News Category: Knee

Younger adults (65 or younger) who want to delay or avoid a total knee replacement may have other treatment options. One of these options is a surgical procedure called opening-wedge high tibial osteotomy. In this procedure, a pie-shaped wedge of bone is removed from the inside edge of the tibia (lower leg bone). The osteotomy is done at the upper end of the tibia just below the knee. The goal is to change the angle of the knee and thus alter the weight-bearing pattern.

Who can benefit from this approach? Well, as the technique describes, patients who put too much weight on the inner (medial) compartment of the knee might do well with this type of osteotomy. By shifting the weight more towards the middle of the knee, ground forces up through the foot when walking are evened out. The result can be to prevent medial compartment arthritis and put off (or even eliminate) the need for a joint replacement.

In this study, patients were not included who had already lost 20 or more degrees of knee extension (their knees were stuck in a bent or flexed position). This surgery was also not recommended if the patient couldn’t bend the knee past 70 degrees or who had an unstable knee joint. Instability was judged by how much the tibia could slide back and forth under the femur (thigh bone). More than a one-centimeter subluxation (movement toward dislocation) was considered a reason to exclude patients. These findings are more suggestive of someone who really needs a joint replacement and wouldn’t benefit from an osteotomy.

There were a total of 20 adults (men and women between the ages of 36 and 67) in this study. All met the inclusion criteria and were treated by the same surgeon. To be included in the study, patients had to have a confirmed diagnosis of medial compartment arthritis. This also meant they had an abnormal alignment of the knee called varus (too much angle putting too much weight on the inside edge of the knee). They all agreed to stay in the study and follow all recommendations made by the surgeon to avoid having a knee replacement.

Results were measured by comparing tests administered before surgery to after surgery values for the same tests. This information was obtained through before and after X-rays and gait (walking) using video data and computer software analysis. Patients walked on a 10-meter long walkway that had a force plate to record the weight-bearing pattern. Several well-known tests (e.g., Lysholm knee scale, Hospital for Special Surgery knee rating system) were used to assess symptoms, function, motion, strength, deformity, and stability.

Of course, the surgery took place between the two sets of measurements. First, the surgeon performed an arthroscopic exam. By inserting a scope inside the knee, he was able to look the joint over carefully for any defects in the cartilage. At the same time, the integrity of the ligaments and joint cartilage were assessed.

Once the arthroscopic exam was completed, then the surgeon performed the osteotomy. The surgeon made the correction to the knee angle and tested it by putting pressure through the heel up into the knee. The osteotomy opening was determined based on the weight-bearing line of the knee joint. [They made sure the weight-bearing line went through the lateral compartment (outside half) of the knee]. The exact steps for this operation are described in this article with X-rays to show the before and after knee angles. The new knee position was maintained with a metal plate and screws. Bone graft material was also placed in and around the opening made by the wedge cut.

Everyone was followed through regular appointments with the surgeon. When X-rays showed signs of solid bone forming at the osteotomy site, then the patients could start to put weight on that leg. Physical therapy was a part of the post-operative recovery plan. By the end of the two-year follow-up period, correction was still maintained for all patients. Not everyone was able to avoid having a knee replacement. About one-fourth of the group had a total knee replacement much later.

Overall, patients improved significantly in terms of decreased pain and improved function. There was evidence of improved gait patterns (returning to normal weight-bearing and load distribution across the knee). All patients were able to remain highly active without any restrictions on their activities.

The authors report medial opening-wedge high tibial osteotomy can provide good results in younger adults who want to avoid knee replacement yet still remain active. They suggest that correcting knee alignment is easier to obtain and control with this type of osteotomy compared with lateral closing-wedge osteotomy, for example.

Results of this study provide short- to mid-term outcomes. Because other studies of osteotomies show breakdown over time, it will be necessary to continue following these patients much longer to see the long-term results. Finding the optimal amount of correction is another area for future study. The authors used the weight-bearing line (making sure it passed through the lateral compartment) to unload the arthritic medial compartment. This may be an ideal method of determining the angle of alignment but future results will be needed to verify this approach.

Did you know that the bone can get bruised? Now that we have technology like magnetic resonance imaging (MRI), discoveries like bone bruising are possible. What does it look like on the MRI? MRIs are made of signals that show up as an image on the computer screen. The signals have various levels of intensity from light to dark. Changes in the signal pattern alert the radiologist to any problems.

In the case of bone bruises, blood pooling, fluid build up (swelling), and increased blood flow to the area show up on the MRI. Water that moves seen within the bone marrow (center of the bone) is another sign of bone bruising. If the injury is severe enough, there can even be tiny fracture lines in the bone referred to as microfractures.

Traumatic bone bruises of the knee are the subject of this article written by two orthopedic surgeons. One surgeon is from Harvard Medical School (Boston). The other hails from Vanderbilt Sports Medicine Center at the Vanderbilt University Medical Center in Nashville, Tennessee.

Bone bruises of the knee from trauma in athletes affect the subchondral bone. This is the first layer of bone underneath the cartilage of the knee. The most common injury associated with bone bruising is a rupture of the anterior cruciate ligament (ACL).

You’ve probably heard of ACL injuries. The ACL is one of two ligaments that criss-cross each other inside the knee. An injury severe enough to pull the ligament off the bone where it attaches can also cause bone bruising. In fact, 80 per cent of all patients who suffer an ACL rupture also have evidence of bone bruising on MRIs.

Without the ACL to hold the tibia (lower leg bone) from sliding too far under the femur (thigh bone) the impact of the injury, the loss of the ligament, and the movement of bone-on-bone leaves the site of the rupture bruised. In fact, there’s even a telltale sign on the bone called the footprint that shows where the impact left the bruise.

Studies have shown that the severity of bone bruising is a direct result of the energy of the injury. Contact injuries (the athlete is hit by another player or falls and makes contact with the ground) have more energy behind them than noncontact injuries (the foot is planted on the ground and the player makes a sudden change in direction).

Recognizing the fact that bone bruising occurs is a fairly new discovery. Knowing what happens in the long-term is unclear. Repeat MRIs show that the bruising goes away over time (usually within 60 days).

Studies done so far don’t show any problem with returning to normal function after a bone bruise. Most athletes are back on the field within six months’ time. The real question on everyone’s minds is whether or not the bruising will result in arthritis later.

We know that damage to the articular cartilage lining the joint is a poor prognostic sign — that means when the cartilage is damaged, it’s very likely there will be problems with arthritis later. As time goes by, researchers will follow patients who have signs of bone bruising and see what happens years later.

Other injuries resulting in bone bruising such as dislocated or fractured patellae (plural for knee caps) will also be investigated. For now, radiologists are working hard to identify locations of bone bruises and the mechanisms behind them.

At the same time, they are categorizing any associated injuries and reporting on bone bruise patterns (what is actually seen on the MRI). In time, there will be some answers about the natural history (what happens over a period of months to years) of bone bruising.

Knee pain is a common problem among the young and old alike. From athletes to middle-aged adults to seniors, knee pain can develop suddenly. There are many potential causes owing to the fact that there can be ligament involvement, cartilage tears, muscle strains, cysts, arthritis, and more.

Most of the time, knee pain is felt in the front of the knee or along either side. Posteromedial pain (inside back corner) is less common and more puzzling — especially when it lasts a long time.

The authors of this article bring to our attention the possible causes of posteromedial knee pain. In particular, the focus is on one that is infrequent but should be considered: semimembranosus tendinopathy.

The semimembranosus muscle is part of what you might know otherwise as the hamstring muscle. It is made up of three separate but conjoined parts. This portion starts at the base of your sit bone (called the ischial tuberosity).

It travels down from the pelvis to the knee and inserts right along the posteromedial corner. The job of the semimembranosus is to flex or bend the knee. If you feel under the knee while in the sitting position you’ll be able to feel the tendon easily.

Overuse of this muscle from sports activities or degeneration from overuse with age is the underlying cause in two age groups: young endurance athletes and middle-aged (and older) adults. The diagnosis can be elusive.

In older adults, there are often many changes in the knee going on at the same time. They could have semimembranosus tendinopathy and bursitis or a meniscal tear or bone spurs rubbing against various tendons. Sometimes they have combinations of pathologies.

No matter the age of the affected individual, the symptoms are the same. Pain is localized right to the posteromedial aspect of the knee. The pain gets worse with activities that involve using the hamstring muscle to bend the knee.

For athletes, pain may come on after increasing their training (e.g., running or cycling). For older adults, it could be associated with going down stairs, walking, or any activity that requires full knee flexion.

A careful examination is necessary to pinpoint and isolate the problem to the semimembranosus tendon. The examiner will look at the overall posture to see what biomechanical problems might be contributing to the problem. Besides palpation (feeling where the pain is located), there are a few clinical tests that can be performed to help make the diagnosis.

The use of imaging studies may help. X-rays don’t usually show anything to suggest a problem with the muscles so the physician must rely on MRIs or even better, bone scans and ultrasound. It’s a tough little area of the knee to really get a view of what’s going on — even with arthroscopy, the problem isn’t easily visible.

When the surgeon can see evidence of a problem, it’s usually the presence of fluid around the bursa in that area of the knee or a thickening of the tendon. Sometimes breakdown of the tissue or scarring called fibrosis can be seen on the ultrasound test.

In some cases, the most accurate diagnostic test and the treatment are the same: local anesthetic injection. The surgeon injects a numbing agent around the semimembranosus tendon where it attaches to the bone. Immediate relief of pain confirms the site of the problem.

What next? The patient is sent to physical therapy where he or she will be instructed in proper use of ice, activity modification, stretching, and strengthening exercises. Posture and alignment will be assessed and corrected with exercises and/or shoe modifications. Sometimes a heel lift is all that’s needed. In other cases, a specific shoe might be recommended.

Medications such as anti-inflammatories may be prescribed. For cases that don’t improve with conservative care, up to three injections can be done. Surgery is a final option for those who have bone spurs that need to be removed or when it is necessary to re-route the tendon.

The surgeon is careful to look for other contributing causes to the problem and treat those as well. Semimembranosus tendinopathy should be suspected when posteromedial pain just never quite goes away. Pain that is pinpointed to the insertion site of this tendon is a pretty good indicator, too.

Results are good when the problem is identified properly early on. Conservative care is all that’s needed for nine out of 10 patients. But a delay in diagnosis because there’s more than one problem or the semimembranosus tendon isn’t considered as a possible cause is all too common.

The authors hope this article will alert physicians to remember to investigate semimembranosus tendinopathy as a potential part of the differential diagnosis when posteromedial knee pain develops in patients of all ages.

Treatment of holes in the articular cartilage of the knee has taken a decided turn in the last 15 years. Surgeons have found ways to either repair or replace the cartilage. Results have steadily improved so the question now is: which method works best?

In this systematic review, surgeons from the Sports Medicine Center at Ohio State University compare autologous chondrocyte implantation (ACI) against other surgical treatment techniques for this problem.

Here’s a little more background information to help you understand the importance of this study. First, there are different kinds of cartilage and locations. The articular cartilage is the one that lines the joints and makes it possible for the joint to slide, glide, and twist smoothly during movements like flexion, extension, and rotation.

Damage to this layer of cartilage can cause pain, swelling, and eventually degenerate into arthritis. It doesn’t have the ability to heal itself when damaged, so these new treatments to repair or replace the cartilage are very helpful. Repair techniques involve marrow stimulation such as abrasion arthroplasty, drilling, and microfracture. Replacing the cartilage defect with healthy donor cartilage consists of autologous chondrocyte implantation, osteochondral autograft, and mosaicplasty.

Second, a systematic review means they have taken a look at all the studies published about repair or restoration of the articular cartilage. By combining the data from all similar, high-quality studies, some patterns in results can be observed and some conclusions drawn about what works, how well it works, and how long the results last. In this review, they found 13 studies that could be included with a total of 917 cases. The statistical significance of findings is much greater with this large a number of patients.

Now, what is autologous chondrocyte implantation (ACI)? It is a restorative (not a repair) procedure. Autologous means the cells are harvested for the implantation from the patient who needs the repair. In other words, you donate your own chondrocytes (cartilage cells). They usually are taken from an undamaged area of the knee that doesn’t bear as much load as the damaged spot.

This procedure is done when there are full-thickness defects in the articular surface of the joint. Essentially, there has been an injury that has pulled off a piece of the layer of cartilage that lines the joint. Full-thickness means the defect goes all the way down to the first layer of bone (subchondral bone.

Studies so far have shown some pretty good results with autologous chondrocyte implantation (ACI). But how does it compare to other restorative techniques used? And now that surgeons have found a variety of different ways to do the ACI procedure, which one works best? Those are the main questions this systematic review was meant to answer.

The four reviewers involved in this study looked at all published studies from 1950 to 2010 using any method of ACI (e.g., periosteal cover, collagen-membrane cover, three-dimensional scaffolds, and different methods of fixation or attachment of the cartilage graft). The surgeries could be done with an open incision or by using an arthroscope with incisions small enough to insert the scope. Only patients having knee cartilage treated were included and follow up was at least one year.

For anyone interested in the methods used, the level of quality of studies included, or more specifics about the patients in the studies, the authors provide a detailed description of each. Type of surgery done, age of patients, and length of time from symptom development to diagnosis to surgery are summarized and reported. Details about the surgical tools and techniques used are also provided.

And, of course, a comparison of results for each surgical technique was summarized. The researchers also took the time to evaluate which patient factors (e.g., age, activity level, duration of symptoms) affected the outcomes for each procedure. In a separate analysis, they also looked at defect factors (e.g., size, depth, location) influencing the results. Complications reported such as infection, blood clot, continued symptoms were compared from one technique to another.

All-in-all this systematic review was thorough and very comprehensive. And here’s a brief summary of the in-depth findings reported by the authors:

Everyone faces the decision to ‘repair or replace’ when it comes to clothes, cars, computers, household possessions, and so on. Sometimes the decision is based on finances. In other cases, it’s just a matter of convenience, time, or personal preferences. But when faced with the same decision for complex knee injuries, suddenly the stakes are much higher.

Knee injuries so severe that there is dislocation, fracture, and/or multiple ligaments ruptured require careful consideration when planning treatment. The decision to repair versus reconstruct is an important one.

In this article, a group of surgeons present an instructional course lecture on the management of complex knee ligament injuries. The information was first presented at the American Academy of Orthopaedic Surgeons’ annual meeting.

Injuries of this type are usually the result of trauma that require emergency evaluation and treatment. The surgeon must quickly but thoroughly assess the extent of damage to the bones, soft tissues, nerves, and blood vessels in the leg. Knee dislocations are notorious for causing nerve injury even when the patella (knee cap) automatically reduces (goes back into place).

Tools used to conduct the evaluation begin with visual inspection (e.g., location of the injuries, signs of blood loss) and include testing for blood supply (e.g., Doppler, CT angiography, ultrasound). The presence of any damage to blood vessels or loss of blood supply to the area means a vascular surgeon must scrub up along with the orthopedic surgeon to perform the necessary procedures.

Before surgery can be done, X-rays and MRIs are taken to identify the extent of ligament injury (location and severity). This information helps the surgeon plan what must be done in the operating room. A plastic surgeon may be needed if there has been so much soft tissue damage that the wound can’t be closed without a graft. Sometimes there are torn or ruptured ligaments that get put on the back burner (repaired later) because of the need to restore blood supply and save the leg first.

When it’s clear that there are multiple ligaments torn, reconstruction (rather than just repair) of the ligaments is usually preferred. Studies show that the outcomes (in terms of symptoms, motion, and function) are better with reconstruction over repair in the management of such complex ligament injuries. In some cases (e.g., medial collateral ligament, four ligament ruptures), the failure rate is much higher (20 per cent) with repair versus reconstruction (only four per cent).

The authors provide detailed descriptions of surgical techniques used to accomplish this type of reconstructive surgery. Location and direction of incisions, source of tissue for grafts, tunnels for the graft tissue, graft positioning, and fixation of graft tissue are discussed. Drawings, X-rays, and color photos taken during surgery are provided to help instruct surgeons in understanding what is recommended for treatment of major injuries of this type.

Because there are many different surgical techniques possible for some of these injuries (e.g., posterolateral corner injury, multiple ligamentous damage), the authors also reviewed all of the evidence of what works best for each one. Preferred techniques and author recommendations are made.

One particularly challenging problem is fracture-dislocation of the patella with multiple knee ligament ruptures. The surgeon has to find a way to anchor the reconstructed ligaments to bones that are often broken into pieces and unstable. There aren’t a lot of studies to show what works best for these types of complex injuries. In general, the results are poor no matter what efforts are made to stabilize the knee. Complications are also common (e.g., infection, pain, scarring).

Most of these complex injuries require staged procedures. That means everything that needs to be done can’t be completed in one day or during one operation. They try and treat any fractures or dislocations the first day. Blood supply is restored and stabilized.

Reconstruction of soft-tissue injuries may be delayed for up to one week before the next stage of treatment can begin. Ligament reconstruction (phase three) takes place three to four weeks later. There may even be a stage or phase four if the knee is still unstable and further reconstruction is needed.

At that point, the main part of the surgeon’s job may be done. Close monitoring and follow-up are the major focus now. But the patient’s work has just begun. Rehab and recovery may take another set of stages over a period of weeks to months. The more damage present, the more extensive the surgery, and the longer the recovery time. Return-to-work and/or return-to-sports for athletes can be achieved with a work- or sports-specific rehab program.

The authors concluded by saying there is still much about the treatment of complex knee ligament injuries that remains unknown. Studies are small and reports of results are fairly limited. There is a need for comparison of various surgical techniques, the timing of surgery (early versus late), and optimal treatment and rehab protocols.

The authors of this study have developed a new way to treat injuries of the posterolateral corner (PLC). They are busy testing the results to see if this reconstruction technique might work better than others currently in use. What is the posterolateral corner (PLC) and where is it located in the body?

The PLC is in the knee where two ligaments and one tendon meet. Posterior refers to the back side of the knee joint. Lateral tells us the affected area is to the side. So we are talking about the posterolateral (side of the knee toward the back) area where the lateral collateral ligament, popliteofibular ligament (PFL), and the tendon of the popliteus muscle all meet.

These soft tissue structures at the posterolateral corner help keep the tibia (shin bone) from sliding backwards under the femur (thigh bone). When the posterolateral corner is injured, knee instability can develop. Injuries in this area occur most often as a result of a car accident, during sports play, or from a work injury.

A person with a weak posterolateral corner will experience hyperextension of the knee when walking or going up and down stairs. Hyperextension means the knee goes back past a straight (extended) position because the mechanism that holds it in neutral is torn or damaged in some way. Every time they take a step, the knee pushes back farther than it should. The natural response to this awkward problem is to walk with the knee slightly bent and avoid full extension.

Walking with the knee bent is a functional solution (it works), but it’s not a very good long-term solution. Surgery to fix the problem hasn’t been very successful. More than one-third of the patients treated for this problem end up with a poor result. What can be done?

Orthopedic surgeons from the University of Connecticut Health Center developed a way to reconstruct the damaged corner. They say they used dual femoral tunnels, a transfibular tunnel, and a free graft. Twenty-four patients were treated with this technique. They all had one or both of the cruciate ligaments (ligaments that criss-cross inside the knee) damaged, too. These were repaired at the same time as the posterolateral reconstruction procedure.

They describe the technique step-by-step but basically, they used donor graft from the hamstrings or one of several other tendons in the lower leg. By making tunnel holes in the bone, they could thread the graft through the bone, hold it in place with screws and restore the natural stability of the knee joint. By creating just the right amount of tension with the screws, they were able to closely mimic the natural, anatomic positioning of the three key features that normally make up the posterolateral corner.

To see how well this new technique worked, they tested the stability of the knee using a special device called the Telos. The patient was placed with the knee bent at a 90-degree angle. A special arm of the Telos pressed a force of 15 kg (2.2 pounds) against the upper part of the shin bone (just below the knee cap). The amount of posterior (backward) movement of the tibia is called posterior displacement.

There’s a small amount of posterior tibial movement expected (and necessary) for normal knee function. Too much displacement is called posterior laxity. Laxity is another word for looseness. Using this type of stress radiography (X-ray), they could measure how much laxity was present after surgery. The images taken by the X-ray were placed on a computer, magnified, and then angles calculated to come up with the measurements.

The results showed a good-to-excellent result for all but two patients. Everyone was able to go back to work at their preinjury level. Those who participated in recreational or competitive sports were also able to return to those activities. Range-of-motion and stability were restored to the knees. There were a few complications as a result of the surgery. One patient had nerve palsy and another was unable to regain normal knee motion without additional surgery. Telos measurements indicated normal posterior translation without side-to-side joint laxity.

The authors suggest that the surgical management used in this study may help improve results after injuries to the posterolateral corner of the knee. The unique features of this surgical technique provide a more natural (anatomical) correction. All indications so far are that this technique is equal to other reconstruction methods with good outcomes. More studies are needed to evaluate patient satisfaction (not just surgeon satisfaction) with the results.

Knee pain from patellofemoral pain syndrome (PFPS) can be helped with a simple taping treatment. But not everyone gets pain relief from this technique. In this study, researchers from Taiwan looked for specific factors or patient variables that might account for the success of this treatment.

Patellofemoral Syndrome (PFS) is a condition that causes pain in and around the patella (knee cap). In the normal, healthy adult, the patella moves smoothly up and down over a groove on the femur (thigh bone) as the knee bends and straightens. PFS can develop when the patella is not moving or tracking properly over the femur. This is a common knee problem in teens and young adults (especially runners and athletes) but anyone can be affected.

Taping as a treatment to help realign the patella was first introduced by a physical therapist by the name of Jenny McConnell. The approach to the problem is used so often now, it is referred to as the McConnell taping technique. But after 20 years of research centered on this technique, there is still much debate and arguing about the best way to treat patellofemoral syndrome. Efforts to use the McConnell taping technique have not always been successful.

A series of studies have been done to help identify when and why McConnell taping works. It has been shown that by holding the patella in place, the taping successfully keeps the knee cap gliding up and down in its own track. Another way in which the taping helps is by sending extra signals through the muscle around the knee cap (the quadriceps muscle). By activating one side of the quadriceps more than the other, the muscle helps pull the patella back in place where it belongs.

But physicians, physical therapists, and athletic trainers using the McConnell taping suspect there are specific patient factors that play a role in the success of this technique. To find out, 100 patients between the ages of 20 and 60 who had already been diagnosed with patellofemoral pain syndrome (PFPS) were enrolled in this study. They all had the typical pain pattern of PFPS with no history of trauma or injury. Pain with activities like squatting, walking long distances, or going up and down stairs is common with PFPS.

X-rays were taken to determine several important angles (Q-angle,lateral patellofemoral angle, lateral patellar dispacement). These three angles help describe the tilt of the patella, position of the patella, and amount of lateral displacement (placement off to the outside of the patellar track). Other measures used to assess the effectiveness of McConnell taping included age, sex (male or female), and body mass index (BMI).

Before the tape was applied, everyone was asked to step down from an eight-inch high step (leading with the “good” leg first while supporting weight on the painful leg). They rated the pain on a scale from zero (no pain) to 100 (worst or severe pain). One physical therapist applied the tape to each patient in the study. The technique used was to push the knee cap to the middle where it belongs then apply tape in such a way as to hold it there.

The pain levels were retested after the tape was applied. Paients were placed in two groups. Group one included those who responded to the taping treatment with a reduction in their pain levels (called the responders). Paients in the second group were called the nonresponders. Responders had at least a 20 point change in their pain scores from before to after taping.

By looking at the patient variables for those who responded compared to those who didn’t respond, they were able to identify three independent factors that might predict who will have a successful response to McConnell taping. Those three factors included lower body mass index (BMI), smaller lateral patellofemoral angle, and larger Q-angle.

The value of this study is that it verifies how complex patellofemoral syndrome (PFPS) is. It is likely that there is more than one cause and possibly more than one factor present at a time. Earlier studies showed the role of abnormal patellar tracking and abnormal muscle activation as potential causes of PFPS. This study adds a short list of specific patient characteristics that likely contribute to the problem and may help predict patients who will respond to the taping treatment.

These findings still don’t explain the exact reason(s) why or how these factors contribute to patient responsiveness to the taping treatment. But the new information will help future researchers explore the underlying mechanisms. The goal is to find effective tresatment for each patient with patellofemoral pain syndrome with long-term relief from painful symptoms.

There’s a lot of confusion right now about the best treatment for tears of the knee meniscus. For sure, we know that removing this C-shaped cartilage in the knee is a bad idea. That just leads to degeneration of the joint and painful arthritis. Repairing the damage and letting the body heal has proven to be a much better alternative.

But even with a partial meniscectomy (removing the ragged edges) and/or repair (stitching the rest back in place), there are still a fair number of patients who do better than others. Or to turn that around, there’s quite a few patients who don’t do as well as others.

The natural question is why not? What gives some patients good outcomes while others still end up with knee arthritis? Reports from various studies are all over the place on this one.

One study says poor outcomes are because the person was older and had a certain pattern of injury. Another says, no, it’s because patients have poor alignment and a high activity level.

Other factors that might play into positive versus negative results include meniscal tears as a result of degenerative disease rather than injury, sex (male versus female), and meniscal tears that occur along with injury to the anterior cruciate ligament (ACL) (ligament inside the knee).

Basically, there is a lack of uniform evidence about what contributes to a good result and what doesn’t. To help sort through all the possible factors that might predict who will have a good result and who won’t when having meniscus surgery, the authors of this report performed a systematic review.

A systematic review means they looked at all of the studies done so far, found the ones with the highest level of evidence, and analyzed the data to come up with some statistically sound conclusions.

We wish we could tell you that the result was clear and now we know the answer. But what they found was that the poor study designs used, the low quality of research, and the fact that so many researchers left out important data means we still don’t have a firm grip on why some patients outperform others after meniscectomy.

Let’s take a closer look at what they summarized from the findings of the systematic review. The first is age. Older folks do indeed have a greater risk of degenerative meniscal tears. And it doesn’t take much for the stiff, dry cartilage to snag on a bone spur or other arthritic lesion in the knee joint and then tear. This type of tear does seem to have a poorer outcome compared to young athletes who injure their knees while playing sports.

What about sex (gender) as a risk factor? Are women more likely to have a poorer outcome? Or do they just complain more than men? As it turns out, it looks like sex alone is not the main determinant. Activity level (greater demand and higher level of sports participation) and type of surgery had a greater influence on the development of arthritis after meniscectomy.

And some of the factors appeared to have more to do with risk factors for osteoarthritis than for meniscectomy. For example, patients with hand arthritis were more likely to develop osteoarthritis in the knee. Genetics and hereditary factors probably play a more important role than meniscal injury.

Obesity defined as a body mass index of 30 or more was an independent risk factor for both osteoarthritis of the knees and poor outcomes after meniscal surgery. That means being overweight puts people at risk for both knee arthritis (with or without a meniscectomy) and poor function after meniscectomy.

There’s been some discussion around the idea that maybe removing one particular side of the meniscus affects the results more than the other. But the results were variable there, too. Some studies measured the amount of meniscus removed.

Others reported on the contact area and force load based on which side was damaged and repaired. It looks like the dynamic loading pattern differs from patient to patient due to alignment and surface structure (how curved the meniscus and joint surface are and how well they match up).

There is agreement on one thing: patients with a torn meniscus and ruptured anterior cruciate ligament (ACL) do have worse results than patients with just a torn meniscus. That seems to make sense at first glance.

But exactly why an ACL deficiency makes matters worse isn’t entirely clear. It could be that without a strong ACL, the loss of the meniscus magnifies the problem. Or it could simply be the effect of the loss of stability on the knee joint without the ACL.

And this is where it gets sticky because there’s some evidence that the type of meniscus tear and how it is treated (e.g., bucket handle tear that is repaired versus removed) enters into the results when there’s both a meniscal tear and damage to the ACL.

Finally, what about skipping surgery and just doing an exercise program? Does that work any better? There aren’t very many studies comparing these two treatment approaches. But the one study that was included looked at just patients with degenerative meniscal tears.

One group had surgery with exercise afterwards. The other group just did the exercises. The results (measured in terms of activity level, pain, and motion) were the same between the two groups. Follow-up was limited to six months so there’s no report on the long-term results.

After all the data was examined, the authors summarized by saying that clearly there’s a lack of uniformity within the literature. They found it very difficult to really make any firm conclusions.

They end by calling for higher levels of evidence and more prospective cohort studies. Cohort studies observe what happens over time rather than putting patients in different treatment groups and seeing how the results compare. Using this research design yields the highest level of evidence.

If you enjoy participating in sports but need surgery to repair or remove a damaged meniscus, this report may interest you. Experts in the surgical treatment of meniscal tears compared the effect of arthroscopic repair versus (partial) removal of the meniscus. The main area of interest was the effect of these two procedures on sports activity after surgery.

The meniscus is a C-shaped piece of thick cartilage in the knee. It has several main functions. One is to provide optimal weight-bearing through the knee. Another purpose is to absorb shock. The meniscus also helps stabilize the joint and help the joint slide and glide smoothly during movement.

There are two menisci: one on each side of the knee. Most often, the medial meniscus (side closest to the other knee) is damaged when athletes and sports players plant the foot on the ground and rotate or pivot the leg to change directions suddenly.

Over the years, it has been discovered that removing the meniscus entirely is not a good idea. Too many people developed early osteoarthritis after a meniscectomy. So, the standard procedure has gradually changed from complete removal to repair of the torn meniscus whenever possible. And when it has to be removed, as little as possible is taken out whenever possible.

So, now the question is: over time (i.e., the long-term or eight to 10 years later), what’s the effect of these two procedures (repair versus partial removal) on sports activity? To find out, the authors of this study reviewed the records of 81 patients treated with one or the other of these two surgical techniques.

Records were kept of the patients’ activity level before the injury and also of their age when the surgery was done. At the same time, an effort was made to see how much osteoarthritis developed and how quickly it progressed (that is, got worse over time).

The type of surgery that was done was determined by the type of rupture. Those patients with a full (all the way through the full thickness of the meniscus) but small (less than one centimeter long) tear had the repair done. The partial removal (meniscectomy) was done on ruptures located where the blood supply was poor or when the tear was too large to repair.

Patients in both groups went into a rehab program after surgery. The specific protocol used depended on whether the procedure was a repair or a partial meniscectomy. For example, the repair group was more limited in the amount of knee motion that was allowed compared to the meniscectomy group.

A brace was used for the patients who had the repair done, whereas the patients in the meniscal removal group had physical therapy right away. Exercises were started without any bracing. Sports activities were allowed four weeks after the partial meniscectomy. Similar activity level wasn’t allowed in the repair group until at least six weeks after surgery.

The success rate was much higher in the repair group compared with the partial meniscectomy group. The more cartilage removed, the worse the osteoarthritis (narrow joint space, bone spurs) later. More professional and recreational athletes were able to resume full sports activity after repair (again compared with the removal group).

Loss of sports activity and obvious osteoarthritic degeneration were clearly more evident in the meniscus removal group. Even though it was only a partial meniscectomy, the negative effects were still greater than with a meniscal repair. Of note is also the fact that there were some failures among the repair group. A lack of healing response leading to new trauma and another tear were seen in a couple of patients. The surgeons were unable to predict when this would happen (i.e., which patients would have a nonhealing response).

The results of this study support the idea that meniscal repair is better than removal — even over a partial meniscectomy. General knee function, level of sports activity, and joint health all measured higher in the repair group. Both clinical tests and X-rays confirmed these findings. And since the type of surgery that can be done depends on the location and size of the tear, return to sports activity really depends on the initial type of tear that is present.

There are many ways to measure the results of surgery for a torn anterior cruciate ligament (ACL). Pain, stability of the knee, and range-of-motion are commonly used. In this study, quality of life (QOL) is the main measure used to assess outcomes. And for the first time, the two main repair methods are compared using quality of life as the primary measure of results.

Quality of life looks at how the patients view the results. Would they rate their outcomes as poor, fair, good, or excellent? Would they have the same surgery done if they had to do it all over?

The two surgical techniques used to reconstruct a ruptured anterior cruicate ligament are: 1)bone-patellar tendon-bone (BPTB) graft and 2) hamstring graft. In each case, the surgeon harvests a piece of the tendon and uses it to create a replacement for the damaged ligament.

Both of these procedures have advantages and disadvantages. To say one approach is better than the other has been difficult. Many studies have been done to compare them. It’s clear that taking a tendon graft from the front of the knee (bone-patellar tendon-bone) makes kneeling painful and sometimes even impossible. Some patients also report numbness or loss of sensitivity at the graft site. Knee pain and difficulty kneeling isn’t a problem when using the hamstring graft. Instead, stiffness and decreased stability may develop.

The unique feature of this study is the fact that all patients (a total of 148) were randomly divided into two groups. One group had the bone-patellar tendon-bone graft. The other had the hamstring graft. Everyone was followed and tested periodically for at least eight years. That length of time is considered long-term. All other published studies have been short-term.

Various well-known tests were used to measure health-related quality of life such as the visual analog scale (VAS), the International Knee Documentation Committee (IKDC), Knee Osteoarthritis Outcome Score, and the Short Form-36. Using more than one tool to measure results gives a three-dimensional peek into all areas of the patient’s life and how the surgery influenced patient activity and satisfaction.

Here’s what they found after gathering all the data and analyzing the difficulty between the two groups. First, there were equal results when comparing knee joint stability and knee function. Stability refers to how stiff versus how loose the joint is when force or load is applied. The stiffer the knee, the more stable it is. Looseness called joint laxity is a sign of an unstable joint. Knee function was defined as a combination of daily activities and sports or recreational activities. Health-related quality of life reflected things like level of pain or other symptoms and how those symptoms affected emotional and mental health.

Second, early reconstructions (within five months of injury) had better results in both groups. This finding was true no matter which type of graft was used. Third, those patients who had a damaged meniscus along with the anterior cruciate ligament injury were more likely to have problems later on. They developed osteoarthritis of the knee and were less likely to continue participating in sports or recreational activities.

And finally, the majority of patients (94 percent) were satisfied and said they had no regrets after their surgery. And in case you are wondering, the bone-patellar tendon-bone group did report knee pain and difficulty kneeling more often than the high school group.

The reported results of this study don’t end the debate of which technique is best for anterior cruciate ligament reconstruction. But the added information that patient quality of life and satisfaction in the long run are the same between these two repair techniques gives patients and surgeons additional information to consider when choosing one approach over the other.

It would seem from this study that a more important factor in final outcomes is the timing of the surgery. Earlier is better and yields improved results. Patients can be assured that no matter which technique is used, the results will be favorable and satisfaction is likely. For patients who want to avoid the possibility of knee pain with kneeling, the hamstring graft may be the best way to go.

Patients with malalignment of the knee that leads to arthritis face some unique challenges. The alignment problems usually mean one side of the knee wears out faster than the other. They can’t just have a knee replacement — or even a unicompartmental procedure. Unicompartmental means just the side that’s arthritic is replaced.

And why not? Because the cause of the arthritis is the way the bones fit together to form the knee. In most cases, there is too much pressure on the medial compartment (that’s the side of the knee closest to the other knee). Replacing the joint (or the medial half of the joint) doesn’t change the alignment issues. That’s where a procedure called tibial osteotomy comes in handy.

In this operation, the surgeon removes a wedge- or pie-shaped piece of bone from one side of the tibia/i (lower leg bone). The purpose of the osteotomy is to correct the malalignment and take pressure off the medial compartment. There are two ways to do this surgery. Both remove bone from the upper tibia near the knee. The medical term for this type of osteotomy is high tibial osteotomy (HTO).

The first way to do the high tibial osteotomy is called a medial opening wedge tibial osteotomy. Bone is removed from the medial side of the tibia, shifting the weight off the medial compartment and more toward the midline. The two edges of remaining bone are held open with a metal plate or special device called a fixator.

The second method is a lateral closing wedge osteotomy. In this type of osteotomy, bone is taken from the lateral side of the tibia (side away from the other knee). The two edges of the bone are then allowed to shift closer together. The effect is the same as the opening wedge osteotomy: to take pressure off the damaged medial compartment.

There are advantages and disadvantages to each type of osteotomy. Many surgeons prefer the medial open wedge osteotomy because there’s less chance of causing shortening of the leg and fewer complications with nerve injuries.

In this study, 106 medial opening wedge high-tibial osteotomies were done for patients who had malalignment leading to arthritis of the medial knee joint. The size of the osteotomy (determined by the amount of bone removed) depended on the overall condition of the knee.

For example, the surgeon looked at the other side of the knee during surgery to see what kind of arthritic changes might have been present there. Most of the time, they tried to correct the alignment to neutral but sometimes it was necessary to overcorrect, shifting weight past the middle to the other side.

The patients were active and interested in delaying joint replacement for as long as possible. In addition to the osteotomy, they also had a microfracture procedure. Microfracture involves drilling tiny holes in the damaged joint surface down to the first level of bone (subchondral bone). Blood seeping into the joint through the holes helps the healing process and aids in restoring joint cartilage.

Patients were followed for up to seven years after the surgery to see how well the knee held up and whether or not joint replacement was required. The term used to describe osteotomies that lasted and delayed the need for joint replacement was survivorship. Failure was defined as anyone who had a joint replacement after the microfracture and osteotomy procedures. The length of time to failure/time to joint replacement was also calculated.

They found that almost all the patients (97 per cent) were active and satisfied with the results five years later. Survivorship remained high (91 per cent) seven years later. Patients who had a failed result were those who had damage to the meniscus (knee joint cartilage) along with arthritic changes of the joint surface. Age and sex (male vs. female) did not seem to have any bearing on which osteotomies survived or failed.

There aren’t too many studies looking at the results of microfracture with medial opening wedge high-tibial osteotomy for painful unicompartmental (medial) knee arthritis. The good-to-excellent survivorship reported in this study will be of interest to surgeons and their patients who want to avoid knee replacement due to activity level or personal preference.

In this review article, orthopedic surgeons from around the country bring us up to date on the latest research and evidence on the management of knee osteoarthritis in young, active adults. This patient population presents quite a challenge as they want to remain active but may be too young for a total knee replacement.

What are their options? On the conservative (nonsurgical) side is exercise, physical therapy, bracing, medications, and injections (steroids or viscosupplementation). When surgery is needed, arthroscopy, high tibial osteotomy, unicondylar knee replacement (replacement of only one side of the joint), or total knee replacement are the choices.

Treatment is determined by the patient’s age, severity of joint damage, and desired level of activity. Management is different for patients who want to return to sports. Returning to normal activity and sports participation may be more likely after a unicompartmental knee replacement compared with a total knee replacement. Some activities are not advised at all after a total knee replacement, whereas other activities can be a part of patients’ lives with experience.

For example, there are no restrictions on activities like walking, low-impact aerobics, golf, bowling, swimming, horseback riding, and dancing. Rock climbing, soccer, singles tennis, football, gymnastics, jogging, handball, racquetball, and handball are on the no-no list. Activities that fall in between must be done with common sense and experience. The questionable activities include road cycling, hiking, cross-country skiing, speed walking, ice skating, and weight machines.

But let’s back up a bit and start with conservative care. What do the experts have to say about each of these modalities? And what’s the evidence to back up those recommendations? Antiinflammatory drugs are used when painful knee symptoms first start. These medications work to reduce pain and inflammation. They can cause some stomach problems so patients
must be followed closely by their physicians when taking these medications.

Many high-quality studies have confirmed that exercise is helpful in reducing pain and improving function. Muscle strengthening is especially helpful in reducing pain. Aerobic exercise contributes to long-term improvements in function. Of course, these programs only work if the patient does them consistently. Once the exercises are stopped, the pain returns and the patient loses ground quickly.

Knee braces can be helpful for some people. Former athletes who have hurt themselves while in action and who want to remain active may benefit from a knee brace. Patients who benefit the most from knee bracing have arthritis on one side of the joint (unicompartmental arthritis) and don’t want (or are too young for) a knee replacement. Bracing helps redistribute the weight and load placed on the joint so that it isn’t all on one side. This type of biomechanical unloading doesn’t work forever but it can delay the need for surgery while still allowing activity.

There are some studies that support the use of foot orthoses (inserts placed in the shoe to correct leg alignment) for patients with medial compartment arthritis. The medial compartment is the side of the knee joint closest to the other knee. Uneven wear on the joint is caused by misalignment of the bones. Placing a specially designed wedge inside the shoe helps shift the foot and realign the knee. The result is to redistribute weight evenly across the entire
joint and unload the medial side of the joint.

One final conservative management tool available to patients with early knee osteoarthritis is the injection of hyaluronic acid (HA). This substance lubricates the joint and can potentially protect the joint surface. This type of injection has some advantages over steroid injections. There are very few harmful side effects of hyaluronic acid and the results last longer than with steroid injections. Either type of injection is meant as a temporary measure to provide short-term relief from pain.

When patients have tried conservative care for at least six months but without satisfactory improvement, then it may be time to consider surgical management. The surgeon may conduct an arthroscopic exam to look inside the joint and see what’s going on. During the arthroscopic procedure, it’s possible to shave off any loose pieces of cartilage and smooth the joint surface. This type of surgery is called debridement. Surgical debridement is used when the arthritis is moderate-to-severe and has not responded to conservative care.

Studies have been published with results on both sides of recommending/not recommending surgical debridement for knee arthritis. There is some evidence to suggest that in the long-run, results following surgery aren’t any better than with an extended period of time in physical therapy and following a home program of exercise.

Surgeons are unable to predict who might benefit from arthroscopic surgical debridement. Many patients who have this procedure end up having a total knee replacement anyway, so the benefit of the arthroscopic debridement is still questionable. It is clear that certain factors such as smoking, obesity, having osteoarthritis for two years or more, and the presence of bone spurs around the joint contributes to worse outcomes after surgical debridement.

Another surgical procedure that has been used to save the joint is called high tibial osteotomy (HTO). The surgeon removes a wedge-shaped piece of bone from the upper part of the tibia (the tibia is the shin bone). The goal of the surgery is to shift weight off the damaged side of the joint more to the middle, healthy portion of the joint.

The high tibial osteotomy procedure allows patients to remain as active as they would like to be. It also saves the joint and preserves bone for a later joint replacement procedure if needed. In some cases, high tibial osteotomy has delayed joint replacement by up to 20 years or more.

It is not recommended for patients who have a previously damaged meniscus, rheumatoid arthritis, or damage to the other side of the joint. Any of these conditions means that both sides of the joint have a significant amount of degeneration. These patients would be a more likely candidate for a total joint replacement.

And that brings us to the subject of unicompartmental (unicondylar) knee replacement and total knee arthroplasty (replacement). More and more people are benefitting from either of these treatments. Better implants, improved surgical technique, and the results of ongoing studies to guide treatment have helped expand the use of joint replacement.

Placement of a unicompartmental joint allows younger patients to remain active in high-demand activities until such time that a total joint replacement is needed.

For those patients who end up having a total knee replacement, there is evidence now to show that 90 per cent of patients still have good knee function up to 10 to 15 years after the implant was put in. This is called the implant survival rate and is much better now with improved durability of the implants used.

In all cases, patients with knee osteoarthritis are treated on an individual basis. Their goals and expectations are taken into consideration when trying to find what treatment will work best for them. Conservative care is the first
choice. Surgery is delayed as long as possible. But when needed, there are several different choices with good results reported. As a result of improved understanding of management techniques, today’s knee arthritis patient can remain active, even returning to sports or high-demand activities.

Are you thinking about having a knee replacement? Wondering whether to stick with the standard surgical procedure or go for the minimally invasive technique? The results of this study concur with others that there really isn’t an advantage of one over the other.

That may surprise you since it would make sense that a smaller incision would be better. With a minimally invasive approach, there’s less disruption of the surrounding soft tissues and less blood loss.

Some studies have shown that there is a benefit with minimally invasive total knee replacement early on in the post-op period. Patients report less pain, faster recovery of knee motion, and shorter stay in the hospital. But there are other studies that fail to show any benefit of the minimally invasive technique compared to the conventional (full incision) approach.

Where does that leave us? More study is needed until the question of which is better (safer and more effective) can be answered. This present study offers some information when comparing the minimally invasive approach (without computer navigation) with conventional knee arthroplasty. Arthroplasty is another term for replacement.

Patients included were first time knee surgeries. Surgeons who participated had experience performing minimally invasive knee arthroplasties (replacements). The surgeries were performed by several different surgeons at different surgical sites.

Post-operative care and rehab was the same for all patients regardless of the group (conventional versus mini). Discharge from the surgical center or hospital took place on the eighth day. Patients were sent to a rehab unit where they continued their rehabilitation for another two to three weeks before going home.

Results were measured by comparing range-of-motion, pain levels, function scores, and ability to complete daily chores and activities. X-rays were also compared from before to after surgery. Knee implant position and angles were measured using the X-rays to get an idea of the alignment of the knee joint.

After reviewing and comparing all values for each patient group, it was determined that there simply weren’t differences in outcomes between the groups. In other words, no advantage was seen with one technique over the other. Does it just boil down to cosmetics then with a smaller incision?

Some experts say that when there is less blood loss (with the minimally invasive technique), there is less risk of infection, shorter hospital stays, and a lower chance of needing a blood transfusion. In this study, there were an equal number of post-operative complications reported between the two groups. So the theoretical advantage of less blood loss was not seen in this study.

Likewise, the minimal gains in motion seen in the minimally invasive group evened out by the time patients were discharged. By day eight, range-of-motion was equal between the two groups. At the six week check-up, there was no significant difference in pain, motion, and function among all the participants.

The authors ended this study a year early because of the remarkable lack of significant differences between the two groups at the end of the first year. They suggest that the minimally invasive approach to total knee replacement doesn’t offer significant benefits over the more traditional or conventional approach.

Minimally invasive techniques require additional training on the part of the surgeon. Implant alignment can be a problem for less experienced surgeons. Clinical results appear to be equal between the standard, conventional approach when compared with the minimally invasive surgery. The results of this study don’t support the use of minimally invasive knee replacement over the standard surgery.

Research into repair techniques for damage to knee cartilage is moving right along. Surgeons in Europe and Australia are ahead of American surgeons as they have moved from first-generation cartilage repair through second generation methods to the more current third-generation approaches.

Only one type of third-generation cell therapy for cartilage repair is available in the United States: the matrix-induced autologous chondrocyte implantation or MACI. MACI is the subject of this review article. Although it is being used by U.S. surgeons, the U.S. Food and Drug Administration (FDA) has not yet approved this type of cell carrier yet.

But let’s step back a minute and get some background information that will help you understand what’s going on. The basic problem is one of damage to the articular (joint surface) cartilage of the knee. The hole or defect can be small but deep (all the way down to the bone). Sometimes, the defect is large (wide and deep).

The affected person experiences knee pain and joint swelling, locking, stiffness, and clicking. The symptoms can be bad enough to interfere with daily activities at home and work and create quite a bit of disability. Sports participation can be out of the question.

Because so many athletes are affected and given the fact that knee joint (articular) cartilage doesn’t repair itself, researchers started looking for ways to treat cartilage injuries of this type. They tried scraping the area and smoothing it down, a procedure called debridement. They tried drilling tiny holes into the bone marrow to stimulate bone healing. That’s called microfracture. And they tried taking healthy cartilage from one part of the knee and transferring it to the lesion to fill in the hole.

All of these treatment methods had problems. There wasn’t one approach that could work well for all different types and sizes of cartilage defects. That’s when cell therapy was developed. Healthy cartilage cells (chondrocytes) were harvested from the knee but instead of using them directly in the damaged area, they were transferred to a lab. In the lab, the cells were used to grow more cells. When there were enough cells to fill in the hole, they were reimplanted into the patient and covered with a patch made of periosteal (bone) cells.

That procedure was called autologous chondrocyte implantation (ACI). It was the first cell therapy devised for the problem of full-thickness (down to the bone) cartilage injuries. That’s why it’s considered a first-generation approach to cell therapy cartilage repair. But again there were problems. The procedure is invasive and requires a two-step (staged) surgical procedure. That means at least two surgeries with all of the possible costs and risks that go with staged procedures.

The next batch of autologous chondrocyte implants were improved and formed the second-generation techniques. Instead of covering the patched up hole with periosteum (bone cells), they tried using a collagen covering. The idea was to prevent overgrowth and keep a smooth surface. Overgrowth of bone called hypertrophy was a real problem with the periosteal patch.

Not quite satisfied that the second-generation approach was the best they could do, scientists continued trying different ways to improve cell therapies. The result was the current third-generation: using a three-dimensional scaffold or frame upon which to grow new cartilage cells. This is the procedure that’s called the matrix-induced autologous chondrocyte implantation (MACI).

MACI is still a two-step procedure that starts with the harvesting of healthy chondrocytes that are then taken to the lab to reproduce. Only this time, they are placed directly onto the scaffold that is made of type I and III collagen tissue. When the transplanted cells (taken from the patient’s body) have reproduced enough (in the lab) to fill in the gaps on the collagen scaffold, then the patient returns to the operating room and the MACI implant is cut to fit the defect and glued in place.

The question this report tries to answer is how well is this third-generation method of cell therapy working to repair damage to the articular cartilage of the knee? Over 6000 MACI implants have been completed (outside the U.S.). Reports have been trickling in over the last 10 to 12 years so the authors reviewed all the published studies and compiled this summary.

Most of the 12 studies that met the requirements for high-quality were case series or case reports (not large randomized, controlled studies). Only one randomized controlled trial was found but in all cases, patients reported significant improvements in pain, function, and activity level. Measurable results based on patient report and MRI studies were seen as early as three months after surgery but more often the benefits occurred during the first year. Post-operative complications were rare and included infection, detachment of the transplant, and overgrowth of the graft.

In summary, matrix-induced autologous chondrocyte implantation (MACI) is a less invasive, third-generation cell therapy treatment technique that has improved on first and second-generation methods of cartilage repair. Surgical time is shorter because there’s no need for a periosteal flap or microsuturing the implant in place (remember they use glue instead). Quality of tissue repair is good and the procedure appears to be safe.

So far, all we have are short-term results. Future studies will continue to report data that will further reflect the long-term results of MACI. Moderate-to-large cartilage defects can be repaired this way. Affected individuals (especially athletes) are able to get back to an active lifestyle, including full sports participation.

Nothing is more frustrating for a professional athlete than an injury — especially one that doesn’t heal. Knowing when to have surgery right away and when to treat the problem conservatively (without surgery) can be a real challenge. That’s the case with tendon ruptures such as the hamstrings.

In this study, orthopedic surgeons involved with 25 professional athletes who had a complete rupture of the distal semitendinosus muscle report the treatment results. The semitendinosus is one of three main parts of the hamstring muscle located along the back of the thigh. Distal semitendinosus tells us the tear occurred down by the knee where the semitendinosus inserts (attaches) to the bone.

Hamstring injuries of the muscle belly are fairly common among athletes. But usually, it’s the biceps femoris portion of the muscle that ruptures. This type of distal semitendinosus injury in this study is uncommon but not rare. The decision whether to send the athlete to physical therapy or to the operating room can be difficult. There are no known predictive factors to guide patient and surgeon.

Predictive factors are characteristics of the patient or injury that are linked with success or failure. With some injuries, the surgeon knows the chances are good (or bad) for a complete recovery (or failure) if X, Y, or Z factors are present. Predictive factors can be things like the patient’s age, severity of injury, sex (male versus female), body part injured, and so on.

The study group was made up of all males who were elite-level (professional major league or national league players) athletes in baseball, football, or hockey. The mechanism of injury was sprinting or taking a long stride (step).

The symptoms described included feeling a pop or sharp, searing knee pain during the activity. The athletes could not straighten the knee all the way and could not walk without a limp. A round mass could be seen and felt along the inside and back areas of the knee. There was pain when trying to straighten the knee and weakness when trying to bend the knee.

The usual treatment plan for injuries like this is conservative care such as rest, use of antiinflammatories, and physical therapy. With time and rehab, it is expected that the athlete will regain motion, strength, and function.

The therapist directs treatment to include sports-specific drills. Special attention is given to make sure the skills needed for the player’s specific position are also addressed. Athletes are allowed to return to practice and play when the injured leg has 80 per cent of the strength of the uninjured leg. The player must be able to sprint without pain as well.

When pain persists and/or the athlete shows no improvement after six weeks of therapy, then surgery is considered. In this study, there were five players who had surgery within the first four weeks of injury. The rest were treated nonoperatively. In the end, half of the athletes ended up in surgery because conservative care failed.

The players who had surgery early on were off the field for about 10 to 12 weeks total. In contrast, the athletes who followed a conservative approach and then needed surgery anyway were out of the game for more than half a year. In professional sports, that kind of delay just isn’t acceptable.

The authors suggest based on these findings that athletes with a distal semitendinosus rupture have surgery right away in order to speed recovery and return to competitive play. Symptoms as described in this report (motion restrictions, tender mass present, knee swelling, inability to walk normally) can guide the surgeon in recommending surgical treatment instead of conservative care. MRIs can be used to confirm the diagnosis.

In summary, there is a lack of evidence and predictive factors to guide treatment of distal semitendinosus ruptures in athletes. Based on this small study of 25 professional athletes, the surgeon must judge the situation based on clinical presentation (symptoms at the time of the injury). Surgery may provide a faster route to recovery and return to competitive play.

Studies show that a torn anterior cruciate ligament (ACL) that isn’t repaired can leave the knee unstable and at risk for gradual degeneration of the joint. Surgery to reconstruct the ligament and repair any damage done to the meniscus is supposed to protect the joint. But does it really?

In this report, a surgeon from France who has been following 100 of his patients gives us a run down on how they are doing 20 to 25 years after reconstructive surgery. Results from this patient group have been routinely reported in the past at regular intervals.

Throughout the follow-up years, certain risk factors that could affect outcomes have also been evaluated. For example, data has been analyzed on the effects of age, surgical delay, joint laxity or looseness after surgery, removal of the entire meniscus, and damage to the joint cartilage. Mostly what they were looking at was how much degeneration occurs in the joint and whether any of those risk factors contributed to the problem.

There were over 400 patients in the initial study but some have died, others have moved, and a fair number didn’t want to still be part of the study after the first 10 years. Of the 100 who are still in the game, the age range when surgery was done was between 14 and 43 years old.

Everyone had the same surgical technique performed. The surgeon used a patellar tendon graft to replace the damaged ACL. An extra bit of support was provided by taking a piece of the iliotibial band from alongside the leg and attaching it to it to either side of the lateral (outside edge) of the joint. This procedure called a lateral tenodesis is no longer part of the ACL routine reconstruction. During the ACL reconstructive surgery, the condition of the joint articular cartilage was evaluated and rated. Any problems with the meniscus were taken care of (repaired whenever possible).

Although the surgical procedure didn’t change much over the years, postoperative rehab has undergone some major changes. For example, up until 1980, patients were placed in a plaster cast with the knee in a slight bit of flexion to protect the healing tissue. The leg was immobilized this way for a full six weeks. After 1980, a removable splint was applied, which the patient could take off when not walking. Knee flexion was allowed from right after the surgery throughout all the phases of rehabilitation.

Now 20 or more years later, more than half (57 per cent) rate their results as excellent. Another 27 per cent say they have good results. Only 16 per cent said that they felt their outcomes were poor to fair. Patients who had damage to the articular cartilage or meniscus were more likely to have less knee function. And between 10 years post-op and the current study 24 years later, there’s been an increase in the number of these patients with osteoarthritis.

Osteoarthritis was judged based on X-rays by looking at the size of the joint space and presence of bony spurs around the joint. Narrowing of the joint space was seen as a result of degenerative deterioration, especially in those patients who had medial meniscus damage or removal. Patients who waited three or more years to have surgery after injuring the ACL were more likely to develop osteoarthritis later.

The patients with osteoarthritis were also less satisfied with their results. They were more likely to experience pain and other symptoms and have lower knee function. Participation in sports and recreation was less in the group with osteoarthritis.

As with most studies that go for a very long time, the surgeon could look back and see some things that were missing. For example, although the medial side of the joint (side closest to the other knee) was examined and gauged for arthritic changes, no one really kept track of what was going on in the lateral compartment (side of the joint away from the other knee). It’s also common for adults to gain weight over time and this change in body weight wasn’t accounted for in analyzing the results either.

All-in-all the results 20+ years after ACL reconstructive surgery have been pretty good for this group of patients. The biggest problem has been arthritic changes that have caused pain and loss of knee function. Only 15 per cent of the group with osteoarthritic changes had similar changes in the other knee. So it wasn’t the case that they would have ended up with arthritis anyway. The loss of the meniscus and damage to the joint cartilage were the biggest factors in the development of osteoarthritis.

Injuries, defects, lesions, or tears of any kind in the joint cartilage can end a sports athlete’s career. Today, there are improved ways to treat cartilage injuries, especially in the knee. One of those methods is called mosaicplasty. This article reviews the uses and long-term results of mosaicplasty in an athletic population.

What is mosaicplasty? It’s a form of osteochondral autografting. That doesn’t really explain anything, does it? Let’s start with the last part of the term: grafting tissue is the moving of some type of soft tissue from one spot to another. It could be ligament, tendon, muscle, or as in this case, cartilage. Autografting tells us the donor tissue being harvested to repair the problem is coming from the patient himself.

Osteochondral can be broken down into two words: osteo for bone and chondral meaning cartilage. So with osteochondral, we have cartilage that has pulled away from the joint with the underlying next layer of bone still attached. We call this kind of damage a full-thickness defect. That is the injury side of things.

Now the repair side of the problem: mosaicplasty. During this procedure, the surgeon harvests cartilage and bone from an area of the knee that doesn’t get much action and isn’t under the pressure of constant weight bearing. The donor or graft is smoothed and shaped to fill in the defect site. Sometimes only one donor plug is needed but some patients in this particular study had as many as nine grafted pieces.

What are the advantages of this treatment? And who is considered a good candidate for the procedure? Mosaicplasty can help save the joint and protect it from further wear and tear around the defect site. Normal joint biomechanics can be restored with this technique and get the athlete back into full sports participation sooner than later. With seasonal sports and a limited amount of playing time, faster return-to-sports can be a huge benefit of a successful mosaicplasty.

Among the athletes with cartilage damage, who can benefit? The results of this study confirm what other studies have shown. Younger athletes who have smaller (and fewer) lesions seem to do the best. But location of the lesion was a key risk factor for successful outcomes. Lesions located on the femoral condyles (large round knobs at the end of the femur (thighbone) seem to respond better than damage or defects to the patella (kneecap).

Athletes from all types of sports were included with no real difference in results based on their sports injuries. Soccer players, handball, water polo, wrestling, gymnasts, and many others had equally good results. Only a small number of patients suffered from post-operative complications such as hemorrhage, infection, or persistent pain and swelling. At least in this study, sex (male versus female) was not a significant factor.

The researchers found that there were some other specific factors that influenced success or failure. For example, smaller defects tended to have less degenerative wear and tear but the plug to fill those holes wasn’t so tough. It’s more difficult to harvest a small amount of cartilage and the smaller grafts are more fragile. The larger graft plugs are more stable making them easier to harvest and insert.

Age was another risk factor for success/failure. Athletes younger than 30 years old had better success rates. Good alignment of the joint is also important. Biomechanics of joint movement that are off or uneven in any way (and not repaired before mosaicplasty) can contribute to uneven forces or load on the joint. Joint degeneration is the result of overuse and uneven weight bearing.

The authors summarize the results of their study by saying that the data supports the use of mosaicplasty for small-to-medium sized osteochondral lesions. Even in high-demand athletes, the grafts seem to hold up well over time with very few postoperative problems. Those problems that did occur (e.g., pain with weight-bearing) were temporary and went away within the first six weeks up to one year.

Problems with donor site pain, swelling, and bleeding may be ended in the near future. Researchers are exploring the use of biodegradable donor site plugs that would fill the harvested empty sites until they fill in on their own with scar tissue. Putting an end to donor site pain is important in an athletic group of patients who are very active participating in vigorous exercise.

Surgeons in Sweden began performing cartilage repair procedures called autologous chondrocyte implantation (ACI) back in 1987. More than 20 years have passed since then. That’s time enough to check back and see how things have gone and what kind of results have been achieved. Patients who had this procedure were asked two basic questions: 1) Are you better, same, or worse? and 2) If you had it to do over again, would you have this surgery?

What exactly is the procedure? Autologous chondrocyte implantation (ACI) involves the use of normal, healthy cartilage cells to fill in a hole (defect or lesion) in the joint surface of the knee. The defect goes clear down to the bone below the cartilage. It’s called a full-thickness cartilage and osteochondral lesion. Osteochondral refers to bone (osteo) and cartilage (chondral).

Autologous chondrocyte implantation is done in two separate steps. First, the surgeon removes the harvested cartilage cells from an area of the knee that doesn’t bear weight. They are taken to a lab where the cells are multiplied until they have enough to fill in and cover over the defect.

A second surgery is done to implant the new healthy cells. If there are any alignment problems or other soft tissue injuries, surgery is done before implantation to correct them. The corrective surgery is a necessary step in order to protect the implanted area. If there are uneven forces within the joint, the load imbalance can reinjure the same spot all over again.

At the University of Gothenburg in Sweden, 341 patients have had the autologous chondrocyte implantation (ACI) procedure. Through a series of mailings, 224 of those patients provided the authors with some feedback on the long-term results of their ACI. Besides answering the two main questions, they reported on pain and other symptoms, activity level, and quality of life.

With any surgical procedure and especially fairly new ones, there are always patients who don’t have the best results. In this group, about one-fourth reported being worse instead of better. But of the remaining majority (three-fourths of the group), 92 per cent said that they would have the surgery again. They reported good results that lasted and were satisfied with the results.

When the researchers took a closer look at the patients and the results, they couldn’t see any kind of link between age and outcomes. And it didn’t seem to matter what size the defect was — the results were equally good for small to large lesions. They did a second analysis comparing results based on the type of lesion repaired.

For example, some patients had the defect on the femoral side of the joint. Most of the lesions were on the medial side of the femur (side closest to the other knee) but there were some on the lateral side (side away from the other knee). Ninety per cent of this group said they would do the operation again because it was so successful in eliminating their pain and restoring the use of their knees.

Some patients had more than one defect in more than one place. Patients with multiple lesions of this type had slightly worse results than single lesions. Patients with bipolar lesions (present on both medial and lateral sides) seemed to have the worst results.

Full-thickness osteochondral lesions of the patella (knee cap) were more complicated to treat effectively. The authors suggested this might be because there were more bony malformations and muscle imbalances to work through compared with patients with femoral lesions.

Patients treated for osteochondral lesions caused by osteochondritis dissecans (OCD) reported the best results. With OCD, the joint surface is damaged and doesn’t heal well. The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies.

This condition can affect adults and children. It’s the younger patients who still had the best results. That may be because they have the ability to heal faster and better than older adults. They are still able to participate in all kinds of physical activities because arthritis hasn’t developed yet.

The authors conclude there is still much to be studied and decided about autologous chondrocyte implantation. Even though they have 20 or more years of information, the ACI procedure that was done in 1987 isn’t the same as what’s done now. So, in the coming years, comparisons between first-generation and subsequent generations will have to be made.

Most of the patients in the study were young athletes, so the effect of aging over time will also have to be examined. Likewise, most of the patients did have other injuries of the meniscus or the ligaments. Treatment results will be compared between patients with and without other injuries. Another area that will bear watching and comparing is the group of patients who had realignment procedures to correct deformities and malalignment problems.

The new second- and third-generation autologous chondrocyte implantation (ACI) procedures will be watched carefully in the next 10 to 20 years. But for now, it’s clear that the first-generation methods were successful and durable (long-lasting).

People with knee osteoarthritis are encouraged to maintain an active lifestyle and to exercise those arthritic knees. But that seems counter intuitive — if your knees hurt, why would you move and exercise them more? This report based on over 2200 people with knee arthritis confirms (again!) the advice to exercise and stay active.

Where does this information come from? The study was done by the Osteoarthritis Initiative — a combination of publicly and privately supported researchers from around the United States. These investigators are from the well-known Rehab Institute of Chicago (RIC), Ohio State University, University of California (San Francisco), and Northwestern University School of Medicine.

Who was in the study? Men and women from age 45 up to 79 years were enrolled. They all had proven knee osteoarthritis (seen on X-rays) with joint narrowing and bone spurs. Some of the people had one knee involved (about one-third of the group), while others (60 per cent) had osteoarthritis in both knees.

Before starting the study, everyone was tested using a timed walk test and the chair-stand test. These are both tests that have been standardized and known to be good measures of physical function in people with arthritis. The walk test measures how quickly a person can walk 20 meters (25 yards). The chair stand test records how long it takes to get up and then sit back down from a chair five times.

Both of these tests require balance, coordination, flexibility, and strength. The knees are actively involved in both tests. The ability to walk, sit, and stand are practical ways to measure function needed to maintain independence in every day activities. The group also filled out a survey about lifestyle activity at home, routine sports or exercise, and walking outdoors.

Other before (baseline) measurements taken included height and weight (body-mass index or BMI), disease severity (calculated by the physician using X-rays), and symptoms (pain, stiffness, aching). A questionnaire assessing general health factors (e.g., smoking, depression, alcohol intake, other diseases or conditions present) was also completed by each person.

The patients weren’t given a specific exercise program to follow. They just went about their everyday ordinary activities. Then they were retested a year later with all the same test measures. When the data was analyzed, it was clear that people with higher activity levels had better knee function and less pain, stiffness, and aching.

One-fourth of the group actually increased their activity levels during the year’s time. Their performance improved on all the test measures. Patients who did the best were married and had a higher level of education. Participation in sports and exercise had the strongest link to best function. And it didn’t seem to matter what activities people were engaged in — participation in any and all were beneficial. Those who did the worst were older women (65 and older) and patients who were overweight.

The results of this study also agreed with others that have been done showing that severity of arthritis is not always linked with outcomes. People can have severe arthritis as seen on X-rays but good function and vice versa (minimal arthritis with the most severe symptoms).

The information obtained from this study was presented to the American College of Rheumatology at their annual scientific meeting in 2008. Getting the message out to physicians is an important part of helping patients with knee osteoarthritis. Other studies have shown that patients are more likely to respond with behavioral changes when physicians give them advice to stay active and when they prescribe exercise.

Older adults who are sedentary (inactive) can change their health status by increasing their activity level and engaging in regular exercise. This study supports the notion that exercising those arthritic knees will help improve symptoms and reduce disability.

The best advice physicians, public health professionals, and physical therapists can give older adults with knee osteoarthritis is to keep moving. Physical activity and exercise are proven to reverse decline and improve function.

There are different ways to surgically repair damaged knee cartilage. The type of cartilage being considered here is the hyaline cartilage that lines the joint and covers the bone. Damage to this layer of cartilage can result in full-thickness lesions that are like small potholes in the surface of the joint. The defect goes all the way down to the bone. The person with this type of injury experiences knee pain and loss of knee motion and function.

One method of repair that has been successful for large, full thickness, painful cartilage lesions is called autologous chondrocyte implantation (ACI). In this technique, a number of healthy chondrocytes (cartilage cells) are harvested (removed) from a nonweight-bearing area of the joint. These chondrocytes are then taken to the lab where they can be stimulated to grow even more healthy cells. When there are enough intact and healthy chondrocytes to patch up the hole, surgery is done to implant them in and around the lesion.

Studies have been done to show how well patients fare after autologous chondrocyte implantation (ACI) for full-thickness articular cartilage defects. In this study, scientists take a look at how well the actual repair tissue holds up over time. Evaluating the quality of tissue after ACI isn’t easy. The surgeon can go back in with an arthroscope and take a look but this requires another surgery and is invasive. During the arthroscopic procedure, the surgeon takes a small piece of the healing tissue to examine it under a microscope. No one knows if this procedure (which disturbs the healing or healed tissue) might cause problems later.

MRIs have been used because it is a noninvasive way to look inside the joint. But standard MRIs don’t show the cellular structure of the cartilage in enough detail to really assess the repair tissue. So the authors of this article conducted a study using a newer MRI technique called dGEMRIC. dGEMRIC stands for delayed gadolinium-enhanced MRI of cartilage. How does it work?

Well, the radiologist puts a dye into the knee joint — that’s the gadolinium compound (short for gadolinium diethylene triamine pentaacetic acid or Gd-DPTA). The gadolinium spreads throughout the joint and into the cartilage. The gadolinium seeps in the best wherever there is healthy cartilage tissue with plenty of glycosaminoglycans (GAG). GAGs form an important component of connective tissues. They attract water, which helps keep the cartilage healthy and slippery for joint motion.

A normal level (concentration) of gadolinium is around 65 mg/mL in normal cartilage tissue. By comparison, severely damaged cartilage from osteoarthritis only absorbs about 10 mg/mL. After the dye is injected into the joint, the patient walks around for about 15 minutes to help spread the gadolinium into the cartilage. Then MRIs are taken to look at the filling of the defect, the smoothness of the surface, and the presence of bone edema. The dGEMRIC technique has the specific ability to measure GAG concentration and give surgeons an idea of how much degeneration is present in the autologous chondrocyte implantation (ACI) repair.

In this study, testing was done anywhere from nine to 18 years after the original autologous chondrocyte implantation (ACI). What they found was good quality of repair tissue — very similar to the surrounding normal cartilage. But there were osteophytes (bone spurs), bone cysts, and bone edema (fluid) also present in, under, or around the repair tissue. These new lesions did not seem to bother the patients or affect knee function.

Age was a factor in that older patients had more cysts and younger patients had more bone spurs. Given the older age of patients with subchondral cysts, the presence of these cysts under the implanted cartilage is probably a sign of osteoarthritis developing. And the presence of osteophytes (bone spurs) seemed to be linked with patients who had a condition called osteochondritis dissecans or who had a different cartilage repair technique called marrow-stimulation. Areas of damage with an irregular surface had better outcomes than defects with a smooth surface. The reason for this is unknown but will be studied further.

The authors concluded that assessing and predicting the long-term durability of autologous chondrocyte implantation (ACI) can be difficult. But studying the results of ACI (and other ways of repairing cartilage defects) is important in order to find the best way to treat the problem. As this study showed, the dGEMRIC technique can be used as a noninvasive alternative to arthroscopic exam and tissue biopsy.

This newer MRI method provides valuable information about the composition of repair tissue. This is a different way to judge the results of autologous chondrocyte implantation from the usual clinical tests (motion, strength, pain, joint stability) performed on the patient. dGEMRIC may become a universally accepted noninvasive way to evaluate the results of all methods of cartilage lesion repair.