News Category: Knee

Rehab experts use various tools to measure progress in patients after an acute injury. Questionnaires or surveys of questions are often used to assess change. This is a quick and easy way to record results when function can’t be
measured directly.

This study is a report of researchers’ efforts to develop a task-specific survey for the lower limb (leg).

Activities of daily living (ADLs) and recreation are the focus of the questions. The survey tool is called the Lower-Limb Tasks Questionnaire (LLTQ).

The authors report the steps they took through five separate studies to design and test the LLTQ. They discuss some of the difficulties creating a reliable and valid survey. For example, the questions must focus only on function.

It’s easy to include questions about symptoms such as pain and swelling. But this crosses over into measuring impairment, not function.

Some questions may be good for athletes but are not suitable for elderly adults. And tasks vary depending upon what stage the patient is at in the rehab process after an acute injury.

The authors present the statistical approaches used and results of all five studies. They found that both ADLs and recreational activities fell under the broader category of function. Both measure different aspects of lower limb function. Either or both can be used to show change in a patient’s function after treatment. And this series of questions can be used for different disorders and anatomic locations affected in the lower limb.

The high levels of reliability and responsiveness make it useful tool for clinical and research settings.

More and more studies are bringing to our attention the differences in knee anatomy between men and women. This is important when considering having a total knee replacement (TKR).

In the past, joint replacements for the knee were designed to fit both men and women. This concept was called a down the middle design. The average size and shape of both male and female knees were combined to come up with a one-design-fits-all kind of approach.

Then a wider range of implant systems was designed. There were still problems with this method. For example, in the average adult female, the smaller sizes were too small. And the larger sizes were too large. The new joint would hang over the edge of the femur (thighbone).

But with modern technology, three-dimensional (3-D) CT scans and computer analysis have started to change things. With new information about the differences in the size and shape of women’s anatomic knees compared to men’s, new implant designs can be made.

Three of those anatomic variations are reported in this article. These differences include a less prominent anterior condyle, an increased Q (quadriceps) angle, and a decreased side-to-side and front-to-back ratio.

The condyle is the bottom part of the femur that forms the top half of the knee joint. The female femur and condyles are not as wide as the male’s. The femoral side of the joint tends to be more of a trapezoid shape in women and a rectangular shape in men.

Without the proper size, shape, and dimensions, the implant can’t reproduce the correct knee motion and biomechanics. The surrounding soft tissues become irritated and off-balance. Because of the differences in anatomy, surgeons often have to make adjustments for women during the operation.

With newer, better implant designs fewer adjustments will be needed. Researchers hope that by making a femoral implant just for women, the knee will work better. There will be fewer problems with patellar (knee cap) tracking. And the joint won’t be overstuffed with an implant that’s too large and doesn’t fit well.

Pain after a total knee replacement (TKR) is usually managed with medication. Narcotics and especially patient-controlled analgesia (PCA) are used for many TKR patients.

But a new study shows that using a periarticular injection may be a better choice. Researchers report the results of injecting a cocktail of drugs into the knee during the operation. The cocktail is a mixture of drugs. It includes a numbing agent like Novocaine, antibiotics, morphine, and steroids (antiinflammatory).

The cocktail is injected into the joint capsule just before inserting the joint liner. Another injection goes into the soft tissues around the joint after the implant is in place.

Pain control using this cocktail isn’t much different from the PCA. But postoperative function, motion, and patient satisfaction are all much improved. In fact, more patients in the cocktail group went home sooner. They also used fewer narcotic drugs overall.

When re-examined at six weeks and three months after the surgery, there were no differences between the groups. The authors predict future advances in TKR won’t be a less invasive operation. It’s more likely that the post-operative period will be managed better.

Patients will have better local pain control. Less tissue trauma during the operation and better pain control mean the patients can have a more advanced physical therapy rehab program. With these improvements, patients will be discharged faster and return to full function sooner.

Patellofemoral arthroplasty (PFA) is the topic of this review article. PFA is the removal and replacement of the patella (knee cap) and the part of the femoral bone it glides over. This operation is used as an intermediary step before a total knee replacement (TKR). It works best for patients with arthritis that just affects the patellofemoral area. If needed, a complete TKR can always be done later.

PFA is not advised for anyone with inflammatory arthritis such as rheumatoid arthritis (RA). Patients who develop post-traumatic osteoarthritis seem to be the best candidates. Patients who have good knee alignment seem to have the best results.

Some alignment problems can be repaired before doing the PFA. For example, a release of tight tissue along the outside edge of the patella may be done. This type of release is advised if the patella is tilted or slightly off the track from where it should be. This helps it return back to the middle over the knee joint where it belongs.

Patients with chondromalacia may not be good candidates for PFA. Chondromalacia is the softening and shredding of the cartilage behind the patella. When PFA is done in the presence of chrondromalacia, there’s a greater chance of ongoing soft tissue pain.

Anyone with a large Q-angle may not benefit from a PFA. The Q-angle is a measure of the angle of the patella tendon as it attaches above and below the patella. Everyone has a Q-angle. Too large of an angle changes the knee biomechanics and represents a precaution to doing a PFA.

The author describes specific techniques to use in the PFA surgery. Postoperative management and clinical results are also reviewed. There are no studies on the best postoperative treatment after PFA. However, there are many studies reporting the outcomes of PFA.

The results have been varied. Some of this variability is linked to the type of implant used. Implant design is improving. There are fewer problems. When problems occur, they are usually caused by soft tissue imbalances or poor position of the implant. These studies are reviewed in detail by the author. Overall, they show that choosing the right patient is the best way to ensure good results.

Many people injure their knees and undergo anterior cruciate ligament (ACL) reconstruction,often because of sports activities. More than 100,000 ACL reconstructions are done in the United States every year. However, despite this number of surgeries, there still isn’t clear data on its long-range benefits. There is also a question as to whether athletes should return to sports that require high-level pivoting following an ACL repair.

In this study, researchers wanted to see if early activity modification and neuromuscular rehabilitation would help bring the injured knee up to an acceptable activity level, without any need for surgery. To do this, the researchers followed 100 patients who had had complete ACL ruptures to assess their activity level and knee function over time. The patients ranged in age from 15 to 43 years, with the average being 25.5 years. They were followed for between 13 and 20 years, average 15 years.

The majority of the patients were male (58 patients) and the right and left knees were equally represented (51 and 49, respectively). Fifty-nine patients injured their knee playing a ball sport, 30 down-hill skiing, and 11 doing other activities. Only 15 patients had only an ACL tear, the others had other tears in the knee as well.

After examining all the patients’ knees by arthroscopy, a small instrument with a camera is inserted into the knee through a small incision, the researchers assigned the patients to one of two groups: neuromuscular training with a physiotherapist, or training alone. The patients used crutches if needed and were not to force movement to the injured knee. Ten patients wore knee braces but the braces still allowed for bending the knee. All patients were advised to avoid contact sports. After 6 weeks into the program, the researchers transfered 49 percent of the patients in the self-monitoring group to the physiotherapy group because their knees were not improving and in some cases, they were worsening.

Follow-up for the patients was done at 1, 3 and 15 years after the initial knee injury. Only 6 patients were not part of the study at the end. As part of the evaluation, the patients filled out questionnaires about their knee and their status: The Tegner activity scale measured activity level, Lysholm knee score measured subjective knee function, Visual Analog Scale (VAS) measured pain levels, and the International Knee Documentation Committee (IKDC) subjective knee evaluation form and the Knee injury and Osteoarthritis Outcome Score (KOOS).

The findings showed that the average Tegner activity level when patients were first injured was between 3 and 9, with the average at 7. One year later, the range was from 2 to 9, average was 6. After 3 years, the range was from 3 to 9, with an average of 6 again, and finally, at 15 years, the range was from 1 to 7, with the average activity level dropping to 4.

Regarding knee function, using the Lysholm score, the patients scored an average of 96 at 1 year and 95 at 3 years. After 15 years, 49 patients scored good/excellent results, while 14 had fair or poor results.

When looking at earlier studies, one study identified patients with ACL injuries equally divided into three groups: “copers, compensators, and non-copers.” However, in the study being reviewed here, the researchers found that there were more copers (42 percent) who were able to return to their previous level of activity, even though they had not had surgery. The authors suggest that the surgery may be needed for people who participate in competitive sports or in sports that require pivoting on the leg within 6 to 12 months of sustaining the injury. That being said, another study did show that in their particular study group, 92 percent of the patients who did not have reconstructive surgery were able to return to playing handball, while only 58 percent who did have the surgery returned to handball.

Returning to this study, the researchers found a slight increase in activity among their patients at year 1, a return to previous level of activity by year 3, and then a significant decrease in activity by year 15. This decrease could, however, be due to life changes and people getting older, not necessarily because of the knee injury.

The authors conclude that the majority of patients with an ACL rupture can be treated without reconstructive surgery if they are followed with an appropriate follow-up, including physiotherapy and education.

Dislocation of the kneecap or patella is rare, but when it happens, it is disabling and can result in complications. The authors of this study found 154 cases of kneecap dislocation written up in the literature and they found that 144 (94 percent) of the patients had undergone surgery. The authors also found that many of the patients experienced complications and needed revisions of the surgery later on.

In this study, the researchers wanted to evaluate the effectiveness of an arthroscopic surgery to fix the dislocated kneecap. This type of surgery requires a couple of small incision for the narrow tools, which are then inserted into the knee to make the repairs. Seven patients with 9 injured knees took part in this study; 6 were women. They were aged from 15 to 38 years, the average age was 25. Three patients had hurt their knees while participating in sports. The time that had passed between the injury and the surgery varied quite a bit, from 6 to 48 months, with the average being 28 months. All of the patients had decreased their level of activity and 5 were severely restricted since the knee injury.

After undergoing the arthroscopic surgery, the patients were told that they could bear weight as they could tolerate and that they should use crutches until they could walk without a limp. They were given exercises and were supervised by a physiotherapist. The patients were allowed to begin, if they wished, to jog, cycle and/or swim 2 months after their surgery, and they could return to their regular sports once they were able to regain full range of motion and full strength in their knees.

The researchers found that the 2 patients who had hurt both knees were so pleased with their surgery outcome on 1 knee that they arranged to have the second knee repaired the same way, one 6 months later, one 18 months later. Of the 9 patients, all were able to regain full range of motion an average of 4 weeks after surgery. The 3 patients who had previously participated in sports were able to resume playing within 6 months of the surgery. After follow-up of between 1 and 8 years (average 2.7 years), none of the patients had any complaints about their repaired knees. There was 1 patient how had re-injured her knee in another accident, 5 years after surgery.

The authors point out that there are weaknesses in the study, including the small number of patients. They also did not have a control group with which to compare the patients. However, the authors conclude that the surgery is successful in treating this type of injury while avoiding the complications that exist with traditional knee repair surgery.

Full-thickness cartilage tears of the distal femur (thighbone) with damage to the first layer of bone are challenging problems. The distal femur is the end of the thigh where the bone meets the lower leg to form the knee joint.

Osteochondral allograft transplantation is one method of treatment for this problem. Osteochondral refers to the bone and cartilage that is replaced. Allograft means donor tissue is used from a cadaver (body preserved after death).

Transplanted tissue is used as early as one week after donor death. There are some concerns about the safety of this tissue. In this study, tissue was implanted no sooner than four weeks after the donor’s death. This gave more time to check for donor risk factors and to test the tissue samples for unknown diseases.

After the tissue was used to repair the cartilage damage, eight patients needed a second operation. This occurred 20 to 60 months after the transplantation was done. Surgeons used this opportunity to recheck the graft and see how it was doing.

They tested the graft by measuring the number of live cells per sample and comparing that to normal cartilage for the same patient. They did the same with cell density. MRIs were also taken before the first operation and after the second procedure.

The authors found no difference in cartilage cells between the implanted tissue and the patient’s own normal cartilage. The MRIs showed the implant was completely incorporated into the joint surface. The improvement in MRIs was significant. In fact, the eight patients’ joint cartilage were classified as normal.

This study showed that donor cartilage can be stored at cold temperatures for four weeks or more before being used successfully. The grafts were incorporated completely. The patients had decreased pain and increased function after the transplantation. More study is needed to assess the long-term results.

The end of the femur (thighbone) that helps form the knee joint is covered with a layer of cartilage. This cartilage is referred to as articular cartilage. This is the cartilage that meets with and glides across the surface of the tibia (lower leg bone).

Young active adults, especially athletes, can injure the articular cartilage. If a piece of cartilage is torn away from the bone, it may even take a piece of bone with it. This is called an osteochondral defect. Left untreated, this focal articular cartilage injury can develop into full-blown arthritis.

In this article, Dr. L. P. McCarty, III reviews the basic science of the normal, healthy articular cartilage. It has four separate zones that help make it strong enough to resist deep shear forces. These are the type of forces generated by many sports activities. Changes in the articular cartilage from arthritis decrease its ability to handle various loading conditions.

Tears in the articular cartilage can be graded according to a system developed by the International Cartilage Repair Society. Grade 0 is normal. Grade 1 is nearly normal (small cracks or tears). Grade 2 is a tear through 50 per cent of the cartilage depth.

Grade 3 describes severely abnormal cartilage. The tear goes down to but not through the first layer of bone. Grade 4 is used to describe a severely abnormal cartilage with both full-depth cartilage and subchondral bone tears.

The author outlines an exam method doctors can use to identify cartilage tears. The physical exam includes gait (walking) pattern, swelling, palpation, and range of motion measurements. Tests are done to check the stability of the other soft tissues (ligaments) around the knee.

X-rays can be used but MRI testing is the best method for diagnosing the problem. Specifics of the MRI changes seen with articular tears are discussed. Part two of this review will focus on treatment once the problem is properly diagnosed.

In this study, the results of a pilot program using a new pain control device are reported. The treatment method is called Biowave deep tissue neuromodulation. The device used is called Deepwave.

Deep tissue neuromodulation is done by delivering low frequency electrical energy into the painful area of the knee. Pain signals to and from the nerves are interrupted resulting in a decrease in discomfort.

Two groups of patients with severe pain from knee osteoarthritis were included. Half were treated with Deepwave. The other half received a sham treatment. This means the device was placed on the patient but it wasn’t actually turned on.

Everyone was treated one time for 30 minutes. Pain, stiffness, and function were measured before and after treatment. These measures were used to determine treatment success. Patients were followed closely during the first 48 hours. They also got a phone call one week after the treatment to check on their progress.

The treatment group had a greater decrease in pain intensity than the sham group. Pain control was much better in the treatment group 48 hours after the nerve stimulation. The live treatment group also reported greater satisfaction with the results one week after the treatment.

Half of the patients in the treatment group reported using fewer pain medications. None of the patients in the sham group reported a decrease in drug use.

The authors suggest the Deepwave neuromodulation device is a safe and effective tool for pain therapy. Improved function with greater activity level is possible with decreased pain levels provided by this device.

More studies are needed to see if this treatment has any negative side effects over time. Since this was a pilot project with only a single dose, other trials with longer treatment are needed.

Mild to moderate strains of muscles such as the hamstrings are fairly common among athletes. This type of injury can be treated with conservative care and don’t usually need surgery. But results are best if surgery is done when there’s a complete rupture of the muscle.

In this report, two orthopedic surgeons share their experience and knowledge of hamstring ruptures. In all cases, the hamstring tendon pulled away from the pelvic bone. The hamstrings attach to the ischial tuberosity. This is the boney bump you can feel when you are sitting.

When tendons rupture, they often pull away from the bone along with a small piece of bone. Surgery to reattach the tendon and the bone fragment helps restore function. Athletes may even be able to return to high-level play in sports.

It isn’t always easy to tell when the hamstrings have been strained versus ruptured. Many injured athletes notice a large bruise along the back of the thigh about a week after the injury. They walk with a stiff-legged pattern to avoid using the hamstring muscle to bend the hip and knee.

The diagnosis is usually made with an MRI. MRIs show how much soft-tissue injury is present. They also show how much of the tendon is ruptured (partial versus complete). If there’s a complete rupture, the MRI shows how far the muscle has retracted or pulled away from its attachment.

The surgeon needs all this information before operating. The authors describe the surgical method they use to repair hamstring ruptures involving two or three tendons.

The tendons are reattached to the bone with suture anchors. The surgeons place five sutures in an X pattern. This method helps avoid stitches bunching up the tendon where it attaches to the bone.

Patients wear a special brace made just for this injury. Following a rehab program, many athletes are able to return to play. This usually occurs between six and nine months after the surgery. Most players are able to return to their previous level of sports participation. If surgery is delayed or not done at all, there is a loss of function and strength.

Total knee arthroplasties, or knee replacements, are popular and effective orthopedic surgeries. They have a good safety record and are quite effective in most cases. However, for patients who require replacements for both knees, there is controversy regarding whether they should be done at the same time, simultaneously, or in two separate surgeries.

In this study, a review of the literature, investigators found 18 previously done studies that encompassed 27,807 patients and 44,684 total knee replacements. Of the replacements, 16,419 were simultaneous bilateral procedures (both at the same time) and 458 were staged bilateral procedures.

Of the 18 studies, six reported on findings of deep vein thrombosis, clots in the blood system, 11 on pulmonary embolism, clots in the lungs, eight on heart complications, and eight on the rate of death.

The investigators found that there were no significant differences between having both knees done at the same time and the staged procedures when looking at the rate of deep vein thrombosis, but there was a significant difference with rates of pulmonary embolism. In some studies, the odds ratio for pulmonary embolism was seven times higher among patients who had the simultaneous procedures over those who did not. When the investigators looked at the heart complications, although there were more in the simultaneous group, the differences weren’t major between the two. Finally, when assessing mortality, this was found to be significantly higher among the simultaneous procedure group. The odds ratio among these patients was found to be as high as 10.15 in one study.

The researchers concluded that, although most patients who need a knee replacement only need one done, there remain many who need both. While it may seem better to do both at the same time because of only one hospitalization, one time under anesthetic, etc., it may be that it isn’t in the patients’ best interest to do simultaneous replacements. The researchers also point out that knowing the adverse outcomes of many simultaneous procedures, surgeons should be made aware and then perhaps limit the simultaneous procedures to patients who do not have cardiac conditions.

More studies do need to be done on this topic, the authors say.

When only one side of the knee joint wears out, a total knee replacement isn’t necessary. A unicompartmental knee replacement (UKR) can be done. Studies show that one unicompartmental implant stands out. The Oxford UKR has been used with a select group of patients with excellent results.

In this review, surgeons from the Department of Orthopedics at the University of Minnesota report on 54 articles published with results of the Oxford implant. The implant was still working well for more than 90 per cent of the patients after 15 years.

Revision surgery was needed for patients who went on to develop disabling arthritis in the other half of the joint. A few patients had revision surgery for implants that came loose. Failures were most often linked with patients who did not have a normal anterior cruciate ligament (ACL).

Overall, the authors report the greatest success with Oxford unicompartmental implants under the following conditions:

Primary care physicians will see many patients with osteoarthritis (OA). In this article, Dr. Stanish, professor of orthopedic surgery and director of a sports medicine clinic in Canada reviews this condition. A special focus is on the use of pharmaceutical agents (drugs) to manage symptoms.

OA affects the cartilage covering and protecting the joints. Age, mechanical stress, and genetics play a role in this disease. Inflammation causes pain and leads to degeneration of the joint. Treatment includes patient education, weight loss, exercise, and drugs.

At first, over-the-counter medications such as Tylenol and nonsteroidal antiinflammatories (NSAIDs) are used. Tylenol is safe, effective, and low in cost. When used properly, it doesn’t cause GI upset.

NSAIDs are used for severe pain. There’s a greater risk of GI and cardiac problems with NSAID-use. Another drug called COX-2 inhibitors have helped to reduce GI problems. Some patients who use COX-2 inhibitors are at risk for cardiovascular events.

Many patients ask about the use of chondroitin and glucosamine products. Studies so far show a wide range of results. Differences seem to be related to the contents and dosage of these supplements. More study is needed to find out which patients can be helped the most from these products.

When standard drugs don’t help, then an opioid analgesic should be considered. There is always a concern about addiction. But for some patients, the effect on pain, function, and sleep makes it worth trying them. With the right dose and an overall management program, most patients do not become addicted.

The authors review other forms of treatment for OA including injections and surgery. New treatments on the horizon are mentioned. Cartilage transplants and gene transfer may help future patients build a new joint surface. Disease-modifying drugs for OA are also being developed.

Tearing or rupturing the anterior cruciate ligament (ACL) is a common knee injury, especially in people who participate in certain sports. Because the injury doesn’t heal on its own, surgeons take some tissue from below the knee or the hamstring area and use this to repair the tear. Tissue taken from your own body to repair an injury is called an autograft.

Researchers wanted to compare the bone-patellar tendon-bone (BTB) autograft to the triple/quadruple semitendinosus (ST) autograft and the effects on the donor sites. The BTB autograft takes tissue from the tendon that connects the kneecap (patella) to the shin; the ST autograft takes the tissue from hamstrings (semitendinosus), found at the back of the thigh.

The researchers thought that the BTB autograft would cause more problems to the patients’ donor site than the ST autograft. They recruited 71 patients with unilateral (one-sided) ACL ruptures to participate in this prospective, randomized trial. The patients would receive one of the two autografts and then would be followed for seven years. To ensure consistency in the surgical techniques, the same surgeon did all surgeries. All patients underwent the same rehabilitation: no weight-bearing on the repaired knee for six weeks, running was only permitted at three months, and contact sports at six month, at the earliest. Of the 71 original patients, 68 patients were followed to the end of the study.

When testing after the recovery, the researchers found that there were no significant differences between the two groups in any of the test findings. Patients in both groups were able to knee-walk, kneel, hop on the affected leg, and extend their leg equally well.

The authors point out that graft choice for ACL reconstruction is still controversial. However, because of the findings from this study, the researchers concluded that both techniques were reliable and provided equal patient outcome in both patient performance and activity level.

After many years there still isn’t agreement about which of the two commonly used methods of repair for a ruptured ACL is the best. Long-term studies may be able to help answer the question of which one is the better choice.

In this study, a single surgeon compared 90 patients with a hamstring tendon graft (HTG) to 90 patients with a patellar tendon graft (PTG). All patients had anterior cruciate ligament (ACL) deficient knees. Everyone was followed closely for 10 years.

X-rays, clinical tests, and reports of pain, activity level, and function were used as the primary measures of results. Failure was defined as graft rupture. After 10 years, the results of the two groups were very similar. There were no differences in the number of graft failures between the two groups.

Function was normal or near-normal in almost all the patients in both groups. As has been reported in many other studies, the PTG had more pain and problems at the harvest site. Kneeling is often a problem for this group. And the PTG had more osteoarthritis of the knee after 10 years compared with the HTG.

Although the authors favor the HTG, they point out that there are other factors in the success or failure of ACL repair. Graft choice is only one consideration. Other factors include the surgeon’s experience, correct graft position, and graft fixation. The presence of other damage to the knee and postoperative rehab can also make a difference.

Major advances have been made in the repair of knee cartilage. Commercially available full-thickness cartilage tissue called osteochondral allografts have been in use for about the last 10 years. Allograft refers to tissue donated to a tissue bank.

Researchers are exploring storage times for the donated tissue. We know that grafts used in the first 14 days of harvest have good-to-excellent results. In this study, the results of grafts older than 14 days are reviewed.

Nineteen patients with damage to the cartilage and first layer of bone on the femur (thighbone) were included. All were treated with osteochondral allograft and followed for at least two years.

Before and after measurements were taken of function. X-rays and special cartilage-sensitive MRIs were taken before and after to document change. MRIs showed that in general, the thickness of the allograft stayed the same. None of the grafts shifted or moved out of place. The grafts filled in most of the defects.

The longer graft storage times seemed to produce better results compared with fresh grafts. There was less swelling around the graft and better shaping and fill-in by the graft material. The scientists weren’t sure how to explain these results.

The authors comment that there weren’t enough patients in the study to answer some questions. Future larger studies should look at the effects of age and body size on results. Results based on the size and type of lesion should also be assessed. Long-term studies are needed to see if the tissue breaks down over time.

In this review article, experts in the field of orthopedic trauma report on the use of bone graft substitutes in surgery. Types of grafts, results of studies so far, and recommendations based on research evidence are presented.

Many patients who need a bone graft donate their own bone. It’s usually taken from the pelvic bone. But problems with the donor site have led scientists to look for better ways to enhance bone healing. Bone graft substitutes are being studied and developed.

In the mid-1990s, a group of 15 proteins was discovered that can help new bone form. These are called bone morphogenetic proteins or BMPs. Doctors see this as a potential treatment for fractures, especially nonunion fractures (breaks that don’t heal).

Some efforts to develop bone substitutes are still in the animal study stages. Others have been used in clinical trials for humans. For example, demineralized bone matrix (DBM) is one source of bone stimulating proteins.

When used in spinal fusions, the DBM has been mixed in a 2:1 ratio with bone graft with good results. This type of use as a bone-graft extender will need further research. Right now the FDA has plans to regulate DBM products as Class-II medical devices. Gene technology used to form the DBM has higher risks and is classified as a Class-III device.

Osteogenic protein-1 (OP-1) is a recombinant BMP available for clinical use. Recombinant means two DNA sequences have been added or combined together to form a new sequence that isn’t found naturally.

Studies with OP-1 have shown a faster healing time, improved wound-healing, and decreased rates of infection in trauma patients. Similar good results were also reported in patients who are smokers. Tobacco use is a known risk factor for poor or delayed healing.

Other studies have shown that growth factors added to DBM are needed to prevent bone graft failure. Composite grafts combining various materials together for the best effect are the subject of much study now. For example, bone marrow mixed with BMP or injected alone seems to work well in animals.

Platelets delivered in the early stages of bone repair may start the steps toward successful fracture healing. Other ways to enhance bone growth in humans will remain a research topic for years to come.

Blood clots referred to as venous thromboembolism (VTE) are a common risk factor after total hip or total knee replacements. Patients are usually put on medication to thin the blood and prevent this from happening. This is called thromboprophylaxis. With shorter hospital stays, there is less follow-up supervision. For this reason, patients must keep taking the preventive medication after going home.

In this study, doctors at the Medical University of South Carolina try to find out the optimal amount of time patients must take thromboprophylaxis. Is 10 days enough time to prevent blood clots? If not, how much more time is needed? Do total hip patients need the same amount of prophylaxis as total knee patients?

A review of the studies published most recently showed that:

Exercise has been shown to benefit patients with knee osteoarthritis (OA). Different exercise programs have been studied such as quadriceps muscle strengthening and progressive resistive exercises.

At the same time, the use of sodium hyaluronate injected into the joint has also been studied. Given weekly over three to five weeks, these injections work well for patients with moderate-to-severe knee pain.

Perhaps combining exercise with hyaluronate injections (HYL) would work even better. That’s the focus of this study. Researchers asked two questions: how well do these two treatments work when combined together? Is a combined treatment approach safe?

Sixty patients with moderate-to-severe pain from knee OA were divided into three groups. Group one received weekly HYL for three weeks (3-HYL). Group two had three weekly HYL combined with a home exercise program (3-HYL+HEP). Group three received five weekly HYL injections (5-HYL).

Pain was used as the primary measure of results. Pain was measured after each patient walked 50 feet. A baseline test was done before treatment and at regular intervals up to one year after treatment.

There was no difference in baseline scores among the three groups. All patients rated their pain as moderate-to-severe. After treatment, everyone reported improved function and at least 20 per cent improvement in their pain levels.

There was much faster and better pain relief in the 3-HYL+HEP group when compared with the other two groups. The results lasted through the final follow-up visit after 52 weeks. Patients in the 5-HYL group also had better results than the 3-HYL group. At the end of the year, there were no differences between the 3-HYL+HEP group and the 5-HYL group.

This study showed there may be an added benefit of using HYL with exercise in cases of moderate-to-severely painful knee OA. Pain relief was faster, greater, and longer lasting for the HYL+HEP group compared with the other two groups receiving only HYL. The authors suggest it may be possible to use fewer HYL injections when patients participate in a HEP.

Arthroscopic treatment of knee osteoarthritis (OA) has become an increasingly popular treatment in the last 10 years. But is there enough scientific evidence to support its continued use?

In this study, researchers from the University of Colorado review the articles published on this topic. They report problems with research methods and design that make conclusions difficult.

Some of the studies are only short-term. Others don’t have a control group (group that doesn’t get treated) to compare results with the treatment group. And sometimes patients in the studies had varying degrees of arthritis severity. This made comparisons difficult, if not impossible.

The authors found some studies with valuable information about the treatment of OA with arthroscopy. Only one study met all of the criteria to be a level one review. Level one is the highest level of evidence possible.

They concluded that there is limited evidence to support using arthroscopy to treat knee OA. Removing a torn meniscus or smoothing joints with low-grade OA may be the best use of arthroscopy. However, arthroscopy should not be used routinely for everyone with knee OA.