News Category: Knee

Can patients rehab at home after an ACL repair? How do their results compare to patients who are directly supervised in physical therapy (PT)? This study compared patients in both programs and reports the results.

Active and passive knee range of motion and strength were the measures used to compare results. All patients did the same program for three months. They started one week after surgery.

The home-based group met with a physical therapist four times during the three months after surgery. Exercises were progressed through each phase of recovery.

The PT-based group went to rehab sessions twice a week for the first seven weeks. They went once a week during weeks eight through 12. The PT-based group had a total of 17 sessions with the therapist during the three months after surgery.

The authors report more patients in the home-based group had better motion (measured at rest). Motion was the same during walking. There was no difference in strength between the two groups.

The results of this study suggest that patients with ACL reconstructions are able to rehab on their own. They need a few sessions with the physical therapist to get started and keep on track.

The results were based on three months of rehab. Longer follow-up is needed to see if the results are the same months to years later.

A small, Japanese study reports the results of a new way to repair the medial collateral ligament (MCL) in the knee. Twenty-seven patients with a torn MCL were treated with reconstructive surgery. The surgeons used a hamstring tendon graft.

The authors of this study describe the surgery in detail. All patients had chronic third-degree MCL injuries. Most had an anterior cruciate ligament (ACL) tear as well. With these combined injuries, their knees were unstable.

Hamstring grafts were taken from the patients to use in the repair. The tendon graft was folded over to make a double-thickness. Sutures and screws were used to hold the graft in place.

Results of this new technique were evaluated. Patient symptoms, range of motion, and joint function were the test measures. Joint looseness or laxity was also measured.

Eighty-eight percent (88%) of the patients had normal or nearly normal knee function after the operation. The rest of the patients had pain or mild instability with light activity.

Using this new method of MCL repair most patients went from having severe joint instability back to normal. The authors conclude this new surgery can restore the function of the MCL with good short-term results.

Further studies are needed to test the stability of the joint under various stresses and forces. Long-term results must be studied before this method is used for all patients with MCL tears.

Tennis players and golfers use videotapes of experts to improve their swing. Can athletes do the same to learn how to land a jump without injuring their knees? That’s the question asked by researchers in this study.

College-aged athletes were divided into four groups. Group one (expert group) watched an instructional videotape of an expert trained in proper landing methods. They were given a checklist of things to try and copy. For example, they were told to land with both feet at the same time. The landing should be done with the knees in the middle (not turned in and not turned out). Just the right amount of hip and knee flexion was advised.

Group two (self group) watched videotapes of themselves as they did three trials of a jump-land. Group three (combo group) watched both the expert and self-videos. Group four(control group) got no instruction or advice.

Before watching the videos, each athlete was tested using a special testing device called a Jump-Ball (patent pending). This is called a baseline test. Each subject did three vertical jumps as high as he or she could. They landed on a force plate to measure ground forces. Subjects were re-tested right after watching the videos and again one week later.

The results showed that each feedback group made softer landings right away. The self-feedback and combo groups kept this skill longer when retested. The feedback groups also had more hip and knee flexion when landing. There weren’t any big differences in the amount of flexion from one feedback group to another.

The authors conclude that learning is improved with visual demonstration and self-analysis. The more athletes become involved in studying and correcting their own mistakes the greater their chances of improving. Videotape instruction is a good way to do this.

Over 1,000 girls ages 14 to 18 from 52 soccer teams were part of this study. The goal was to see if a sports-specific exercise program could reduce the number of anterior cruciate ligament (ACL) tears in females.

A second equally large group of players were compared to the first. The second (control) group did the traditional warm-up exercises. The first (research) group did special warm-up activities, stretches, and exercises just for soccer players. They also watched a soccer training video.

After one soccer season the sports-specific exercise group had 88 percent fewer ACL injuries compared to the control group.

Studies in soccer and other sports show that specific exercise training can cut down on knee injuries. This current study shows how exercise training to improve landing can make a big difference in female athletes.

There’s some concern that an athlete with an unrepaired anterior cruciate ligament (ACL) ligament tear will end up with knee osteoarthritis years later. This study followed athletes who are from the former East Germany. Each one had an unrepaired (unstable) knee for 35 years.

Athletes in the Olympic training group from 1963 to 1965 who tore their ACLs were treated nonoperatively. Surgery was not done at that time because the results of previous operations were not acceptable.

Instead athletes were put in a cast for six weeks. Everyone returned to their previous level of sports participation after a full rehab program. The athletes were very motivated to go to the next Olympics.

The doctors reported that none of the athletes was able to compete in the World Championships or the Olympic games because of knee problems. Almost all of the athletes had the meniscus removed within 10 years of the ACL rupture. Severe cartilage damage and osteoarthritis was found in the knees of all athletes examined. All but one athlete had severe symptoms of pain and the knee giving out from underneath them.

In the United States all residents 65 years old or older are eligible or are on Medicare. This is the first report using Medicare claims to study the results of total knee replacements (TKRs).

By using Medicare claims, researchers could count how many adults over 65 have a TKR each year. They also looked at number and type of problems after the surgery. Here are the results:

In this study doctors compared the results of two types of informed consent: verbal and video. Before any surgery takes place patients must sign a form agreeing to the operation. It’s called informed consent. By signing this form, the patient says in effect, “I agree to this operation. I understand the risks.”

During the informed consent process the doctor or an assistant usually gives verbal instructions. The operation is explained step-by-step. The patient can ask any questions or ask for more information. In this study one group was given verbal instructions. The second group watched a video with the same instructions. Patients in both groups were planning to have arthroscopic knee surgery.

Both groups answered questions after the informed consent process. The results of the survey were reviewed to see how much the patients understood and remembered. The two groups were compared based on education level (less than 12th grade or more than 12th grade).

The authors reported greater understanding in the video group. Both groups were equally satisfied with the information. In both groups patients with more than a high school education understood the instructions better. Patients with less than a 12th grade education had the greatest gain in understanding from the video method.

In this study doctors report on three cases of insufficiency fractures of the tibia in older adults. Insufficiency fractures occur when the bone isn’t dense enough or strong enough to withstand everyday stresses. They occur most often in older women (over age 65) who have osteoporosis.

All three patients had knee joint pain along the medial (inner) tibial line. The tibia is the lower leg bone. The pain came on without cause or injury in two cases. The third woman reported pain that occurred when she was stepping down off the bus.

X-rays didn’t show any changes in the early stages of the insufficiency fractures. Bone scans were used to diagnose the problem. Treatment was with pain relievers, rest, and crutches for support. Six months to two years later, all three patients continue to have mild pain from time to time. Pain relievers are all that’s needed to manage.

The authors conclude that knee pain from insufficiency fractures is unique and difficult to diagnose. Early stages of this condition don’t show up on X-rays. It’s easy to think the patient is suffering from osteoarthritis. Early diagnosis with advanced imaging is needed to avoid full fractures from occurring.

More and more patients are becoming part of the decision-making process in health care. Studies show a better result after medical treatment when patients’ needs and wants are met. In this study, researchers at Yale University compared doctors’ and patients’ ratings of knee pain and function for each patient before and after surgery.

Patients either had an anterior cruciate ligament repair or a meniscectomy. Patients and surgeons rated pain and function one week before surgery. Ratings were given three days after and again 24 weeks after the operation.

It turns out doctors downplay patients’ pain before surgery. They also say patients will get more function than the patients were expecting after surgery. The doctors base their thinking about function from what they know about other patients after surgery.

The results of this study show that doctors’ talks with patients before surgery are important to the final outcome. Shared decisions by patients and doctors are a part of this process. It’s important for doctors to know what their patients think is a successful result and to help them achieve it.

This is part two of a study started in 1986. The doctors decided to extend the study to look at results five to 12 years after lateral retinacular release (LRR). The lateral retinaculum is a band of fibrous tissue along the outer edge of the kneecap (patella).

A LRR is done to decrease pressure on the patella. In a LRR the surgeon cuts through the retinaculum, the joint capsule, and the attached synovial tissue. Two groups of patients were included. Group one had knee pain but a stable patella. Group two had signs of patellar instability.

Previous studies have shown that the good effects of LRR may not last. Patients with instability may end up with patellar subluxation. This means the patella doesn’t track evenly in its groove over the femur (thigh bone). Instead, it slides too far to the outside. The authors say it’s likely the results are so variable because LRR is not suitable for all patients with knee pain.

The results of this study show group one kept their good results over the long term. Patients with instability (group two) had a major decrease in results. Results went from 72 percent satisfactory down to 50 percent. Group one was able to return to previous levels of sports and activity. Group two did not.

The authors conclude that LRR is best used for patients with a tight retinaculum in a painful but stable patella. LRR has the best results when followed by a rehab program to regain muscular control of patellar tracking.

During arthroscopic surgery of the knee, the surgeon flushes the joint with a saline solution. The fluid is kept at room temperature. Later an ice pack is put on the knee. The ice decreases pain and swelling. In this study researchers look at the effect of these actions on the joint temperature. They also measure the core body temperature.

New technology has brought temperature measurement systems to the operating room. These systems allow measurement of temperature inside the joint. In this two-part study, scientists measured the knee temperature before irrigating the joint. Temperature was taken every 30 seconds during the irrigation. Body temperature was also checked every 10 minutes.

Then a bag of ice was placed on the skin for one hour. Joint and body temperatures were measured to see if there was any effect. The authors report a drop in knee temperature right away with the saline flush. A lower knee temperature resulted in a slightly lower body temperature.

The results of this study show that the human temperature regulating system can keep the body temperature close to normal when the temperature inside the knee joint is lowered. Putting ice on the outside of a joint doesn’t affect core body temperature much.

Joint laxity may be a factor in anterior cruciate ligament (ACL) tears. Since women have more ACL injuries than men, laxity may be the cause. In this study joint laxity in men and women was measured. All subjects were involved in intercollegiate athletics.

A special device called an arthrometer was used to measure the motion of the lower leg bone (tibia) as it moves forward against the thighbone (femur). This motion is called a “drawer” motion. Too much forward motion, called the anterior drawer sign, suggests ligamentous laxity.

Range of motion in other joints was also measured. These measures were used to judge overall ligament laxity. Several positions were also used to assess laxity such as being able to touch the thumb to the forearm with the wrist bent. Bending forward and touching the palms to the floor with the knees straight was also measured.

The results of measurements taken showed that general joint laxity is linked with ACL tears in women. The ability to hyperextend the knee was found in both mend and women with ACL injuries. Both groups of men and women with ACL injuries had greater elbow extension, too.

The authors conclude that this study shows a link between knee hyperextension and ACL tears in all athletes. It still doesn’t explain why women have higher injury rates. More study of this problem is needed to find a way to prevent ACL injuries in all athletes, but especially among women.

When total knee replacements became a treatment option for arthritis, surgeons questioned whether to keep or replace the kneecap (patella). To this day the debate goes on without a clear answer. In this study researchers looked at all the studies done on this topic. They covered a period from January 1966 until August 2003.

This type of review is called a meta-analysis. This type of study helps water down any strong bias one way or the other. It helps point out any findings that are the same over time. This study combined two kinds of surgery: patella replaced (resurfaced) and patella retained (unresurfaced).

Several measures were used to compare the two options. The main outcomes were number of patients who had a second operation, patellar pain or other problems, and knee function (including climbing stairs). Patient satisfaction was used, too.

The overall results show an advantage for replacing the patella during knee joint replacement. Results were better with the resurfaced patellae. Even so the authors said the information didn’t lend itself to any firm conclusions. There were just too many variables to take into account.

What can be done about joint stiffness after a total knee replacement (TKR)? When all else fails, the implant can be revised. But does this really solve the problem? That’s what researchers at the Florida Orthopedic Institute report on in this study.

Sixteen knees were revised based on patients’ complaints of pain and stiffness. Everyone had efforts made to restore motion before revision, including a trial of physical therapy. Some had the joint stretched or manipulated under anesthesia. Several had release of scar tissue by arthroscopic surgery.

In the end, implants in all the knees were changed. The surgeon decided at the time of the operation what to remove and what to use as a replacement. Dense scar tissue was seen in all the patients. Continuous passive motion machines were used after the revision surgery. And everyone had physical therapy.

Data showed two-thirds of the patients were happy with the results. They had less pain, more motion, and greater knee function. The remaining patients had complications or continued stiffness after the revision.

The authors report that even though the patients were satisfied, the results were only “modest” improvements from the surgeon’s point of view. Too many patients didn’t have a good outcome after the revision. The authors concluded that it may be unrealistic to
expect much improvement after revision of TKR for stiffness.

You may have heard about the use of continuous passive motion (CPM) after total knee replacement (TKR). It uses a mechanical device that moves the knee through a preset range of motion. The idea is that early and constant motion after surgery will help the joint heal faster.

But does it? Results of many studies don’t agree. Some say that CPM helps speed recovery while others say it doesn’t. In this study three groups of patients were compared. The first group used CPM in the standard way. They started with the knee straight. The CPM was set to bend and straighten the knee. The second group started in flexion and moved into extension. The third (control) group didn’t use CPM at all.

The two CPM groups used it twice a day for three hours over five days. Everyone in all three groups had the same physical therapy program after TKR. Results were measured by range of motion and knee function. Everyone was followed at five days, three months, and one year after the operation.

There were some differences among the groups when measured at day five. The second group that started in flexion had more motion than the other two groups. All other measures were the same for all three groups at three months and again at one year. Patients in all three groups had the same length of hospital stay and number of rehab visits.

The authors say their results agree with some studies and disagree with others. Although one CPM program increased flexion early, the end results were the same for everyone. This study agrees with others that suggest CPM isn’t needed after TKR. An aggressive physical therapy program is all that’s needed.

Patients who’ve lost a leg may be at risk for increased arthritis in the other knee. The reason for this is the way they change their walking pattern. Using a prosthetic device on the amputated leg changes the person’s stride length and walking speed. It also shifts more of the load to the normal leg (knee).

Men over the age of 40 from the Veterans Administration (VA) were involved in this study. One group had lost the leg by some kind of trauma. It was amputated either below the knee through the lower leg bone (transtibial) or above the knee (transfemoral). The other group didn’t have an amputation at all. The amputee group had been walking with a prosthesis for at least five years.

Patients in both groups were asked questions about knee pain, stiffness, and crepitus. Crepitus is the crunching sound or feeling heard or felt during knee motion. Pain intensity and interference with daily activities was recorded. Age and body weight were taken into consideration. Data was viewed to see if the level of the amputation made a difference.

Here’s what they found:

At least one out of every five top athletes is affected by jumper’s knee sometime during his or her athletic career. These are the new findings of a study from the Norwegian University of Sport and Physical Education.

Jumper’s knee is another name for patellar tendonitis. It’s an inflammation in the tendon that connects the patella (kneecap) to the tibia (shinbone) caused by forceful jumping or running.

Players often compete with painful symptoms. This may go on for months to years. Jumper’s knee can threaten a promising athletic career. Some sports are affected more than others. According to this study, volleyball and basketball players are affected most often. These are sports that emphasize weight and jump training.

Men have jumper’s knee more often than women in the same sport. It does not appear that training level accounts for this difference. It’s more likely that men are able to generate more force through the knee and tendon when jumping. This is true even when men and women are playing the same sport.

This is the first study to report on how often jumper’s knee occurs in a broad range of sports. The authors suggest that the 20 percent rate of jumper’s knee across nine different sports is actually a low number. It’s likely that many other athletes are affected but weren’t included because they were too disabled to train or compete.

Replacing just part of a knee joint because of arthritic changes is on the rise. Early reports of unicompartmental knee replacement (UKR) weren’t very favorable. Since then results have improved. In this study, researchers at the Rush Medical College in Chicago, Illinois, report on the long-term results of UKR in 62 patients. All received the same kind of implant (Miller-Galante cemented modular implant). All were followed for at least 10 years.

It seems that better methods of surgery, improved tools, and more careful patient selection has made a difference. The UKR requires a shorter hospital stay with lower costs. The patient is walking sooner than with a total knee replacement (TKR). The UKR holds up well under normal wear and tear.

The main problem is continued wear on the side of the joint that wasn’t replaced. At some point the patient may need to convert to a TKR. In this study only two of the 62 patients needed revision surgery to replace the entire joint. Ninety-six percent of the patients still had the UKR after 10 or more years.

The authors conclude that the Miller-Galante UKR implant used in their study has excellent results. Both the X-rays and clinical exam confirm this result up to and beyond 10 years after the original operation. Careful selection of patients is still required for the best results.

So it’s been a year since you had a total knee replacement (TKR), and your leg strength still isn’t what it should be. Join the club. Researchers confirm that despite decreased pain and increased motion after TKR, walking and stair climbing speeds are reduced by 50 percent compared to normal adults in the same age range.

Knee pain doesn’t seem to be the problem. Weakness of the quadriceps muscle is the main problem. The quadriceps muscle along the front of the thigh straightens the knee. Muscle activation and atrophy account for 85 percent of the change in quadriceps strength. Failure to voluntarily contract muscle fibers seems to be the biggest problem.

But if pain isn’t causing failure of the muscles to contract, what is? Researchers aren’t sure. Until this mystery is solved, they suggest the rehab program should focus on improving quadriceps muscle activation as early as possible after surgery.

More studies are needed to find out which rehab program is best. High-intensity muscle contractions may be the best way to start. Biofeedback and neuromuscular electrical stimulation may also help improve quadriceps strength.

In this report, researchers at the University of Thessaly in Greece propose a new clinical test for meniscal tears of the knee called the Thessaly test. Using two groups (injured adults and a control group), they were able to show the test can diagnose medial meniscus tears with 94 percent accuracy. Accuracy was slightly higher (96 percent) with lateral meniscal tears.

The Thessaly test is done standing barefoot first on the normal, healthy leg. The patient holds the examiner’s hands for balance. The patient bends the knee of the standing leg 5 degrees and rotates the knee and body in and out three times. The test is repeated with the knee flexed 20 degrees. Then the test is done on the involved or injured leg.

Patients with a meniscal tear feel pain or discomfort along the joint line on the side of the tear. They may have a feeling of locking or catching. In this study all test results were checked and confirmed with an MRI. Accuracy was slightly less (90 percent) when there was a meniscal tear and a tear of the anterior cruciate ligament at the same time.

The Thessaly test may help find meniscal tears without the use of an MRI. This will save money and also help doctors in areas of the United States and other countries where MRI is not available.