnish Degenerative Meniscal Lesion Study Group was published in the New England Journal of Medicine and attempted to determine the efficacy of partial meniscectomy without osteoarthritis. Patients were randomized to either arthroscopic partial meniscectomy or sham surgery. The authors concluded that the clinical outcomes after arthroscopic partial meniscectomy were no better than those after the sham surgical procedure. However, there are several important limitations of this trial that make it difficult to generalize to the 700,000 arthroscopic partial meniscectomies performed in the United States each year. In this small sample of 146 patients, patients with traumatic meniscal tears and locking symptoms—those most likely to benefit from a partial meniscectomy—were excluded. In addition, although patients with radiographic arthritis were excluded, most of the patients in the study had degenerative changes at the time of arthroscopy. Therefore it is difficult to determine whether the patients were symptomatic from their chondral degeneration or their degenerative meniscal tear. In our opinion this study does not change the role of surgery in current clinical practice. The primary indication for arthroscopic partial meniscectomy remains symptoms of well-localized joint line pain with acute onset and mechanical symptoms such as catching or locking that have failed comprehensive nonoperative management.
Arthroscopy The Journal of Arthroscopic and Related Surgery 05/2014; 30(5). DOI:10.1016/j.arthro.2014.02.012 · 3.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Multiple systems for classifying osteochondritis dissecans (OCD) of the knee have been reported. These existing classification systems have some similar characteristics, such as stable lesion/intact articular cartilage and presence of a loose body. However, variations are found in the number of stages and specific lesion characteristics assessed. Currently, no system has been universally accepted. A future classification system should be developed that reconciles the discrepancies among the current systems and provides a clear, consistent, and reliable method for classifying OCD lesions of the knee during arthroscopy.
Clinics in sports medicine 04/2014; 33(2):189-197. DOI:10.1016/j.csm.2013.11.005 · 2.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The authors' preferred treatment algorithm for osteochondritis dissecans (OCD) of the knee is based on skeletal maturity, OCD lesion stability, and OCD lesion salvageability. For unstable yet salvageable OCD lesions, the senior author's preferred treatment is fixation with bone grafting. For unstable and unsalvageable OCD lesions, the senior author's preferred treatment is autologous chondrocyte implantation with bone grafting.
Clinics in sports medicine 04/2014; 33(2):375-382. DOI:10.1016/j.csm.2014.01.002 · 2.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design. MATERIALS AND METHODS: Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores. RESULTS: The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. CONCLUSION: Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 03/2013; 22(10). DOI:10.1016/j.jse.2013.01.026 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Arthroscopic partial meniscectomy can be complicated by excessive resection, damage to articular cartilage, neurovascular injury, persistent drainage from portals, and infection; the procedure can be rendered more difficult, and the outcome less certain, if the surgeon fails to recognize concomitant injuries, malpositions the portals, or misidentifies the components of a meniscus tear. We review the problems that can occur as a result of errors made before, during, and after surgery.
Clinical Orthopaedics and Related Research 12/2012; 471(5). DOI:10.1007/s11999-012-2735-3 · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Although many etiological theories have been proposed for osteochondritis dissecans (OCD), its etiology remains unclear. Histological analysis of the articular cartilage and subchondral bone tissues of OCD lesions can provide useful information about the cellular changes and progression of OCD. Previous research is predominantly comprised of retrospective clinical studies from which limited conclusions can be drawn. QUESTIONS/PURPOSES: The purposes of this study were threefold: (1) Is osteonecrosis a consistent finding in OCD biopsy specimens? (2) Is normal articular cartilage a consistent finding in OCD biopsy specimens? (3) Do histological studies propose an etiology for OCD based on the tissue findings? METHODS: We searched the PubMed, Embase, and CINAHL databases for studies that conducted histological analyses of OCD lesions of the knee and identified 1560 articles. Of these, 11 met our inclusion criteria: a study of OCD lesions about the knee, published in the English language, and performed a histological analysis of subchondral bone and articular cartilage. These 11 studies were assessed for an etiology proposed in the study based on the study findings. RESULTS: Seven of 11 studies reported subchondral bone necrosis. Four studies reported normal articular cartilage, two studies reported degenerated or irregular articular cartilage, and five studies found a combination of normal and degenerated or irregular articular cartilage. Five studies proposed trauma or repetitive stress and two studies proposed poor blood supply as possible etiologies. CONCLUSIONS: We found limited research on histological analysis of OCD lesions of the knee. Future studies with consistent methodology are necessary to draw major conclusions about the histology and progression of OCD lesions. Inconsistent histologic findings have resulted in a lack of consensus regarding the presence of osteonecrosis, whether the necrosis is primary or secondary, the association of cartilage degeneration, and the etiology of OCD. Such studies could use a standardized grading system to allow better comparison of findings.
Clinical Orthopaedics and Related Research 09/2012; 471(4). DOI:10.1007/s11999-012-2619-6 · 2.88 Impact Factor