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.
Background:
The long-term prognosis and risk factors for quality of life and disability after anterior cruciate ligament (ACL) reconstruction remain unknown.
Hypothesis/Purpose:
Our objective was to ...identify patient-reported outcomes and patient-specific risk factors from a large prospective cohort at a minimum 10-year follow-up after ACL reconstruction. We hypothesized that meniscus and articular cartilage injuries, revision ACL reconstruction, subsequent knee surgery, and certain demographic characteristics would be significant risk factors for inferior outcomes at 10 years.
Study Design:
Therapeutic study; Level of evidence, 2.
Methods:
Unilateral ACL reconstruction procedures were identified and prospectively enrolled between 2002 and 2004 from 7 sites in the Multicenter Orthopaedic Outcomes Network (MOON). Patients preoperatively completed a series of validated outcome instruments, including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale. At the time of surgery, physicians documented all intra-articular abnormalities, treatment, and surgical techniques utilized. Patients were followed at 2, 6, and 10 years postoperatively and asked to complete the same outcome instruments that they completed at baseline. The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of the outcome.
Results:
A total of 1592 patients were enrolled (57% male; median age, 24 years). Ten-year follow-up was obtained on 83% (n = 1320) of the cohort. Both IKDC and KOOS scores significantly improved at 2 years and were maintained at 6 and 10 years. Conversely, Marx scores dropped markedly over time, from a median score of 12 points at baseline to 9 points at 2 years, 7 points at 6 years, and 6 points at 10 years. The patient-specific risk factors for inferior 10-year outcomes were lower baseline scores; higher body mass index; being a smoker at baseline; having a medial or lateral meniscus procedure performed before index ACL reconstruction; undergoing revision ACL reconstruction; undergoing lateral meniscectomy; grade 3 to 4 articular cartilage lesions in the medial, lateral, or patellofemoral compartments; and undergoing any subsequent ipsilateral knee surgery after index ACL reconstruction.
Conclusion:
Patients were able to perform sports-related functions and maintain a relatively high knee-related quality of life 10 years after ACL reconstruction, although activity levels significantly declined over time. Multivariable analysis identified several key modifiable risk factors that significantly influence the outcome.
Background:
Graft selection for anterior cruciate ligament (ACL) reconstructive surgery is a controversial topic. Few studies have compared graft outcomes in adolescents.
Purpose:
To identify factors ...related to ACL graft failure in an adolescent cohort.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
After institutional review board approval was obtained, adolescent subjects (age range, 11-18 years) who underwent primary ACL reconstruction surgery at a large tertiary pediatric hospital between July 2005 and July 2009 were identified through a query of International Classification of Diseases, 9th Revision, diagnostic and Current Procedural Terminology codes. Subject data were obtained by means of a retrospective chart review, phone survey, and the administration of functional knee outcome instruments. A multivariate Cox proportional hazards regression analysis was used to analyze factors related to graft survival.
Results:
The average ages at surgery in the allograft (n = 38) and autograft (n = 35) groups were 15.29 ± 2.24 and 15.60 ± 1.57 years, respectively. There were 11 graft failures (28.95%) in the allograft group compared with 4 graft failures (11.43%) in the autograft group. In the multivariate model, graft type (P = .0352) and postoperative knee laxity according to the Lachman test (P = .0217) were the only variables significantly related to graft survival. The hazard of graft failure was 4.4 (95% CI, 1.23-18.89) times greater in the allograft group compared with the autograft group. The hazard of graft failure was 5.28 times (95% CI, 1.1-12.72; P = .0217) greater for a subject who demonstrated increased postoperative knee laxity relative to the contralateral knee. The risk for autograft failure tended to remain constant 24 to 48 months after initial surgery, whereas the risk for allograft failure continued to increase during postoperative months 24 to 48. There were no differences (P > .05) between the allograft and autograft groups with respect to International Knee Documentation Committee score, Lysholm score, and the rate of return to previous activity level.
Conclusion:
Graft type and postoperative knee laxity were identified as significant predictors of graft survival. On the basis of this large retrospective cohort, we recommend the use of autogenous grafts in children and adolescents undergoing primary, transphyseal ACL reconstruction. Patients who demonstrate increased translation during a postoperative Lachman test should be carefully followed because of concerns for subsequent graft failure.
The Principles of Knee Joint Preservation Kraeutler, Matthew J.; McCulloch, Patrick C.; Vidal, Armando F.
Arthroscopy,
12/2023, Letnik:
39, Številka:
12
Journal Article
Recenzirano
The 3 primary factors involved with preservation of the knee joint include joint alignment, meniscal status, and ligament stability (in particular that of the anterior cruciate ligament ACL). These ...factors are interdependent and result in knee joint homeostasis when all factors are stable. When a deficiency exists in one of the factors, it will affect the others. For example, the ACL and posterior horn of the medial meniscus both act as restraints to anterior tibial translation. Thus, medial meniscal deficiency increases the risk for failure of ACL reconstruction, and chronic ACL insufficiency increases the risk for medial meniscus tears. Furthermore, all 3 of the factors of joint preservation have an impact on the articular cartilage status of the knee joint. Studies have shown that cartilage-preservation procedures do not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligament deficiency. When evaluating patients with knee cartilage pathology, surgeons should be aware of the various factors involved in knee joint preservation and, if surgery is indicated, all factors should be addressed in order to support a successful result.
Background:
The timing of treatment for pediatric anterior cruciate ligament (ACL) injuries remains controversial. The risks of delaying reconstruction and the differences between age groups are ...poorly defined.
Purpose:
To investigate factors that contribute to the prevalence and severity of concomitant chondral and meniscal injuries among patients aged 14 to 19 years versus those aged ≤14 years at the time of ACL reconstruction. The hypothesis was that concomitant injuries would be more prevalent in older versus younger subjects. Also, a delay in surgery would be predictive of the presence and severity of concomitant knee injuries requiring additional operative procedures.
Study Methods:
Cohort study; Level of evidence, 3.
Methods:
All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. The location, severity, and treatment of all concomitant knee injuries were recorded. Chi-square tests were used to compare the prevalence of chondral and meniscal injuries in the older (age, 14-19 years; n = 165) versus younger (age, ≤14 years; n = 66) cohorts. A multivariable logistic regression analysis was used to identify factors related to the presence of a concomitant injury that required additional treatment. Kaplan-Meier analyses were used to explore the relation between time to surgery and meniscal injury severity.
Results:
There was a significant relationship between time to surgery and the development of an irreparable meniscal injury (P < .05 for all) in both the younger and older groups. Time to surgery correlated with severity of chondral injury in the younger cohort (P = .0343) but not in the older cohort (P = .8877). In the younger cohort, only a delay in surgery >3 months (odds ratio OR = 4.8; 95% CI, 1.7-14.4; P = .0027) was significantly predictive of the presence of an injury that required additional operative procedures. In the older patients, a return to activity before surgery (OR = 3.8; 95% CI, 1.52-11.9; P = .0034) and obesity (OR = 2.5; 95% CI, 1.1-7.4; P = .0381) were significantly predictive of an injury that required additional operative procedures.
Conclusion:
Compared with younger subjects, the prevalence of concomitant knee injuries as well as the need for additional operative procedures was greater among older subjects. A delay to surgery correlated with increased severity of injury among both older and younger populations. A delay in surgery >3 months was the strongest predictor of the development of a concomitant injury in the younger cohort. A return to activity and obesity were significantly related to the presence of a concomitant knee injury in the older cohort.
Background:
The effect of coronal plane alignment on the outcomes of repairs of the medial meniscus root remains unclear.
Hypothesis:
Increased preoperative varus alignment is associated with higher ...failure rates and lower patient-reported outcomes (PROs) after isolated repair of the medial meniscus root.
Study Design:
Case series; Level of evidence, 4.
Methods:
Patients aged 18 years or older who underwent arthroscopy-assisted repair of the medial posterior meniscus root over a 7-year period were included. The mechanical axis of the knee was measured preoperatively. Osteoarthritis was assessed radiographically preoperatively and at the final follow-up according to the Kellgren-Lawrence grading scale. Failure was defined as any patient having to undergo revision root repair, partial meniscectomy of the previously repaired meniscus, debridement, lysis of adhesions, or conversion to arthroplasty.
Results:
A total of 53 patients (29 women, 24 men) with a mean age of 51.3 years were included in the follow-up analysis. The mean time of follow-up after surgery was 3.3 years (range, 22-77 months). Significant improvements were observed in all PROs analyzed. Decreased varus as measured by alignment percentage was correlated with baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain (P = .023) and WOMAC Stiffness (P = .022). Alignment percentage was also significantly negatively correlated with postoperative WOMAC Stiffness (P = .005) and positively correlated with Lysholm (P = .003) and International Knee Documentation Committee (P = .009) scores. Higher baseline Kellgren-Lawrence grade was correlated with worse postoperative PROs (P < .05), except 12-Item Short Form Health Survey Mental Component Summary and satisfaction. Eight patients who underwent a concomitant high tibial osteotomy (HTO) achieved lower PROs in all scales analyzed, regardless of their alignment. When excluding patients who underwent HTO, postoperative Lysholm score (P = .004) and postoperative WOMAC Stiffness (p = 0.014) were inferior among the patients with >5° of varus.
Conclusion:
Lower extremity alignment closest to neutral correlated with improved PROs. Patients who underwent a concurrent HTO had worse PROs than those who did not undergo HTO.
Focal cartilage defects in the knee are commonly found on MRI and arthroscopically. When these lesions are symptomatic and fail nonoperative management several surgical strategies are available. ...Common surgical techniques include reparative (ie, microfracture) and restorative procedures (ie, autologous chondrocyte implantation, particulated juvenile allograft cartilage, osteochondral autograft transfer, and osteochondral allograft). Each of these surgical procedures have shared and novel complications associated with their use. This article provides a detailed, case-based discussion of common complications encountered in surgical procedures for focal cartilage defects of the knee, highlighting causes, clinical recognition, and how to address and avoid these complications.
Background:
There is no consensus on technique of choice for repair of bucket-handle meniscal tears (BHMTs).
Purpose:
To determine factors that affect patient outcomes and failure rates in patients ...undergoing all-inside repairs of BHMTs.
Study Design:
Systematic review.
Methods:
A systematic review of 3 databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. All English-language literature from 1993 to 2019 describing clinical outcomes for patients undergoing all-inside BHMT repair with ≥12-month follow-up was reviewed by 2 independent reviewers. Patient characteristics (patient sex, age), intraoperative factors (laterality, concomitant procedures, surgical technique, implants utilized), and postoperative outcomes (failure rates) were analyzed. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS).
Results:
Fifteen studies (1 level 1, 4 level 3, 10 level 4) with 763 total patients (64% male; average age, 26.4 years range, 9-58 years; average follow-up, 39.8 months range, 12-120 months) including 396 all-inside BHMT repairs were included. Six devices were used for repair including the Meniscal Repair System, FasT-Fix, Meniscus Arrow, Biofix Arrow, RapidLoc device, and PDS II suture, with failure rates of 13.5%, 22.4%, 27.1%, 42.9%, 45.2%, and 0%, respectively. The overall repair failure rate was 29.3% at an average of 13.0 months (range, 5.0-32.4 months), but 19.0% for devices still in use. The RapidLoc and Biofix Arrow had higher failure rates than other devices (P = .0003). Women (31%) were less likely to experience a failure than were men (69%) (P = .03). Longer follow-up duration resulted in higher failure rates (>30 months, 34.4%; <30 months, 23.4%; P = .016). In 4 studies reporting on both all-inside and inside-out repairs, no significant differences in failure rates were observed. No significant differences in failure rates were found between medial and lateral repairs nor repair with and without concurrent anterior cruciate ligament reconstruction (P > .05 for all). The overall average MCMS was 54.4 ± 12.
Conclusion:
The overall failure rate after all-inside repair of BHMTs is 29.3% at an average of 13.0 months, with no difference in failure rates between medial and lateral meniscal repairs. The variables shown to negatively affect the failure rates were the RapidLoc and Biofix Arrow, male sex, and longer follow-up duration.
Background:
Knee laxity in the setting of anterior cruciate ligament (ACL) injury is often assessed through physical examination using the Lachman, pivot shift, and anterior drawer tests. The degree ...of laxity noted on these examinations may influence treatment decisions and prognosis.
Hypothesis:
Increased preoperative knee laxity is associated with increased risk of revision ACL reconstruction, increased risk of contralateral ACL reconstruction, and poorer patient-reported outcomes at 6 years postoperatively.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
2333 patients who underwent primary isolated ACL reconstruction without additional ligament injury were identified. Patients reported by the operating surgeons to have an International Knee Documentation Committee (IKDC) grade D Lachman, anterior drawer, or pivot shift examination were classified as having a high-grade laxity. Multiple logistic regression models were used to evaluate whether having high-grade preoperative laxity was predictive of increased odds of undergoing subsequent revision or contralateral ACL reconstruction within 6 years of the index procedure, controlling for patient age, sex, body mass index, Marx activity level, sport, graft type, medial meniscal treatment, and lateral meniscal treatment. Multiple linear regression modeling was used to evaluate whether having high-grade preoperative laxity was predictive of poorer IKDC or Knee injury and Osteoarthritis Outcome Score Knee-Related Quality of Life (KOOS-QOL) scores at 6 years postoperatively, after controlling for baseline score, patient age, ethnicity, sex, body mass index, marital status, smoking status, sport participation, competition level, Marx activity rating score, graft type, and articular cartilage and meniscal status.
Results:
In total, 743 of 2325 patients (32.0%) were noted to have high-grade laxity on at least 1 physical examination test. High-grade Lachman was noted in 334 patients (14.4%), high-grade pivot shift was noted in 617 patients (26.5%), and high-grade anterior drawer was noted in 233 patients (10.0%). Six-year revision and contralateral ACL reconstruction data were available for 2129 patients (91.6%). High-grade prereconstruction Lachman was associated with significantly increased odds of ACL graft revision (odds ratio OR, 1.76; 95% CI, 1.10-2.80, P = .02) and contralateral ACL reconstruction (OR, 1.68; 95% CI, 1.09-2.69; P = .019). High-grade prereconstruction pivot shift was associated with significantly increased odds of ACL graft revision (OR, 1.75; 95% CI, 1.19-2.54, P = .002) but not with significantly increased odds of contralateral ACL reconstruction (OR, 1.30; 95% CI, 0.89-1.87; P = .16). High-grade prereconstruction laxity was associated with statistically significantly lower 6-year IKDC (β = −2.26, P = .003), KOOS-QOL (β = −2.67, P = .015), and Marx activity scores (β = −0.54, P = .020), but these differences did not approach clinically relevant differences in patient-reported outcomes.
Conclusion:
High-grade preoperative knee laxity is predictive of increased odds of revision ACL reconstruction and contralateral ACL reconstruction 6 years after ACL reconstruction. Poorer patient-reported outcome scores in the high-grade laxity group were also noted, but the difference did not reach a level of clinical relevance.
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