News Category: Knee

Orthopedic surgeons are rethinking the role of surgery in the reconstruction of anterior cruciate ligament (ACL) ruptures. We know the ACL damaged knee is at risk for early arthritis. In fact, studies show patients with an ACL rupture (rupture means torn completely through) eventually develop knee osteoarthritis (OA) a full 15 years sooner than adults the same age without this type of knee injury.

Surgery to reconstruct a ruptured ACL is usually done to spare the knee joint further damage. Without an intact ACL, the tibia (lower leg bone) slides forward under the femur (thigh bone). This excess joint motion can cause wear and tear that a stable joint would not be subjected to.

Many times, a force strong enough to cause a complete rupture of the ACL is enough to damage other soft tissues in the knee such as the joint cartilage or the meniscus. Without these additional protective structures, the joint is at increased risk for degenerative changes leading to arthritis. Preventing this early development of osteoarthritis (OA) is another reason surgeons recommend surgery when the ACL is ruptured.

Surgeons must consider whether the surgery itself may be a risk factor for later osteoarthritis (OA). And beyond that — whether the type of surgery performed is a risk factor for OA. The two major types of ACL reconstruction involve taking a piece of donor graft tissue from some other area of the same patient’s knee and using it to replace the torn ligament.

In this study from the Australian Institute of Musculoskeletal Research, degenerative changes in the knee after ACL reconstructive surgery are investigated. The researchers limited their research to patients who had a bone-patellar tendon-bone (BPB) autograft. Autograft refers to the fact that the donor tissue is the patient’s own graft material.

The results of previous studies have indicated that osteoarthritis may occur more often after bone-patellar tendon-bone (BTB) grafting. The authors questioned this finding and suggest there are other risk factors potentially associated with poor outcomes following BTB reconstruction.

To explore this idea further, they followed 114 of their own patients who had the BTB procedure. Follow-up was considered long-term with an average time of 13 years. X-rays were used to identify and rate severity of arthritic degenerative changes throughout the follow-up period. Whenever possible, X-rays of the uninvolved knee were used as the control group since that leg had not been subjected to surgery.

Tests of knee motion, strength, and function were also used to assess changes over time. They found that one-third of the group developed abnormal to severely abnormal arthritis changes. This rate of 33 per cent was higher than the 12.8 per cent rate of knee osteoarthritis in the general population. In other words, the injured knee was significantly more likely to show signs of osteoarthritis compared with the nonoperative side.

After analyzing all the data, there were several risk factors identified for osteoarthritis after BTB grafting. These included: 1) injury to the first layer of bone under the articular cartilage of the knee joint (chondral bone), 2) a previous knee surgery, and 3) not returning to sports. Previous knee surgeries reported in this group included arthroscopic exam, meniscus cartilage repair or removal, and/or removal of a bone tumor.

Two-thirds of the group returned to sports activity. It was the remaining one-third who did NOT return to sports who had the highest incidence of degenerative osteoarthritis. This group had the highest reported pain and dysfunction after surgery, which may explain why they did not return to their previous level of sports activity.

The authors concluded that there is indeed a higher rate of degenerative joint changes after bone-patellar tendon-bone (BTB) grafting for rupture of the anterior cruciate ligament (ACL). Whether or not a different reconstructive technique would have the same effect was not determined in this study. But a number of other risk factors may be the real key to the early development of arthritis observed in this patient group.

The most significant contributing risk factor seems to be the presence of chondral damage at the time of the initial injury. This association may be explained by microscopic damage to bone cells. This damage is made worse when surgery is delayed and the patients continue to walk on that leg with a change in normal knee joint biomechanics. Meniscus damage also contributes to changes in the load bearing on the joint leading to osteoarthritis. The use of a bone-patellar tendon-bone graft may not be the main predictor of early degenerative bone disease.

In this study from Italy, orthopedic surgeons transplanted donor menisci (plural for meniscus) in the knee of 32 patients and then reported the results over the next three years. Allografts (donor menisci) were used. And they used a specific technique of suturing the graft cartilage that was different from other studies.

Instead of taking plugs of bone and using them like pegs to hold the donor graft cartilage in place, they used sutures. But that wasn’t what made their surgical approach so unique. They also secured or “fixed” the graft to the anterior capsule (anterior means front, capsule refers to the cartilage and connective tissue that forms a cap around the knee).

In other studies, surgeons either used bone plugs or sutured the graft to the anatomic or original insertion point on the tibia (lower leg bone). But the authors say their technique is faster and easier. And now their results show the outcomes are just as good as other methods of graft fixation. They suggest that the best way to get optimal results with meniscal transplantation is to select the correct graft size for each patient, place the graft anatomically, and secure it in a way that promotes biologic healing.

By fixing the sutures to the front of the tibial plateau, they were also able to make a single tunnel through the tibial bone using an arthroscope. With this approach, they could also complete all suturing inside the joint, referred to as an all-inside method of fixation. There is less disruption to the soft tissues of the knee with this method, which could also promote faster healing and recovery.

But how do the results match up with other techniques (e.g., using bone plugs instead of sutures, placement of the sutures in the anatomic location)? Using pain, knee motion, and function as the main measures of results, they found significant improvements in 94 per cent of the patients in their group. There was reduced pain and improved knee function still present three years after the procedure.

Magnetic resonance imaging also showed this surgical method offered a protective effect to the bone underneath the transplanted cartilage. This is referred to as a chondroprotective effect. The only concern was for the graft extrusion observed on MRIs in two-thirds of the group.

Extrusion of the graft refers to pushing of a part of the graft material out of the knee joint cavity. This extrusion was more common in grafts on the lateral side of the knee (the side away from the other knee). There did not appear to be any effect of this extrusion on patient pain or function — at least not in the short-term. Long-term studies may show a different result.

No one knows exactly why graft extrusion occurs. But it is commonly reported in all studies involving meniscal transplantations. Experts suggest a variety of possible reasons for this problem. The fact that the lateral side pushes out more often than the medial side (side closest to the other knee) suggests factors involving biomechanics and load distribution.

But it could be there are effects of surgical technique from putting too much tension on the sutures, using a graft that’s too large for the space (called “overstuffing”), or when the sutures do not reattach the graft at the anatomical location (where the meniscus normally inserts into the bone).

Given the short-term success of this surgical technique, the authors suggest a longer study to follow these patients 10 years or more. A longer period of time would help show whether or not there is a true chondroprotective effect of meniscal allografts. Future studies could also compare allografts implanted this way versus implants secured with bone plugs. Comparing different types of MRIs (e.g., taken while lying down versus standing on one leg or both legs) might also offer some additional information.

The meniscus is a commonly injured structure in the knee and this injury can occur in any age group. That’s what makes it an area of study for orthopedic surgeons. For quite some time now, surgeons have been able to repair torn or damaged menisci (menisci is plural for meniscus) using minimally invasive arthroscopic techniques.

Ten years ago, a new arthroscopic approach called the all-inside method was introduced. There are several benefits to this technique. First of all, only a few small puncture holes are needed to slip the surgical tools into the joint. No large scars are needed. The back of the knee doesn’t have to be opened to tie the sutures (an inside-out technique). Healing time is shorter.

In this systematic review, results of the all-inside repair technique are compared with outcomes for an inside-out approach. Studies included were confined to patients who had just a meniscus tear without injury to any other part of the knee. And the type of meniscus tear was limited to bucket-handle tears only. A bucket-handle tear refers to a meniscal injury affecting the entire inner rim of the medial meniscus. Medial means closer to the middle of the body.

There are two menisci between the tibia (shinbone) and femur (thighbone) in the knee joint. There is a C-shaped medial meniscus on the inside part of the knee, closest to your other knee. On the lateral side of the knee (side away from the other leg) is a U-shaped lateral meniscus.

In younger people, the meniscus is fairly tough and rubbery, and tears usually occur as a result of a forceful twisting injury. The meniscus grows weaker with age, and meniscal tears can occur in aging adults as the result of fairly minor injuries, even from the up-and-down motion of squatting.

Most studies involve patients who have both a meniscal tear and injury to the anterior cruciate ligament</i (ACL). This review isolated studies that only included patients with isolated medial meniscus bucket-handle tears. With these limitations, they were able to find a total of eight studies (139 patients) using the inside-out suture technique. The combined results of these patients were compared with the combined results from 14 studies including 172 patients with the all-inside repairs.

Results were measured by looking at failure rates, patient report of symptoms and function, operative time, healing rate, and complications. The first thing the study showed was that there weren't very many differences in results using these measures between the two groups. For example, the failure rate was 17 per cent for the inside-out repairs and 19 per cent for the all-inside repairs.

Patients reported similar results in terms of symptoms, knee function, and activity. Complications were fairly equal between the groups, just different for one technique compared with the other. The all-inside approach was more likely to cause local soft tissue irritation with knee swelling. The implants used as sutures for the all-inside repair (arrows, screws, staples, or sutures) were more likely to pull out and shift position (called migration).

Complications with the inside-out repair technique included a higher number of nerve irritations or nerve injuries. In these cases, the tip of suture arrows pressing against the nerve caused pain and had to be removed. These results highlighted one of the main advantages of the all-inside repairs — decreased risk of damage or injury to local blood vessels or nerves (neurovascular structures). Although local nerve injury can occur with the all-inside approach, the number of cases is much smaller compared with the inside-out method.

The final conclusion from this study was that most patients having an arthroscopic medial meniscal repair for an isolated bucket-handle tear have good results. There isn’t any difference between the two different approaches (all-inside versus inside-out) as measured by repair failure, complications, and patient report. There may be some differences in terms of costs and long-term results or differences based on patient age that could be investigated in future studies.

So many young people (especially athletes) injure their anterior cruciate ligament (ACL), it has become a major concern among sports health professionals. Girls and women seem to be at greater risk than their male counterparts. Much research has gone into trying to understand the risk factors in order to prevent this potentially disabling injury.

In this literature review, researchers at the McClure Musculoskeletal Research Center at the University of Vermont teamed up with others from the Department of Ocean and Mechanical Engineering in Florida and the Department of Kinesiology at the University of North Carolina to take a closer look at what might be going on.

They carried out a computer search for articles published over a 60 year span of time from 1951 to 2011. They found 21 articles on the hormonal, genetic, and cognitive factors that might contribute to anterior cruciate ligament injuries. These are considered intrinsic factors. Intrinsic refers to something within us.

Two other risk factors of interest included previous injury and extrinsic (outside ourselves) factors. Extrinsic risk factors examined include things like the weather, shoe wear, playing surface, time of year, indoor versus outdoor play, and even the amount of rainfall for outdoor events.

Some of these extrinsic risk factors may create greater risk for ACL knee injuries when combined together. For example, certain types of grass trap the cleats of the athletes shoes increasing the risk of an ACL (or other knee) injury. Wet and rainy weather is better than dry weather before soccer games played outdoors. Hot weather is a risk factor for ACL injuries in open stadiums when compared with cooler temperatures.

With females it’s easy to think the major difference is hormonal and look for a connection with the menstrual cycle. But there isn’t a standard way to accurately determine where a girl or woman is in the menstrual cycle at the time of the ACL injury.

Some studies have attempted to see if females are more likely to injure their knees at a particular time in the menstrual cycle. It’s also possible the risk is no different over the course of time for females. But due to a variety of study designs and differing ways of analyzing the data, no consensus or agreement has been made.

Scientists have discovered receptor sites on the anterior cruciate ligament (ACL) for hormones such as estrogen and progesterone. Just the presence of these places for hormones to attach to cells suggests hormones may influence ligaments. But what the connection is or exactly how these hormones affect the ACL is a big unknown right now.

Hormonal influences aren’t the only possible reasons why females are susceptible to ACL injuries. We know that women playing basketball and soccer are much more likely to injure their ACLs than men playing these same sports at the same level. There may be some anatomic reasons for this. For example, women have a different shape to the bone structure forming the knee. The female ACL is more elastic and less stiff than the male ACL. Female athletes move differently than male athletes and with that difference comes a difference in muscle activation patterns.

The conclusion of this literature review is that it’s highly likely there are multiple factors involved in ACL injuries among females. Whether this is a combination of intrinsic factors, extrinsic factors, or both remains to be proven.

Two areas still being researched are genetic links and brain function. Genetic factors associated with ACL tears have been identified in two studies. And slower mental processing with slower reaction time has been reported in another study. More studies are needed to really examine each of these factors individually and also when combined together in different ways. With more information about risk factors, it might be possible to screen athletes for risk and use prevention strategies to avoid such injuries.

You may be surprised to find out that the number of knee replacements in adults ages 45 to 65 tripled in the last 10 years. What could account for this increase? Researchers at Brigham and Women’s Hospital in Boston, Massachusetts may have found the answer.

Their research uncovered the following surprising statistics:

Anyone facing the prospect of anterior cruciate ligament (ACL) reconstructive surgery will be faced with one major decision. And that is: what type of graft should be used? In some cases, surgeons may just make that decision for the patient. However, more and more consumers want to participate in this type of decision-making.

But there’s no clear-cut, single answer to what type of graft should be used. Each one has its advantages and disadvantages. To help surgeons and patients alike, the authors of this article reviewed all studies published to see what the current evidence suggests.

To begin with, it helps to understand there are allografts and autografts. Allografts refer to tissue from a donor bank. The major disadvantage of an allograft is the body’s tendency to reject tissue it considers “foreign” or “nonself.”

But the advantages are great in that the patient does not suffer pain or infection at the donor site. There is a faster healing time with only one wound to heal. And for some people for whom appearances are important, one less scar is worth the risk of using someone else’s tissue for the procedure.

Autografts refer to tissue harvested from the patient. There are three places the autograft (donor) tissue usually comes from: 1) bone-patellar tendon-bone (BPTB), 2) hamstring tendon, and 3) quadriceps tendon. As you might guess from what has been said so far, the donor site can cause a more painful response than even the primary surgical site.

Patients who have tendon harvested from the front of the knee (two of the three options) can end up with pain along the front of the knee. The painful symptoms can be severe enough to keep them from being able to bend the knee fully or kneel down. That may not sound like much of a problem until you can no longer bend down to tie your shoe, tend a garden, play with grandchildren, or slide into home plate for an athlete.

Given the fact that anterior cruciate ligament ruptures are very common injuries requiring surgery, you might think the decision about which graft tissue is best would be decided by now. But in fact, despite many studies comparing these different approaches, there are still many unknowns and gray areas.

That’s because different studies use a variety of different outcomes to measure results by. They also don’t follow-up with patients for the same length of time after surgery. Some results may be reported after six months, one year, or two years while others extend outcome measures up to 10-years.

Another factor involves rehabilitation programs. Post-operative protocols may differ from one surgeon to another contributing to differences in results. Not to mention the fact that some patients are athletes who rehab differently while preparing to get back into their sport activity. They may count whether or not they return to full participation in their sport as the litmus test for a successful result.

Not only that but there are different ways to attach each graft type adding to the complexity and challenge for the surgeon in deciding which way to go. Many patients do choose which graft type they want so they aren’t randomly put in treatment groups and compared. This can create a treatment bias.

To help compare each technique used from study to study, the authors of this study used seven basic measures. These included knee stability, leg strength, function, return-to-sports, patient satisfaction, complications, and cost. Here’s what they found to help you with your decision.

When it comes to post-operative knee joint stability (joint “give”, laxity, or looseness versus tightness of the joint) it looks like there’s no difference between allografts and autografts. The primary difference is in terms of rupture rate. Improper preparation of allografts (e.g., sterilization, drying) can result in more graft ruptures years later compared with autografts.

Concerning muscle strength. There is agreement among studies that quadriceps strength seems to be equal among the various autografts. The hamstring muscle group is more likely to lag behind in recovering full strength, especially for patients who have a hamstring graft.

Return of overall function seems to be equal among all graft types. But return-to-sports varies widely. The majority of patients (75 per cent) get back to playing but not all return to their preinjury level of participation. Some athletes have to gear down to a lower intensity level of activity while others change the sports activity altogether.

One more area of concern and comparison is complications (e.g., pain, infection, graft failure or rupture). Most patients expect a certain amount of pain right after surgery. But when pain lasts months-to-years later, this symptom becomes a complication. Kneeling pain persists more often with patellar donor grafts. Other long-term annoying symptoms at the harvest site can include numbness, tenderness, or irritation.

Results also showed that infection rates are not higher with allografts. Disease transmission from allograft (donor) tissue (e.g., hepatitis, HIV) occurs in less than one out of every 1.6 million patients.

Finally, graft failure or rupture is more likely occur when there is significant joint laxity (looseness) after surgery. Another significant risk factor is return to sports that require sudden turns or changes in direction (pivoting), sidestepping, and jumping. Studies show that younger, more active patients are the most likely to experience ruptures with an allograft.

In the end, patient satisfaction is rated high (in the 90 percentile) no matter what type of graft is used. If you take cost into consideration, the autograft is less expensive than the allograft. This is due to the cost of the donor tissue (can be as much as $1,000).

In summary, when deciding graft type for ACL reconstruction surgery, each individual patient must make his or her decision about graft type based on known pros and cons of each graft type and technique. This decision is based on age, type of physical activity level desired after surgery, surgeon recommendation, and awareness of advantages, disadvantages, complications, and costs of each procedure.

After surgery to repair or reconstruct a torn or ruptured anterior cruciate ligament (ACL), patient and physical therapist diligently work to restore normal knee range-of-motion. Why is this so important?

Because studies show that loss of knee motion can lead to osteoarthritis in later years. And restoring and maintaining knee motion is one thing patients can do to possibly prevent (or at least delay) osteoarthritis from developing.

In this article, an orthopedic surgeon and a physical therapist team up to discuss the problem of osteoarthritis after ACL surgery. The surgeon focuses on surgical techniques that can prevent impingement while the therapist provides details on how to accurately measure and restore knee motion. Together, they review and present the results of six studies on this topic. They also discuss what is “normal” knee motion.

Most studies examining joint motion after ACL surgery are not long-term. Funding, maintaining contact with patients, and other factors make it more difficult to continue following patients for 10, 20, or more years in order to look for trends in osteoarthritis.

Only six studies were available with X-rays to confirm osteoarthritic changes in the joint after ACL surgery. And the results reported were mixed: some studies reported a link between ACL, loss of knee motion, and osteoarthritis. Others showed a trend but not a clear association. In all of the studies there was a decline in patients’ subjective sense of how the knee was functioning.

Besides loss of motion, there was one other important factor in the development of osteoarthritis after ACL surgery: damage to the knee cartilage. This included both the C-shaped meniscus and the articular (joint surface) cartilage. There is nothing the patient or therapist can do to regenerate knee cartilage. But together they can continue to work on restoring normal, full motion.

That brings us to the second topic of the article: what is normal knee motion? The authors suggest using the standard range from zero (full knee extension) to 135 (full knee flexion) won’t work for everyone. Some people naturally have knee extension beyond zero. That condition is called hyperextension.

Restoring knee extension to zero after ACL surgery in someone who has five or 10 degrees of extra extension (or flexion) in the other knee isn’t going to feel “normal.” Rehab must continue until both knees have equal amounts of motion. This of course assumes the other knee has not been injured or altered from normal.

Using a series of photos with a patient who has uneven knee extension, the therapist shows how to properly assess and measure knee joint motion. Another series of photos demonstrate ways to treat the knee to gain additional flexion and extension. A detailed description is provided of the techniques for both measuring and restoring knee motion.

With proper measuring, the therapist can identify even small (three to five degree) losses of motion early on. This is important while the graft tissue is still remodeling in order to regain full motion. Waiting too long can result in a stiff, painful, and weak knee. Studies show that small losses of either knee flexion or extension can lead to knee osteoarthritis. This is especially true when there is any damage to the cartilage.

Early postoperative rehab focuses on reducing swelling and preventing bleeding into the joint. This can be done with special leg stockings, cold therapy, and emphasizing knee motion. Knee extension is restored first, and then knee flexion. When knee motion on the operative side equals motion on the uninvolved side, then the patient progresses to the next stage of strengthening and motor control.

The long-term studies that are available showed a significant increase in the number of patients with loss of knee motion who developed abnormal joint findings as seen on X-rays. Such changes were observed as early as five years after ACL surgery in patients who had loss of knee motion. On the flip side, patients with known cartilage damage but who maintained normal knee motion were much less likely to develop knee osteoarthritis.

And there is one more factor to consider. Studies show that patients who go into knee surgery with no swelling and full motion are more likely to regain their normal motion early on after surgery. So this finding points to the need for a delay in surgery in order to give the patient time to complete a preoperative therapy program. When there is no measurable swelling and joint motion is “normal” for that patient, then surgery can be scheduled.

In summary, the authors of this article point out that a loss of knee motion may be a significant contributor to knee osteoarthritis after ACL surgery. In the past, our thinking was that the loss of motion developed as a result of the osteoarthritis, not as a primary factor in causing the arthritis. This is a shift in thinking that will require a change in when and how knee joint motion is measured. There also needs to be a shift in the way ACL rehab is carried out (both pre- and post-operatively).

Some people in the medical field say there are no such things as “accidents.” There are always reasons why people get sick or are injured. And this idea may be very true when it comes to ruptures of the anterior cruciate ligament (ACL) of the knee.

Sure it’s easy to say the ligament ruptured when the athlete was tackled and another player landed on that leg. Or when the basketball player’s foot was planted on the floor and she got knocked over while trying to pivot and shoot.

But the truth is these events happen many, many times to other athletes who don’t end up with an injury. So the question becomes what risk factors contribute to injuries like a ruptured ACL? And is it possible to modify those risks to avoid or prevent such disabling trauma?

In this article, athletic trainers from the University of Vermont do a literature review looking for neuromuscular and anatomic risk factors. They labeled the research as Part 1 indicating that they will continue this research and report on other types of risk factors later.

In this first part, knee geometry, alignment, and joint laxity are half the focus. Knee geometry refers to three specific measures of shape, depth, and angle that have been linked with ACL injuries. These include decreased intercondylar femoral notch size, decreased depth of concavity of the medial tibial plateau, and increased slope of the tibial plateaus.

The second area of interest (neuromuscular risk factors) included posture, landing biomechanics, ground reaction forces, core stability, trunk displacement, and active proprioceptive repositioning error. Changes in movement patterns from any one of these factors increase the strain on the ACL and seem to be contributing to the increased risk of ACL injuries.

These anatomical and biomechanical terms may not mean much to you, but surgeons examine the anatomic features for ways to reconstruct and realign the knee after injury. And physical therapists and athletic trainers study ways to work with athletes who may have one or more of the neuromuscular variations that could increase the risk of ACL injury. The authors do provide an in-depth discussion of each anatomic and neuromuscular risk factor mentioned here.

The benefit of research of this type is in being able to counsel athletes wisely and develop effective prevention strategies. Injuries like ACL ruptures can end an athlete’s career — or at least sideline the player for a season or more. There is a future risk of knee osteoarthritis that must be considered as well.

With proper training and good body mechanics, even athletes with nonmodifiable anatomic risk factors may be protected from such injuries. Knee geometry cannot be changed but balanced muscle strength, motor control, and neuromuscular coordination could make a difference.

Exercise programs aimed at these areas during different stages of growth and development may help. Further research is needed to fully understand all ACL risk factors and find appropriate prevention strategies. The role of skeletal and muscular maturation versus conditioning must be evaluated as well.

Pain along the outside (lateral) knee is sure to get anyone’s attention but especially the active athlete preparing for competition. There are a half dozen problems that can cause this type of symptom but the most common is a condition known as the iliotibial band syndrome (ITBS).

In this review article, orthopedic surgeons and a physical therapist team up to provide us with an updated understanding of the iliotibial band syndrome (ITBS). They review the involved anatomy, offer ideas as to the possible cause(s) of ITBS, and discuss treatment approaches. The surgeons present specifics of surgical care while the physical therapist highlights the nonsurgical management.

What exactly is iliotibial band syndrome (ITBS)? Iliotibial band (ITB) syndrome is an overuse problem that is often seen in bicyclists, runners, and long-distance walkers. Athletes who participate in skiing, rowing, triathlons, and field hockey have also reported ITBS as a problem limiting their sports activities. As mentioned, it causes pain on the outside of the knee just above the joint.

The ITB is actually a long tendon. (Tendons connect muscles to bone.) It attaches to a short muscle at the top of the pelvis called the tensor fascia lata. The ITB runs down the side of the thigh and connects to the outside edge of the tibia (shinbone) just below the middle of the knee joint. You can feel the tendon on the outside of your thigh when you tighten your leg muscles. The ITB crosses over the side of the knee joint, giving added stability to the knee.

The lower end of the ITB passes over the outer edge of the lateral femoral condyle, the area where the lower part of the femur (thighbone) bulges out above the knee joint. When the knee is bent and straightened, the tendon glides across the edge of the femoral condyle.

The ITB glides back and forth over the lateral femoral condyle as the knee bends and straightens. Normally, this isn’t a problem. But the bursa (fluid-filled protective pad) between the lateral femoral condyle and the ITB can become irritated and inflamed if the ITB starts to snap over the condyle with repeated knee motions while walking, running, or biking.

In long distance runners, impingement of the iliotibial band against the lateral femoral condyle causes enough friction to create this condition. As the knee bends 30 degrees and straightens fully (to zero degrees), the iliotibial band slides through an area called the impingement zone.

People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far, too fast, and they end up running, walking, or biking more than their body can handle. The repeated strain causes impingement leading to this syndrome.

Some experts believe that the problem happens when the knee bows outward. This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. Pronation of the foot occurs when the arch flattens.

An accurate diagnosis and examination is important so that the proper treatment can be applied. For example, impingement versus bursitis versus flat feet would be treated differently from a tendon that is simply too short and too tight. In almost all cases, conservative care is tried first before considering surgery.

The physical therapist evaluates each patient and performs clinical tests that assess iliotibial band tightness and function. A program of activity modification, stretching, manual therapy (e.g., soft-tissue mobilization to break up adhesions), and equipment change are key features of the physical therapy program.

The therapist will also evaluate the athlete’s equipment (shoes, cleat type and position, bicycle seat and handlebars) and make recommendations for changes. Running form and training programs are reviewed and instruction given to reduce iliotibial band impingement.

But when nonoperative care fails to change the symptoms, it’s time to consider something else. No amount of activity modification, stretching, or change in shoe wear helps the patient with a chronically shortened, tight iliotibial band. Surgery to release the tissue is the treatment of choice. The surgeon may inject the area with cortisone to see if surgery will help. Studies show that patients who respond well to the injection tend to have good surgical outcomes.

Surgery may be done percutaneously (through the skin without a large incision) but open incision may be required. Using diagrams (drawings), the surgeons show and describe the type of surgical Z-lengthening procedure used to lengthen the iliotibial band.

They report being able to increase the stretch of the band by 1.5 centimeters (that’s a little more than half an inch). That may not seem like much but combined with a bursectomy (removal of the inflamed or irritated bursa), it is enough to give relief from the painful symptoms. In many cases, the athletes are able to return to full participation in their chosen sport within eight weeks’ time after the procedure.

In summary, iliotibial band syndrome is a fairly common problem among many athletes, especially runners. Working with a physical therapist to change posture, form, flexibility, and movement patterns is the first place to start. Only in persistent, chronic cases of inflammation is surgery considered as the preferred treatment method. The goal of all treatment is to return the athlete to pain free full participation in sports and activities.

Physicians use knowledge of risk factors to assess which patients might respond best to each treatment approach available for many problems. In this study, German surgeons take a closer look at factors that might increase the risk of revision surgery after autologous chondrocyte implantation or ACI.

ACI is a cell-therapy approach to treat deep or large defects in the knee joint cartilage. It involves using cartilage cells (chondrocytes) to help regenerate articular (joint surface) cartilage. Studies show that in about one-fifth of patients who have this treatment, there is a failure of the cartilage cells to regenerate and fill in the hole.

In cases of treatment failure, a second (revision) surgery is required. Surgeons would like to spare patients both the failed results and the need for more surgery. Identifying risk factors that could increase the likelihood of treatment failure would be helpful. Surgeons could screen patients before surgery and perhaps choose a different treatment approach if it looks like there are indicators that autologous chondrocyte implantation (ACI) might fail.

To conduct this study, 413 patients who had the first ACI procedure for a full-thickness defect (down to the bone) were followed. Anyone who had a failed response was examined more carefully. Data collected about patients with failed outcomes was analyzed.

The kinds of information collected included age, sex (male or female), type of defect (size, location), body mass index (BMI, a measure of obesity), smoking history, and number of previous knee injuries or surgeries. Follow-up was a minimum of at least two years. Some patients were followed for up to 11 years.

Criteria for a second surgery included continued knee pain, loss of knee function, and MRI evidence of pathology. Patients with other knee injuries (e.g., ruptured ligaments, torn meniscus) were not included so there would be no confusion about who had a true failed implantation and who had other causes of knee pain.

Just about one-fifth of the group (21.3 per cent) needed revision surgery. They didn’t all have the same exact problem. Problems ranged from too much cartilage regrowth (called transplant hypertrophy) to not enough (insufficient regeneration). In some cases, there were loose pieces of cartilage in the joint space or bone cysts that formed.

The factors that were most significant for failed ACI included being female, having a previous bone marrow treatment, the use of a periosteum patch to cover the ACI, and previous knee surgery (or surgeries) on that knee. There was no apparent link between age, smoking history, body size, or defect size or location.

A periosteal patch is a thin layer of bone harvested from a nonweight-bearing portion of the knee joint used to cover the implanted cartilage cells. It’s a bit like placing a manhole cover over an open hole. It protects the healing lesion that has been filled with chondrocytes (cartilage cells).

Whenever possible, minimally invasive arthroscopic surgery was done to address the problem. Sometimes the surgeon just had to clean out the area of any bits of debris, bone, or excess cartilage. This procedure is called debridement. In some cases, the surgeon opted for a different surgical approach rather than revise or repeat the chondrocyte implantation.

What conclusions did the researchers come to from this study? The four factors identified can be easily evaluated in patients before considering autologous chondrocyte implantation (ACI) as the treatment of choice for cartilage defects. These factors should be included in the decision-making process and determination of prognosis.

Two recommendations were made regarding the surgical procedure itself. First, whenever possible, contributing knee problems (e.g., ligament instability, boney malalignment) should be treated along with the ACI procedure. And second, making sure the transplanted cartilage is attached to nearby healthy cartilage might help.

The issue of nicotine use may require additional study. Past research results have linked nicotine with greater risk of developing cartilage defects and delayed healing. Nicotine appears to have a toxic effect on chondrocytes (cartilage cells) and may contribute to the formation of holes and defects in the cartilage. The role of nicotine in failed chondrocyte transplantation was not obvious in this study.

If athletes decide to have reconstructive knee surgery for a deficient anterior cruciate ligament (ACL), then is return-to-sport a measure of success for that surgery? Short-term (12 month) studies show that most people have not returned to their preinjury level of sports play following reconstructive surgery for a torn ACL. That’s why the authors of this study extended the timeline to look at medium-term results.

They surveyed 314 athletes of all ages two to seven years after their ACL surgery. Athletes who filled out the self-report questionnaire answered questions about their level of sports participation before the injury and after the surgery. They also commented on overall knee function.

Almost everyone (93 per cent) tried to participate in their sport after their surgery. Only about half of them were successful. And only one-third were playing competitively. Athletes who returned to sports at their preinjury level by the end of the first year didn’t always stay in their sport competitively. That told the researchers that short-term results (12 months after surgery) aren’t always an accurate reflection of what will happen months to years later.

They noticed that men were more likely than women to get back into the game in that first year. But the final mid-term outcomes weren’t any different between men and women. This could mean that women may take longer to rehab and recover but in the end, the results are the same as for men.

In any case, if someone does not return to full participation in their sport at a preinjury level after ACL surgery in the first year, this does not mean they won’t ever get back their full function later. And that is an important finding physicians, physical therapists, and sports trainers can offer athletes who still have not regained full strength, function, and ability by the end of a year.

What keeps people from getting back into the game sooner than later? Why do some athletes stop playing and competing altogether after ACL reconstructive surgery? The hope of the researchers who conducted this study was to find some answers to these questions.

Some things to know about this group of patients: they all had surgery with the same surgeon using the same surgical technique. And they all followed the same post-operative rehab program with a physical therapist. Variables that differed from patient to patient included age, lifestyle factors, and exposure to sports opportunities.

Analysis of the data collected included these factors because the researchers thought perhaps younger patients were more likely to be involved in school sports. They would therefore have more opportunities for sports participation. Older patients might be prevented from getting back into play because of family or work. And as it turned out, more patients 25 years old and older were, in fact, not playing anymore compared with the younger (less than 25 years of age) athletes.

That brings us back to the original question: is return-to-sport a reasonable measure of ACL surgery success? The answer to that question is more of a maybe yes/maybe no than a definite yes or a definite no. This study provided evidence that failure to regain preinjury sports ability is directly linked with the function of the operative leg. Other personal factors also played an important role in the decision to return-to-sport.

Much has been written about the use of autologous chondrocyte implantation (ACI) to treat deep or large defects in the knee joint cartilage. But what happens afterwards? Are people able to put weight on the leg right away? Most of the patients are competitive athletes (that’s how they damaged the knee in the first place). Are they able to return to competitive play? How long does that take?

These are some of the questions surgeons from the Department of Orthopedic Surgery at the University Hospital Freiburg in Germany researched and wrote about. They reviewed all previous studies published on the topic of postoperative rehabilitation following autologous chondrocyte implantation (ACI). They summarized their findings in this article.

Autologous chondrocyte implantation is a fairly new cell-therapy for cartilage defects of the knee. The first study published on the topic was in the early 1990s. So it’s been around for about 20 years but it is still being studied and improved upon.

The basic technique involves harvesting healthy cartilage cells from a non-weight bearing surface of the patient’s knee joint. Those cells are transplanted and used to fill in the defect (hole) in the damaged cartilage lining the joint surface.

The goal of the procedure is to create biologic remodeling of the cartilage. But that’s only part of the total picture. The athlete still has to regain knee motion and strength. Recovering normal nerve and motor control over all movements is essential. Athletes must be able to make quick changes in direction, move from one position to another, jump, and pivot over and over. Without normal neuromuscular control, reinjury is a real concern.

Rehab must be guided according to what’s happening with the transplanted tissue. Studies show that these transplanted chondrocytes (cartilage cells) start to stick right away. Care must be taken not to disturb them. Load and shear forces must be avoided. At first, the area remains more liquid than solid (like jello just starting to set up).

But movement is important because the old saying, motion is lotion is still true. Movement and the pumping action of the knee as it bends and straightens is what help deliver blood to the area. Blood with its oxygen and nutrients feeds the chondrocytes. So how do we keep the knee moving without walking on it?

That’s where rehab specialists (physical therapists) come in. The therapist moves the leg for the patient starting on day one after surgery. This is called passive range of motion (PROM) exercise. Some surgeons are trying continuous passive motion (CPM) machines with patients. The leg is placed in this motor-driven device and moved continuously bending and straightening the leg for the patient.

Studies using CPM following knee replacement surgery have not shown an overall benefit. There is limited evidence to support the use of CPM after autologous chondrocyte implantation. More studies are clearly needed. Whether passive motion is delivered by hand or by a machine, the goals are the same: prevent scar tissue from building up, restore joint motion, and keep the quadriceps muscle tuned up.

The physical therapist addresses other areas as well. The knee joint (including the patella or kneecap) is manually (a hands-on treatment technique) mobilized or moved. The therapist does this without moving the joint by gently applying traction and tiny oscillations (movements) to the bones that make up the joint. Mobilization techniques are also applied to the soft tissues around the joint to keep them soft, moveable and free of adhesions.

Other treatment modalities (tools) used by the therapist during the early post-operative phase include cold therapy (called cryotherapy) and manual lymph drainage. These two therapies may help decrease swelling, pain, and decrease the temperature around the healing cartilage. Cryotherapy is important because studies show that too much heat in a joint can cause breakdown of the chondrocytes (cartilage cells).

When the incisions heal, patients can begin aquatic (water-based) therapy. Aquatic therapy is considered beneficial throughout the postoperative period. Working in the water reduces the effects of gravity and therefore unloads the joint. The weight-bearing force placed on the joint is only 25 percent of the body weight when the water is up to the armpits. Moving through water at waist level reduces the load to 50 per cent of the person’s body weight.

When the repair tissue starts to solidify (moves from a jello to spongy consistency), then there is enough strength to withstand some partial weight-bearing activities. How much weight and how soon the patient can put weight on the knee are still unknown areas. Some therapists have experimented with partial weight-bearing (minimal loading of the knee) as early as two weeks after implantation.

Around eight weeks after surgery, the transplant has filled in the defect and new, healthy cartilage cells are present. As the tissue continues to build and remodel over the next weeks (the patient is now three to six months out from the surgery), the therapist steps up the rehab program. Patients are instructed how to increase weight-bearing and improve walking pattern. Pool-therapy is especially helpful in starting gait training. Full weight-bearing on land is usually allowed eight to 12 weeks after the implantation procedure.

Around six months post-op, the transplanted tissue changes from spongy to the consistency of soft plastic. Now the therapist can progress the rehab program to focus on strengthening, endurance, and functional training. Studies consistently show that quadriceps strength is a major factor in the success of this procedure.

In fact, regaining full quadriceps strength is considered the most important goal of rehab following autologous chondrocyte implantation (ACI). Additional areas of focus in rehab include restoring proprioception (joint sense of position) and sensorimotor control.

Full return-to-sports can still take a while. The final healing phase of the chondrocytes is called maturation. If there are no complications (e.g., wound infection, overgrowth of the graft, graft failure), the entire process from start to finish can take two to three years. The biggest deterrent to recovery is putting weight on the joint too early and/or another traumatic injury disturbing the delicate transplanted tissue.

For physical therapists working with patients who have had an autologous chondrocyte implantation procedure, the authors of this review article provide a detailed proposed rehabilitation plan. They present a step-by-step protocol from the preoperative phase (before surgery) through the early weeks after surgery (one to six weeks postoperative). Details of the rehab program from weeks six to 12, 12 to 26, and beyond 26 weeks are also included.

The authors conclude by pointing out the need for future high-quality studies in this area. Patients, surgeons, and physical therapists need evidence-based research to formulate rehab programs that meet individual athlete’s needs. Cartilage repair is a fairly new procedure. Everyone wants the best outcomes possible and that means finding the right postoperative training protocol. The surgical procedure is important but the follow-up is equally important.

Knee replacements have been around long enough now that their track record is clear. Ninety per cent of these implants last 15 to 20 years without problems. Patients experience a pain free return to normal function. Reports of patient satisfaction are high. But that doesn’t mean problems can’t or don’t occur — they can and they do.

Three of the most common (and biggest) problems include osteolysis (bone resorption), delamination (plastic covering joint surface wears away), and fracture (of the implant or the bone supporting the implant). In this instructional course lecture from the American Academy of Orthopaedic Surgeons, the problem of osteolysis is addressed.

What really causes osteolysis after a knee replacement? Why does this complicating factor result in implant failure? And how should the problem be handled? These are the three main topics discussed in this course lecture. Let’s take a look at each one.

First, the main reason osteolysis occurs is because tiny particles flake off from the polyethylene (plastic) portion of the implant. The body responds to this debris as it would any “foreign invader.” It sets up an inflammatory response to destroy the particles. In the process, bone is destroyed as well.

Studies show the debris can be made up of different sized flakes of material. The smaller pieces are the ones that seem to trigger the inflammation. Larger particles aren’t as likely to start a foreign-body cellular response, but instead delaminate or wear away the smooth surface of the implant. Either way, the end-result can be osteolysis and implant failure.

The implant itself can be a source of problems. Different design features have advantages but also disadvantages. For example, efforts have been made to shape the implant so that it conforms better to the bone. Implants with small contact areas have less surface area to spread the force and load placed on the knee. The increased stress on the implant also increases the risk of wear and osteolysis.

A second design feature is the placement of holes in the baseplate of the implant. The holes actually gave particles of debris a way to migrate or move into the joint. Screws used to hold the tibial portion of the implant in place did the same thing.

The locking mechanism on the implant is another design feature that is intended to hold the implant steady. But even the tiniest movement or slippage of that locking feature and the backside of the tibial implant starts to wear. Over time, the finish on the surface of the implant wears away resulting in delamination, greater stress on the implant, and resulting implant failure.

Not only is the implant itself a potential source of problems, but the way the implant is manufactured has actually been identified as a factor. Off-the-shelf implants that are machined to finish them (rather than compression molded) are more likely to have surface irregularities that lead to delamination.

And one final manufacturing factor that affects how well implants hold up is the method of sterilization used. Of course the sterilization process is important and must be done but the way in which it is done can contribute to oxidation (breakdown) of the polyethylene. When that happens, the same results occur: debris formation, bone osteolysis, and implant failure.

Scientists are studying ways to prevent this oxidation. Additives such as vitamin E have been added to the polyethylene in an effort to maintain the stable properties of the plastic. The hope is that by stabilizing the plastic portion of the implant, there will be less uneven load and better resistance to wear and tear.

Let’s shift our focus now to the management of osteolysis. The first thing to know is that patients must be monitored so that the start of any osteolytic process can be seen and dealt with. Small areas of osteolysis don’t require intervention but just observation over time. If the problem starts to get worse, efforts must be made to put a stop to the progression.

Right now, there isn’t a “best known” treatment to halt the progression of osteolysis. Medications such as antiinflammatories and bisphosphonates (prevent bone resorption) are the first thing to try. Studies are really needed to see if this approach is effective. With large bone lesions, the polyethylene liner is removed and replaced.

Surgeons are advised to make sure the polyethylene liner (original and/or replacement) isn’t old (i.e., hasn’t been on the shelf a long time) and that the liner is smooth with no cracks or damage to the surface. It is also necessary to check the locking mechanism to make sure it is working properly. If the bone lesion is just too big and continuing to get larger, the surgeon may have to replace the entire implant.

Every effort is made to prevent bone loss from the osteolysis and during the revision surgery. X-rays, CT scans, and/or MRIs help give the surgeon additional information about the location, size, and extent of the osteolysis. Bone grafting may be necessary to fill in the holes and stimulate bone growth and repair. The course instructor offers fellow surgeons ideas for surgically treating complex reconstructions required for osteolytic lesions.

Surgeons are always looking for ways to improve surgical technique in hopes of better outcomes for their patients. In the case of anterior cruciate ligament (ACL) reconstruction, there’s been a slight shift in how the tunnels are drilled through the bone for the graft tendon. Along with that change comes the ability to place the graft in a more natural position. The net result is a more anatomic reconstruction.

It is always the case that ACL surgery is done with an eye toward restoring all the damaged structures to as normal as possible. That way, the patient has a fighting chance of returning to normal function with a stable knee. But it is also agreed that the anatomy of the anterior cruciate ligament is complex and difficult to mimic.

One of the more difficult aspects of ACL reconstructive surgery has always been drilling through the tibia (lower leg bone) in order to thread the tendon graft through the hole to the right spot for attachment. This type of tunnel is called a transtibial tunnel.

The tunnel drilling technique used until recently often placed the graft in a vertical (up and down) position. As a result of the slightly off-anatomic position, the knee could end up unstable even though the graft was intact.

Over the years surgeons have tried different ways to approach this problem. They have tried changing the way the second tunnel is constructed. This second tunnel is through the femur (thigh bone). They have tried making the tibial tunnel up higher and shorter. And they have used different starting points for the tibial tunnel along the medial side of the knee (side closest to the other knee).

None of these efforts has proved successful. Problems with joint instability, altered joint kinematics (movement), and early degenerative arthritis have occurred. The latest trend has been to drill the two tunnels separately from each other rather than using the entrance to one tunnel (tibial tunnel) to drill the second (femoral) tunnel. This approach is referred to as independent drilling of the tibial and femoral tunnels. The tunnels and subsequent graft line up in a more anatomic center.

Results of studies so far suggest that this more anatomic approach helps improve rotational stability of the knee. CT scans provide an accurate way to look at the bone tunnel position and compare the position to the results. In this way, researchers have systematically looked for the optimal tunnel (and graft) angle and position.

At first, these varying tunnel drilling techniques were tried on cadavers (bodies preserved after death for study). Using a robotic force sensor system, they were able to test for knee stability in all directions.

Now clinical studies of this independent drilling method have confirmed the improved results with shorter recovery time, earlier return to sports activity for athletes, and fewer failed ACL reconstructive surgeries.

In summary, the shift to independent drilling of femoral and tibial tunnels during ACL reconstructive surgery makes it possible to mimic the more natural or anatomic placement of the graft. The result is a more stable knee. Surgeons are advised to pay attention to optimal tunnel placement as well as graft position and go for the most anatomic alignment possible. Specific details of how to do this are included in this article for surgeons who may be interested in pursuing a more anatomic ACL graft placement.

Orthopedic surgeon Robert A. Arciero from the University of Connecticut Health Center says that repairing damaged ligaments in the knee is “doomed to fail” if injury to the posterolateral corner remains unrecognized and untreated. Dr. Arciero offers his own solution to the problem.

You might not realize it, but the knee actually has corners. It may look like your leg is round on the outside but inside are complex bony and soft tissue structures in a location referred to as a corner. Injury to any of these “corners” that goes untreated can create a painful, unstable knee even after surgery for the presenting knee problem.

There are two corners in the front (anterior) and two in the back (posterior. Then add one from each side: medial (side closest to the other knee) and lateral. Combining front and side and back and side gives us corners named anteromedial, anterolateral, posteromedial, and posterolateral.

The corners of the knee are made up of a very complex system of soft tissues woven together. The way in which they share the load makes an injury of one ligament likely to affect the function of others as well. Sometimes where one ligament ends and another begins is impossible to tell. Likewise, many of the ligaments are attached to the joint capsule surrounding the joint (or to the joint itself) in very unique ways. Connective tissue called fascia is also part of the soft tissue structures that helps hold everything together at each corner.

Treatment for any of the corner injuries requires careful and accurate diagnosis. The surgeon depends on the physical examination and imaging studies for this. In the case of a posterolateral corner (the subject of this article), the surgeon tests for ligamentous laxity of the posterior cruciate ligament (PCL), anterior cruciate ligament (ACL), and the medial collateral ligament.

There are specific hands-on clinical tests (e.g., dial test, drawer test, tests for varus and rotational laxity) that can be performed to assess the integrity of each of these ligaments. The surgeon relies on the uninjured leg to serve as the “normal” results (along with clinical experience having seen other knees as well).

None of these tests are 100 per cent reliable. For example, studies have shown that an isolated tear of the posterolateral corner may not show up easily. An MRI may be needed to fully evaluate a knee for a posterolateral corner (PLC) injury. The presence of bruising on the medial side of the bone is a red flag of potential damage to the PLC.

Identifying all of the damaged soft tissues in a knee injury is important. An isolated posterolateral (PLC) injury may not require surgery. Conservative (nonoperative) care for an isolated PLC injury has the same results as doing surgery. Surgery is only advised when PLC injuries are accompanied by damage to the cruciate ligaments as well. When surgery is needed, it should be done within three weeks of the injury.

Early surgery has been shown to have better results compared with delayed procedures. And reconstruction of the corner (rather than just attempting to repair the damage) is more likely to be successful. With reconstruction, there is more knee stability, better function, improved range-of-motion, and less risk of arthrofibrosis (stiff knee from fibrous adhesions).

The main focus of this surgeon’s report on posterolateral corner injuries is the reconstruction technique he uses. This approach called the dual femoral tunnels, trans-fibular tunnel, free graft is described with interoperative photos and drawings to help surgeons understand the method. Patient positioning on the operating table, place to make the incision, and type of incision are discussed.

The basic idea behind this procedure is to use tendon graft material (from the hamstrings muscle), thread it through two tunnels placed in the bones around the knee in order to secure it to the bone. One type of screw is used to hold the graft in place. Another screw called the interference screw helps determine the amount of tension places on the graft. The position, angle, and tension of the graft material are very important in restoring the right amount of rotation, motion, and angle of the joint itself.

After surgery, patients are in a cast that holds the knee straight and allows for minimal weight-bearing. This period of immobilization lasts about four weeks. During that time, the patients are allowed to do leg raises but active knee motion doesn’t begin until the cast comes off in a month. Then the serious business of rehabilitating the knee begins.

A physical therapist supervises a program of active motion, strengthening, and for athletes a return to sports. Most athletes are back to 80 per cent of quadriceps strength between six and nine months. But for some, full return to a pre-injury level of function can take up to a year or more.

The authors conclude by saying that the best reconstruction technique for posterolateral corner (PLC) knee injuries remains a point of considerable debate. The important thing is to recognize the need for PLC reconstruction. When this area of the knee joint is damaged but goes undiagnosed, reconstruction surgery for the cruciate ligaments is doomed to failure. The double femoral tunnel, fibular-based method of PLC reconstruction described here works well to restore knee stability.

Complete knee dislocations don’t just occur in athletes or as a result of a traumatic injury. For some people, knee dislocation occurs during daily activities. Knee dislocations have been reported when stepping off a curb, going down a stair, walking, or even while just standing still. This type of knee dislocation is referred to as a spontaneous dislocation, ultra-low energy trauma, or low-velocity injury.

Fortunately, low-velocity knee dislocations of this type are rare. Even so, it would be helpful to identify risk factors for these injuries and prevent them altogether. According to a study from the University of Tennessee, one major risk factor is severe obesity.

In a study of 17 patients with low-velocity knee dislocations that occurred during daily activities, the average body-mass index (BMI) was 48. Normal BMI is less than 25, while severe obesity is anything 40 or higher. The full range of BMIs in these 17 adults was from 30 to 68.

The extreme load from their massive, shifting body weight put more pressure on the soft tissue structures than they could bear. The result was rupture of the ligaments, shift of the bones, stretching of the nerves, and tearing of the blood vessels.

When a knee dislocates, there is usually ligamentous damage and there may be nerve and blood vessel injuries as well. Multiple ligaments can be ruptured including the anterior cruciate ligament, posterior cruciate ligament, and the medial and lateral collateral ligaments.

In some cases, the dislocated knee can be relocated without surgery. But if there’s been damage to the nerves or blood vessels then surgery is required. Surgery to repair or reconstruct the ligamentous support was needed in half the group in this study. Two-thirds of the group was stabilized with splints, braces, or external fixation of some type.

The most serious complication of knee dislocation in this group was leg amputation due to loss of blood supply (called ischemia) from vascular injury. Other problems included infection and postoperative arthrofibrosis (stiff knee from adhesions). One patient died of a heart attack, which was considered a complication of the surgery.

Taking a closer look, analysis of the data showed that nerve injuries occurred when the BMI was 42 or higher. Vascular injuries occurred at a BMI of 48 or higher. Patients with a BMI of 51 and higher were at increased risk of both nerve and blood vessel trauma. Patients who had surgery to repair ligamentous and other soft tissue damage had higher function and better overall results.

In summary, the authors point out that severe obesity is a major risk factor for spontaneous, atraumatic (without trauma) complete knee dislocation. There is a potential for serious complications such as loss of limb (amputation) and even death associated with these injuries. The higher the body mass index, the greater the risk of vascular and nerve injuries.

Many people in need of a knee replacement hold off much longer than they should. The reason? They’ve heard horror stories about how painful the knee will be after surgery. They are told that it’s a different kind of pain — much worse in some ways than the arthritic pain. But in time, the pain will work its way out and they will be able to move pain free once again.

In fact, this bad reputation of postoperative pain after total knee replacement has a large measure of truth. There are many physiologic, biologic, and patient-related reasons for this increased pain. In this article, orthopedic surgeons explain the pain mechanisms and describe a new approach to pain management for this problem.

Why is the pain so much worse after knee joint replacement? First of all, the surgery sets up an alarm in the nervous system that signals to the brain that there is a problem. But the signals that get started amplify and prolong the initial pain until it becomes severe and chronic.

At the same time, the tissues are injured as the surgeon cuts through the skin and removes the old joint. The body responds with an inflammatory cycle that releases many chemicals and substances that have the effect of lowering the pain threshold. That means it takes very little to set off the pain signals and a lot to turn them off. Not only are the cells of the injured tissue reacting, but so are all the pain receptors in the surrounding tissue that hasn’t even been touched.

Not everyone has the same pain responses so there must be individual factors at work, too. Some people just perceive greater pain than others when given the same stimulus. This could be a matter of coping skills, the presence of psychologic depression, or the lack of certain enzymes needed to benefit from pain medications.

Studies show that patient-controlled narcotic pain medications work much better than nurse-administered methods. Instead of waiting for the nurse to bring the next dose of pain medication, the patient can decide when it is needed. Staying on top of the pain is a key part of successful pain management. Delaying medication too long can make the pain cycle much worse.

The new pain management protocol proposed by the authors has two parts. The first is called preemptive analgesia. This refers to the fact that it is easier to prevent pain than to try and get rid of it once it starts. Getting control of pain signals in the disrupted soft tissues before those adjacent nerve cells can start firing is important.

The second part is called multimodal analgesia. This refers to the use of a variety of different medications to achieve pain control. Using low doses of several drugs helps turn off the multiple pathways pain messages are relayed to the brain. The best approach is to combine both approaches (preemptive analgesia and multimodal analgesia).

The program begins two days before surgery when patients are started on an antiinflammatory medication. One hour before surgery, a narcotic (e.g., oxycodone) is given. Then during the surgery, the knee is injected with an antiinflammatory and narcotic.

Pain controlling medications and antiinflammatories are continued after surgery. The patient is sent home with pain relievers, sleep aids, and antiinflammatories. Other medications such as Tylenol, gabapentin, clonidine, and ketamine are also used as needed.

Sometimes medications are combined together and injected as one. This is referred to as a drug cocktail. The authors of this article are actively researching various combinations of medications in these cocktails. They are trying to find the most effective combination and just the right dosages of each individual drug. The mixture is injected into all four quarters of the knee (front, each side, back).

Pain levels, pain intensity, and pain duration are used to measure results. Other measures used to assess outcomes include amount of narcotic needed, any sleep disturbance reported, knee range-of-motion, and nausea/vomiting present.

They are finding that the approach reported here is giving superior pain control and much improved functional outcomes. All of this takes some change and cooperation among the many surgical partners. The surgeons, pharmacists, anesthesiologists, nurses, physical therapists, and patient/family must work together to create as pain free of a surgical response possible. Communication and collaboration are the key but as the authors put it so well, “the result is worth the effort.”

Many people with knee injuries want to wait before having surgery to repair a torn anterior cruciate ligament (ACL). And there is evidence to support this decision for some patients. But in many cases, the ACL isn’t the only injury present. Often, the meniscus and joint cartilage are torn, too. How does delaying surgery affect the repair rate for these associated injuries?

In this study, a large amount of data from the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry was used to answer three questions:
1) What’s the relationship between time-to-surgery, age, and sex (male versus female) on the injury pattern (e.g., just meniscus, just cartilage, both meniscus and cartilage).
2) What is the effect of time-to-surgery, age, and sex on repair rates for ACL plus a torn meniscus?
3) How do the results of this study compare with other (previously reported) studies?

Kaiser Permanente is a large health care facility located across the United States in 35 medical centers and 431 medical offices. They serve more than 8.8 million members. The special registry for ACL patients used for this study included patients from three different locations under the care of 20 surgeons.

The information for each patient treated surgically to reconstruct a ruptured ACL was placed into the computer database. Information included patient demographics (age, occupation, sex, date-of-injury, date-of-surgery). The record for each patient also included type of soft tissue injury and results of surgical repair (repair rates).

By running various computer statistical programs, the authors were able to analyze and evaluate a total of 1252 patients. They found that delaying surgery (12 months or more) was linked to a greater risk of medial meniscus and joint cartilage injury. The delay was also likely to result in a reduced repair rate.

That answers the first question (relationship between time-to-surgery and the effect of patient variables on injury pattern). And it also answers the third question (how do these results compare with what other studies have reported). The results of this Kaiser study are very similar to other smaller studies that showed a delay in time-to-surgery was linked with poorer outcomes.

This Kaiser study took a look at more than just time-to-surgery by comparing age and sex as additional possible risk factors for greater injury and decreased repair rates. What else did they find here? Younger patients were more likely to just suffer an ACL tear without other soft tissue injuries. Females made up more of the younger age group than males. Men tend to participate in active sports longer so injure themselves across a broader range of ages.

Being male and older age were also risk factors for meniscal and cartilage injuries. Men were at greater risk of lateral meniscus injury and combined injuries (e.g., ACL tear plus meniscus AND cartilage damage). Time-to-surgery and age didn’t seem to be linked with lateral meniscal injuries.

What are the implications of these findings? Surgeons may want to advise patients to consider surgery sooner than later. A simple ACL tear can become a full rupture and lead to additional soft tissue injuries of meniscus and cartilage. Chronic knee instability may be avoided with early repair and restoration of the anterior cruciate ligament.

For those individuals who wish to wait (delay surgery), activity modification is important. They should be advised to avoid pivoting or twisting type actions of the knee (especially with the foot planted on the ground). Ligament repair should be done before returning to these kinds of activities, which increase the risk of further damaging the meniscus and cartilage.

Athletes who continue to suffer pain and loss of knee function from patellar tendinopathy can benefit from surgery. Significant pain relief and return to full sports participation is possible. These are the reported results from a recent European study.

Sixty-four patients with patellar tendinopathy who did not get relief from their symptoms with conservative (nonoperative) care were included in the study. Alignment or overuse problems of the knee structures is a common problem among athletes. Strain, irritation, and/or injury of the patellar tendon often produce pain, weakness, and swelling of the knee joint.

In the acute form of this problem, patellar tendonitis (also known as jumper’s knee) develops. When the condition goes on for more than three months (six months at the outside), it is considered a chronic problem.

In the chronic phase of this condition, microtears in the tendon have failed to heal. Instead, poor blood supply leads to changes observed in the tendon-bone interface as well as in the fibrocartilage of the patella (knee cap). Ultrasound studies have also shown the formation of cyst-like cavities where the tendon attaches to the bone.

Knee pain and tenderness where the patellar tendon attaches to the bottom of the patella (knee cap) is the most common symptom. It is usually activity-related (i.e., occurs with movement especially running, repeated jumping and landing, and kicking).

Nonoperative care is the first-line of treatment for this problem. The best approach (one that works for everyone every time) remains uncertain. Instead, the patient tries activity modification, rest, antiinflammatory medications, exercises, cold therapy, steroid injections, deep friction massage, or some combination of these approaches.

When conservative care fails to improve things, the athlete may be directed to a surgical solution. Unfortunately, the best way to treat this problem surgically remains as much a mystery as the best nonoperative approach. The first decision regarding surgical treatment is whether the procedure should be done arthroscopically or with an open incision.

That’s where this study comes in. The 64 athletes were treated arthroscopically by one surgeon. One-third of the group was involved in professional sports (soccer, basketball, and volleyball). Those athletes involved in recreational sports were also engaged in jogging and tennis.

The technique used was debridement (shaving or clearing away) of abnormal tissue and removal of the lower pole (portion) of the patella. In particular, the surgeon removed an area of fat called the Hoffa fat pad. This layer of adipose (fat) tissue is located behind the patellar tendon. That’s the area where there is the most loss of blood flow. Shaving this tissue away helps stimulate a more natural healing process.

Before and after surgery results were compared using pain, knee motion, and knee function as outcome measures. Specific tests used to assess the results included the International Knee Documentation Committee (IKDC), Lysholm score, and Victorian Institute of Sport Assessment-Patella (VISA-P).

Despite concerns that arthroscopic surgery for patellar tendinopathy might not be the ideal choice, the majority of these patients had excellent mid-term and long-term results. Before and after testing showed significant improvements that lasted at least three years.

Some of the patients were followed for up to 10 years with the same continued good results. Best of all, half of the professional players were able to return to full sports play within three months of the surgery and there were no complications for anyone enrolled in the study.

For those who were either unable to return so quickly or who still had ongoing pain might have gotten better results with open surgery. The open procedure gives the surgeon a better look in order to determine all areas of abnormalities requiring treatment.

Determining who would respond well to arthroscopic surgery and who is going to need an open approach is the next step in researching this problem. For now we know there are, indeed, many athletes who will respond well to arthroscopic treatment of chronic tendinopathy. Their return to full sports action in a short period of time is proof of that.

Athletes who want to get back into action after an anterior cruciate ligament (ACL) tear are often advised to have surgery as soon as possible. But is this advice really warranted? Do players with deficient ACLs who have surgery have better results than those who don’t? These are the questions explored by the author of this article.

A literature review was done to answer the question. The author (a physical therapist and director of the Jerusalem Sports Medicine Institute) searched for information to answer two other questions. First, is it possible to identify patients with an ACL tear who need surgery in order to be able to return-to-play? And second, what are the differences between those who can go back to play without surgery (called copers) and those who require surgical reconstruction of the knee (the noncopers)?

There is actually a third group of ACL injured and those are the adapters — athletes who manage without surgery by reducing or modifying their activity level. This group is unable to resume high-level sports activities but must lower their sports participation in order to avoid surgery.

Current evidence does not support the need for immediate surgery for all ACL tears. It is possible that even with ACL repair or reconstruction, the high-level of sports play will not protect the knee from future injuries. And there is some question whether this type of surgery really restores full stability and biomechanical function of the knee.

With all that in mind, let’s take a look at what was found in the literature to clear up some of these questions. Of the 65 published articles that were included in the study, only five were specifically looking at copers versus noncopers.

To better understand the specifics of copers versus noncopers, copers were defined as athletes who could go back to their preinjury level of sports without knee problems. They did not have episodes of the knee giving out from underneath them. And they were even able to perform activities requiring jumping, pivoting, cutting, and quick stop-start moves. Noncopers were unable to return to their previous level of activity and/or they reported episodes of knee instability described as “giving-way.”

As it turns out, noncopers really do have significant objective findings to explain why they can’t perform normal knee activities. Their quadriceps muscles are weak and the noncopers have decreased quadriceps control. They have more cocontraction of the quadriceps and hamstrings muscles (both contract at the same time), and significant changes in the way the knee moves.

Cocontraction is just one way the body has of automatically protecting an injured joint by increasing stiffness around the joint. This is an effective way to help the joint compensate for loss of ligamentous support. Some studies also showed that the way the quadriceps and hamstrings muscles contract during movement changes in noncopers.

Now that we know there are true (measurable) differences between copers and noncopers, the next natural question is: can a noncoper rehab successfully to become a coper without surgery? Right now, that question isn’t really asked and noncopers are routinely referred for surgery. There hasn’t been a tool or test that can sort out one group from the other.

We do know that specific training programs that include strength training combined with perturbation (balance) training helps retrain the muscles (reducing cocontraction) and restores more normal knee motion. But does this training eliminate the need for surgery? The answer to this question remains unclear and points to the need for further study of this problem.

Several groups around the world have started studying ACL injuries with this intent and focus. Their preliminary results show that as many as two-thirds of athletes with ACL injuries can obtain good knee function and return to sports with the rehab program just described. But the recovery period takes time and some athletes may still opt for surgery in hopes of a faster return-to-play.

There are still many other factors and variables that must be examined when studying the results of treatment (conservative versus surgical) for ACL injuries. The risk of future injury or development of osteoarthritis has been raised as an issue. It’s possible that these problems are just as likely for copers as noncopers (i.e., those who don’t have surgery versus those who do). If that’s the case, then the idea of preventing these problems by having surgery comes under fire.

Complications of surgery must be considered as well as changes in the way patients move and function when they fear another injury. It may seem like this literature raised more questions than it answered. This highlights the fact that decisions about treatment for ACL injuries are complex. The bottom-line is that there’s enough evidence to support a nonsurgical approach to ACL tears — even for athletes who intend to return to full sports participation. Finding a way to sort out who will do well without surgery and who won’t is the next step.