News Category: Knee

Even though half a million knee replacements are done each year in the United States, there are other treatment options for some patients. If one side of the joint has worn down from problems with alignment, an osteotomy is one possible alternative choice. In this review article, the uses and types of osteotomies available are presented. The authors also discuss when to perform an osteotomy and when to avoid using this technique.

What’s an osteotomy? Basically, an osteotomy is a surgical procedure whereby a bone is cut to shorten, lengthen, or change its alignment. Around the knee, it’s the tibia (the lower leg bone) that is involved. The various kinds of osteotomies are often named for their location. The two most basic types are opening wedge and closing wedge osteotomies.

When is an osteotomy a good idea? The purpose of the osteotomy is to shift the patient’s body weight off the damaged area to the other side of the knee. This makes better use of the cartilage that is still healthy.

The surgeon removes a wedge of the tibia from the healthy side of the knee. It might be taken from the inside (medial) of the tibia (meaning the side of the knee closest to the other knee). That’s an opening wedge osteotomy or medial opening wedge HTO. HTO refers to high tibial osteotomy meaning the wedge is removed right at the upper end of the tibia just under the knee joint.

A closing wedge osteotomy (also known as a lateral closing wedge HTO) takes the piece from the lateral tibia and allows the remaining edges of bone to collapse toward each other to close the gap. Once the wedge is removed, the bones are brought together and held in place with a metal plate or pins.

Whether it’s an opening or closing wedge procedure, an osteotomy allows the tibia and femur to bend away from the damaged cartilage. A tibial osteotomy can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years.

There are some advantages and disadvantages to the osteotomy approach to unilateral (one-side of the joint) arthritis. As mentioned, it can help patients put off joint replacement. And unlike joint implants, with an osteotomy, it’s still possible to engage in high-impact activities like jumping and running.

The disadvantage is that there is a risk of continued knee pain. It’s a trade-off: with osteotomy, there is a greater activity level but more discomfort. With a joint replacement, the pain is gone (or very minimal) but limited activity.

Patients recover faster from a closing wedge procedure since there’s no need for bone grafting. There are fewer potential complications and patients walk (bear weight) sooner after a closing wedge osteotomy.

Opening wedge osteotomies major disadvantage is the fact that the open space has to be filled in with bone graft. It takes longer to heal and there can be pain at the donor site if the patient uses his or her own bone. But the opening wedge procedure has one advantage the closing wedge doesn’t — it allows the surgeon to make precise changes in the angle of the bone, which, in turn, directly affects the alignment of the joint.

More and more surgeons are using computer navigation to give the most accurate realignment possible. Injuries to the nerves and blood vessels in and around the knee can also be avoided with arthroscopic computer navigation. Bleeding into the muscles along the front of the leg can cause a potentially serious condition called anterior compartment syndrome.

There are some complications from osteotomies that can’t be prevented by using arthroscopic or computer navigated technique. For example, sometimes there is a loss of correction before the osteotomy even heals. Once it’s cut into, the bone can fracture with either an opening or a closing wedge procedure. Infection, blood clots (deep vein thrombosis or DVT), and failure to heal are other possible post-operative problems.

Today, osteotomy as a procedure has expanded in its uses and combined with other joint sparing techniques like cartilage preservation, soft tissue reconstruction, and meniscal transplantation. Anyone who is a candidate for these other procedures who also has some alignment problems can have a realignment osteotomy done.

Studies have shown improved results when surgeons look for and treat knee malalignment along with these other procedures. Placing the knee in neutral alignment, reducing alignment deformities, and restoring the weight-bearing axis through the center of the knee is the final goal. The use of osteotomy to correct leg alignment will continue to increase as surgeons treat ligament-deficient, unstable knees before signs of arthritis develop.

It’s clear now that damage to the meniscus (cartilage) of the knee should be repaired whenever possible. But there’s another type of cartilage in the knee called the articular cartilage. This is the cartilage that lines the joint and sits right up against the bone.

We don’t know for sure that if left alone, the articular cartilage would eventually heal on its own. The process of what happens over time without intervention or treatment is called the natural history of a condition.

Right now, it’s assumed that damage to the articular cartilage leads to arthritis sooner than later. But there’s no real evidence to support this view. Most of the studies done so far haven’t been on single (isolated) defects of the articular cartilage. Injuries treated have included additional damage to the joint such as an ACL tear (ACL = anterior cruciate ligament).

The articular cartilage doesn’t have much of a blood supply of its own. It relies on movement of nutrients in fluids that cross the cartilage bringing supplies like a wagon train. But the fluid can’t cross holes in the cartilage and that’s a problem. Without a healthy, intact matrix of bone and cartilage, it’s like the wagon coming to a canyon with no bridge to get across.

Surgeons have only one study of the natural history of unrepaired articular cartilage to rely on for data. And that was done more than 10 years ago on young athletes. It showed a 79 per cent success rate with no treatment applied.

Since that time, three different surgical techniques have been developed and tried for this type of injury: 1) microfracture, 2) autologous chondrocyte implantation (ACI), and 3) osteochondral autograft transplantation (OAT). Here’s a brief explanation of each one.

Microfracture involves drilling tiny holes through the cartilage, past the first layer of bone underneath, and into the bone marrow. There’s a rich blood supply there and drops of blood well up through the holes to aid the healing process.

Autologous chondrocyte implantation requires removing some of the healthy cartilage cells, taking them to the lab, growing more healthy cells, and then putting them into the holes or defects in the knee.

And osteochondral autograft transplantation refers to harvesting healthy cartilage cells from a part of the knee that doesn’t bear weight (and isn’t damaged) and using those plugs to repair the damaged area.

Which one of these three methods is the best and holds up the longest? That’s what these orthopedic surgeons wanted to find out. They searched the published studies to find evidence that would support one over another. After comparing all the high-quality studies available, here’s what they found.

Knee injuries can really lay an athlete low. Those injuries affect the medial side of the knee most often (the side closest to the other knee). The soft tissues involved are first the superficial medial collateral ligament, then the deep medial collateral ligament, and finally, the posterior oblique ligament.

The medial ligament is one continuous structure with these three separate parts that all attach to different places along the knee but all work together to stabilize the medial side of the joint.

Each of these ligaments is important in stabilizing the knee for actions needed in sports like skiing, ice hockey, and soccer. For example, in these activities, the athlete must be able to bend the knee while rotating and changing directions quickly. Planting the foot and moving the knee in the opposite direction can cause a tear to any of these stabilizing soft tissues.

What can be done about medial knee injuries? Well, surprisingly, treatment is more and more conservative (nonoperative). The medial collateral ligament has a rich blood supply that makes healing without surgery possible. The torn ligament goes through all the normal stages of healing and eventually fills in with fibrous scar tissue.

The anatomy and biomechanics of these ligaments actually help determine the best treatment approach. Each portion (superficial, deep, or posterior) has its own purpose and function. For example, the superficial and deep portions of this ligament work together to keep the knee joint from sliding into a knock-kneed (valgus) position. At the same time, the posterior aspect of the ligament does the same thing when the knee is in a slightly flexed position (from zero up to 30 degrees of knee flexion).

Understanding the anatomy and function of the separate parts of this medial ligament guides the surgeon in first deciding whether or not surgery is needed and secondly, what kind of repair or reconstruction is needed. Some injuries when left untreated can increase the risk of another injury. All of these factors are taken into consideration when arriving at a plan of care.

Another thing the surgeon pays attention to is the grade of ligament injury. This is a way to classify how severe is the injury. The classification scale goes from grade I (mild joint laxity from a strained but not torn ligament) to grade II (partial tear of one or more portions of the ligament with separation or gapping of the joint with stress testing), and grade III (complete rupture of the ligament and more than 10 millimeters of joint laxity or gapping).

The injury is graded using both clinical tests (stress testing of the joint) and imaging studies such as X-rays and MRIs. Measuring how much the joint gaps (separates) helps determine the grade.

From animal studies, we now know that putting the leg in a brace or splint and staying off it is not such a good idea. Patients who start early motion actually have improved healing (faster with better results). The actual rehab program depends on how severe the injury is. Grades I and II are treated with controlled motion and protected weight-bearing. Grade III requires a slightly different protocol but can still be successfully managed without surgery.

Surgery may be necessary for some patients. Each individual is examined and evaluated on a case-by-case basis before making this decision. Surgery is more likely when there is more than one ligament damaged. If the anterior cruciate ligament (ACL) inside the knee is torn, then surgery is almost always required.

Of course the type of surgery depends on the specific damage. The surgeon may be able to simply repair the ligament by sewing the ends together. Sometimes it’s necessary to augment the repair by using donated tissue grafts sewn into the healing natural ligament to help strengthen it.

Newer reconstruction techniques have been developed that have led to better results than ever before. Reconstruction is used with grade III (ruptured) ligaments and completely replaces the damaged tissue with grafts taken from a donor bank or from one of the patient’s own tendons.

After surgery, early motion and strengthening are the keys to a good result. A physical therapist will guide them through the necessary exercises and advice regarding precautions. A hinged brace is used right away that allows protected movement.

The therapist supervises and progresses the rehab program on a week-by-week basis. Usually full weight-bearing is achieved around six to seven weeks after surgery. Special attention is paid to the way the patient walks as it is important to restore a normal gait (walking) pattern without compensatory movement.

Strengthening exercises are performed until full knee motion and joint stability are restored. Another aspect of rehab is proprioceptive training. Proprioceptive exercises are designed to restore the knee’s accurate sense of position. It’s important that the knee respond to the tiniest bit of motion in order to prevent future injuries.

Eventually it is possible to walk for two miles at a fast pace without a limp. At that point, jogging, squatting, and plyometrics are introduced. Plyometrics involve making fast changes with momentum (speed).

In summary, all grades of medial collateral ligament injuries from mild to severe are successfully treated today. Conservative (nonoperative) care is usually the first step even with grade III injuries.

Surgery may be needed if conservative care is unsuccessful in restoring knee stability. This is especially likely if other structures of the knee (e.g. anterior cruciate ligament) have been damaged at the same time. From the very start of recovery and rehab, patients are warned to be patient because it can take up to nine months before they can get back to full speed on the field, ice, or court.

A knee replacement has become so common any more we tend to forget that it is still major surgery and a fairly complex one at that. With so many aging adults in America, the number of total knee replacements has increased dramatically. And along with that has come the need for revision surgery. Such a second surgery may be done when the implant fails or the patient has knee pain that doesn’t go away with exercise.

In this article, surgeons from the American Academy of Orthopaedic Surgeons offer a mini-instructional course on revision surgery for total knee arthroplasty (TKA). Arthroplasty is another name for joint replacement. The title of the article says it all: Revision total knee arthroplasty: What the surgeon needs to know.

As you might imagine, the surgeon can’t just go into the operating room and take the old implant out without some serious planning and preparation ahead of time. First, the patient must be examined. Maybe the knee pain isn’t really coming from the joint replacement. Knees can hurt when there is a problem up above in the spine, pelvis, or hip and even from down below (ankle).

Of course, there could be a real problem with the implant such as fracture, loosening, or sinking of the device. Infection is always a possibility as is malalignment of the implant and/or of the knee joint.

X-rays, MRIs, CT scans, bone scans and other imaging studies are used to help determine what’s going on. But even before that, it’s quick and easy (and much less expensive) to do some blood work and/or take a small sample of the fluid from the joint to look for infection.

Sometimes infections can be cleared up with antibiotics but if not, removing the implant may be necessary. If revision surgery is called for (regardless of the reason), the surgeon must go back to the medical records and find out what type of implant was used. The patient’s alignment and muscle control must be examined to look for uneven pull on the joint or other problem areas related to bone and soft tissues. These must be corrected during the revision procedure.

Next, the surgeon must decide what surgical technique would be best for each patient. What kind of incision is needed for the intended procedure? A larger incision is required when the surgeon has to clean out the entire joint from infection and get a good look at the condition of the bone. Should the incision be straight or curved? Is more than one incision needed? Can the incision from the first surgery be re-used for the revision surgery?

The authors provide an in-depth examination of these questions and their answers. Specific surgical techniques are discussed in detail with drawings offered and photographs provided that were taken during revision surgery.

Instructions are also covered regarding removal of the implant. Once again, the surgeon doesn’t just crack open the knee, remove the implant, and that’s it! Each step of the revision procedure has good, better, and best ways to approach it.

Remember, the implant was put into the joint with the intent to stay. It doesn’t just pop out. Special surgical tools such as high-speed drills, surgical hammers, and small oscillating saws are used to separate the implant from the bone. Sometimes it’s impossible to keep from removing additional bone and that can affect both the revision and the patient’s leg length.

The next step is to reconstruct the joint. Taking the implant out is only part of the process. Now the bone is reshaped, bone grafts may be added, bone defects filled in with cement, and a new implant put into place.

Selecting the right implant for the revision requires an additional set of decisions based on analysis of patient factors such as age, condition of the bone, diagnosis, activity level, and so on.

The advantages and disadvantages of each component of the new implant are discussed for the surgeon’s consideration. When we say each component, we are referring to both sides of the joint implant: the tibial side (lower half of the joint at the top of the lower leg) and the femoral side (upper half on the thigh side of the knee). Revision surgery may need to remove and replace both component parts.

And there’s actually a third piece: the patella or kneecap. It might be possible (and it’s actually preferable) to keep the patellar component whenever possible. But if it’s cracked, worn, imbalanced, or loose, then it must be removed and replaced as well. And a new patellar component will be chosen that will work well with the new implant.

Throughout the revision process, the surgeon is evaluating joint angles, alignment, muscle balance, leg length, and the need to fill in or augment where there has been an excess loss of bone. The goal is to make sure the joint line (where the two halves of the joint meet) is at the same level on both knees.

Once the implant is inserted, the postoperative process begins. The patient must watch for any signs of infection. Whether infection develops after the first procedure or after the revision procedure, the treatment approach is the same.

First, tests are done to identify what type of organism is growing. The most appropriate antibiotic to combat the infection is selected. If that doesn’t work, then surgery is done to clean out the infection (a procedure called debridement) and possibly replacement of the liner that’s part of the implant.

After debridement, tntravenous antibiotics are given for six weeks but patients are warned that the success rate is fairly low. That’s why revision surgeries are done in the first place. If the revision surgery was required because of infection, then the procedure is slightly different. The implant is removed but the new implant isn’t put in until the infection is cleared up completely. A temporary spacer is put in the joint instead and the operation becomes a two-part or staged procedure.

In summary, this review article is as close as it comes to learning everything you ever wanted to know but were afraid to ask about revision total knee arthroplasty. Patients will appreciate how much thought and effort goes into such a procedure. Surgeons will be reminded as well of all the considerations, factors, and hidden variables that must be uncovered and analyzed in the course of the pre-operative planning through to the postoperative phase.

Articular cartilage is flexible body tissue that connects the joints. Although it is quite strong, it doesn’t heal easily once damaged. Because it doesn’t heal easily, torn cartilage of the knee, after trauma or degeneration, is a challenge to treat and can cause significant pain and disability if left untreated or not treated effectively. The authors of this article reviewed the basics of various available treatments, when they may be used, their advantages and disadvantages, and outcomes.

Bone marrow is used for many treatments these days, including repair of injured articular cartilage of the knee, a microfracture. It is the most commonly used treatment for small lesions that cause pain and disability. The pros for the treatment include that is it straight forward to perform and not terribly expensive. A surgeon stimulates bone marrow by making a small hole in the bone to allow mesenchymal cells to flow into the lesion (injured area), where they help form blood clots. These then begin to help the lesion heal. For this method of treatment to have a chance of being successful, the patient must have a contained lesion that can hold the blood clot. It will not be effective if the blood can leak out.

Two cons for this procedure exist. One is mesenchymal cells decrease as patients age. If there are not enough to help form clots to fill the lesion, the healing won’t be complete and will likely result in an unstable repair. The second is although the post-operative rehabilitation period is demanding, it is critical for proper healing. The patients who have had the repair on a femoral (thigh bone) end of the knee may not bear weight for six weeks and must perform passive motion exercises from zero to 60 degrees for six weeks after surgery. This improves the circulation, giving the cartilage the nutrition it needs to heal effectively. Patients who had the procedure on the patella (kneecap) or the trochlea inside the joint), weight-bearing is allowed after surgery, but they are not allowed to bend their knee more than 40 degrees, so it must be kept braced. As with the other group, passive motion exercises begin immediately, for six to eight hours per day.

The outcome of the procedure is generally successful if the blood clot filled the lesion and the patient participated in the required post-surgery rehabilitation program. According to one study, by Steadman and colleagues, their study that involved patients under the age of 45 years, achieved significant improvement following repair of the microfracture. Another group of researchers, led by Mithoefer, found overall good to excellent long-term results in most of their patients (67 percent), fair in 25 percent, and pour in 8 percent. In this study, better outcomes were found in patients with lower body mass index. As well, the researchers had found, using MRI after the procedure, that 54 percent of the patients had good filling of the lesion, 29 percent had moderate filling, and 17 percent had poor filling. Recent studies that have looked at high-level athletes. In one, 25 National Football League players were treated with this method and 19 returned to their previous level of play the following season.

The authors point out that “Proper patient selection and meticulous attention to technical detail are critical to achieving a successful outcome following microfracture.” That being said, this method of healing microfractures is not permanent and the results do deteriorate over time.

Other researchers have looked at adjuncts, add-ons, to marrow stimulation. One researcher, Hoemann, and his team, investigated adding chitosan, a thrombogenic and adhesive polymer (compound) to the marrow procedure. The addition of chitosan was to improve the fill and add strength. Another researcher, Strauss, and colleagues, tried using hyaluronic acid viscosupplementation, which he found to provide even better fill and stronger tissue resulting. However, these have not been tested yet in clinical trials.

Platelet-rich plasma is a blood product that is rich in platelets, which help blood clot. The theory behind using this product is this is product of the body with growth factor and other cells and factors that can help promote healing. Very early studies have been promising, but there have not yet been any clinical trials for this plasma either.

Whole tissue transplantation, called autologous osteochondral transplanation or autologous osteochondral mosaicplasty could be used to resurface the defects in the knee. The tissue is harvested from the the patient’s femur (thigh bone) and transferred to the defective area. One of the main advantages to this procedure is its relatively short rehabilitation time after. The disadvantages include possible problems with the patient’s donor site, limited availability for grafting, and not filling the lesion entirely.

Unlike the previous two procedures, this has been studied in clinical trials. One study of 53 athletes (26 professional and 27 recreational), done by Gobbi and colleagues, found that six years after the procedure, nearly 70 percent of the patients were close to normal. The patients who responded best were younger, had the problem for fewer than 12 months, had a lesion less than 2 centimeters in diameter, and had had not had previous surgery or procedures. In another study by Namdari and colleagues, 24 professional basketball players underwent this procedure. Unlike Gobbi’s study, in this one, eight athletes were unable to return to play and of those who did return, most were unable to regain their previous level of ability. Another issue with the grafts and plugs is the stability after surgery. How stable they are depends on several technical factors.

Reviewing overall outcomes of autologous mosaicplasty shows that it is fairly successful. In one study, the largest series of 831 procedures, was evaluated by Hangody and Fulles. They found good-to-excellent results for 92 percent of femoral (thigh bone) lesions, 87 percent of tibial (shin bone) lesions, and 79 percent of patellofemoral (between the kneecap and femur) lesions.

A similar procedure, osteochondral allograft transplanation, uses cartilage from a cadaver. The advantages include being able to craft the exact size needed for the lesion and there being no donor site complications for the patient. However, there are limitations and they include limited resources for the donor tissue, high cost, possible rejection by the recipient’s body, the graft not “taking,” possible disease transmission, and the difficulty of the procedure itself.

Allografts can be fresh, cryopreserved, or fresh frozen. All have their advantages and disadvantages:

Fresh: Advantages include better viability of the tissue. Disadvantages are the short period of storage time and higher rate of disease transmission.
Cryopreserved: Advantages include being able to preserve the tissue for longer periods and the reduction of disease transmission. Disadvantage is the only intermediate viability and success.
Fresh frozen: Advantages also include longer preservation time and decreased disease transmission. Disadvantages include even further reduction of viability and success.

A study of 55 knees, done by Chu and colleagues, using osteochondral allograft (fresh) found good-to-excellent results. In reviewing the use of preserved tissue, a study by Williams and colleagues found no correlation between functional outcome and the graft storage time of up to 42 days. A similar study, by McCulloch and colleagues, had similar findings after comparing stored grafts with fresh grafts.

Autologous chondrocyte implantation is yet another procedure that was first performed in 1994. In this procedure, the surgeon implants a transparent (<hyaline-like) cartilage rather than fibrous cartilage. This particular procedure requires two surgeries, however, and has a lengthy rehabilitation period. It is also technically demanding, and has had several complications. Complications include issues with the donor, or harvest, site, as well as graft failure, delamination (shrinking of tissue) and tissue hypertrophy (enlargement of tissue).

Of 23 patients who have undergone this new procedure, 14 of 16 patients who had femoral lesions had good-to-excellent results. Another study, this one of 126 patients, showed that 76 percent of the patients reported good outcomes of quality of life, knee pain and overall health. This was found whether the patients had undergone previous treatments and procedures or not.

Finally, synthetic scaffold treatments involve delivering chondrocytes (cartilage cells) to the lesion, using an absorbable scaffold that support the cells until healing takes places. There are several advantages to this treatment, including the ability to evenly distribute the cells over the lesion, there is no need to harvest cells from a donor site, and it is a technically easier procedure than some others.

The authors concluded that given the lack of well-designed studies comparing the various treatments, it is not possible to say if one is better than another. They did find, however, that bone marrow stimulation is effective if the lesion is filled completely and the patient is compliant with rehabilitation. Mosaicplasty, while effective, has limited graft availability and may cause problems at the donor site. Allografts are effective for large lesions and hyaline-like implants could result in better long-term outcomes. Using synthetic scaffolds to deliver the chondrocytes is a promising treatment, but has yet to be proven in clinical trials.

Knee pain over the front of the knee, anterior knee pain is quite common, particularly in teens and young adults. What causes this knee pain can be controversial. Many physicians believed that it is caused by chondromalacia patellae, also known as runner’s knee, but other causes have also been proposed.

Typically, the person complains of a deep-seated ache and pain just behind the patella (kneecap), most often when climbing stairs, sitting with bent knees, or getting up from a sitting position. Although the pain seems to be more common with bending the knee, it may also be painful to extend the knee if there is resistance. It may also feel unstable, as if the knee won’t support the leg. Because this type of pain could be the cause of other problems that need treatment, such as a tear, which could require surgery.

In coming to a diagnosis of chondromalacia patellae, x-rays are only useful in the later stages. Earlier diagnosis could be made with arthroscopy, exploration of the joint using long, slender instruments inserted through tiny incisions, but ultimately, fewer than 10 percent of patients with chondromalacia patellae end up needing surgery, so arthroscopy is an invasive procedure that may not be necessary. The authors of this article looked into the connection between the symptoms of anterior knee pain syndrome and chondromalacia patellae, as well as different tests used for diagnosis.

Researchers recruited 56 patients, aged between 18 and 25 years, 21 of whom had one knee examined and the other 35 had both knees examined. The patients were all in the Finnish military and who were physically active as a result. Assessments included medical examination of the knee, and measurements of motion, muscle strength, limb length, and muscle girth. Tests were also done to assess walking gait, stationary running, hopping and squatting. The McMurray and Apley tests were performed to detect any mechanical problems with the knee, and x-rays from all angles were done.

The first treatment for all patients was nonoperative: rest or limited activity and nonsteroidal anti-inflammatory-drugs (NSAIDs) when needed. If the physician was considering performing arthroscopy, the patients were first encouraged to perform physiotherapist-supervised exercises to strengthen the muscles. If there was no response to nonsurgical treatment and physiotherapy, then an arthroscopy was performed after most patients underwent a magnetic resonance imaging scan (MRI).

Upon reviewing the findings from the examinations, tests, and arthroscopies, the researchers found that arthroscopies confirmed the suspected diagnosis of chondromalacia patellae in 25 of the 56 knees. Eight of the 25 with chondromalacia patellae were rated at a level of grade I (some softening of cartilage), nine were grade II (more softening), eight were grade III (thinning of the surface of the cartilage), and none were grade IV (rough cartilage is smoothed down). Twenty-five knees had synovial plica, a fold of tissue causing irritation in the knee, four had tears, four had lesions, and six knees were normal. One of the issues the researchers were looking for, an association between the severity of chondromalacia patellae, seen by arthroscopy, and anterior knee pain, was not found.

Before the arthroscopy, the researchers noted that:

– 12 knees did not have pain, while 36 did
– 36 of 43 plain x-rays taken showed normal findings in the knee
– Six knees had subluxation (partial displacement) or lateralization (sideways movement) of the kneecap
– One knee showed signs of Osgood-Schlatter disease, which causes knee pain
– One knee had irregular surface of the kneecap

Despite these findings, the arthroscopies found that 14 of the knees that appear normal did have chondromalacia patellae.

The authors concluded that chondromalacia patellae cannot be diagnosed based on symptoms alone or with current physical examination. The researchers found no connection between the severity of or lack of symptoms and the severity of the diagnosed condition. MRI scans did prove accurate for moderate to severe cases, but was not effective for milder cases.

Blood loss is a fact of life when surgery is done on any body part. Total knee replacements require cutting into the bone and that’s a major cause of blood loss. In an effort to reduce this problem, surgeons are studying what patient factors might be contributing to the bleeding. Is it the patient’s age? The way the tourniquet is applied to the leg? The patient’s sex (male versus female)?

In this study, surgeons from France take a look at fixation methods as a potential risk factor for bleeding. Fixation refers to the way in which the implant is placed and held in the bone. Some implants can be put in place without cement to hold them there. This method is called a press-fit fixation. The bone is cut and the implant pressed into the bone in such a way that it holds without cement.

The other most common fixation method is with cement. There’s been some suggestion that blood loss is more likely with cementless implants. That’s because once the bone is cut, there is quite a bit of bleeding and nothing to stop it.

The exact mechanism by which cemented implants might reduce bleeding isn’t completely clear. Some experts suggest that when cement is used to hold the implant against the bone, the cement itself may plug some of the bleeding vessels. Others propose that heat released by the cement coming in contact with the bone might cauterize bleeding blood vessels.

There are very few studies comparing blood loss between cemented and hybrid implants. That makes the results of this study of great interest. A hybrid implant refers to a joint replacement that has one side cemented (the tibial component) and one side that is uncemented (femoral component). A total of 130 patients formed two groups based on fixation type (Group 1: cemented hybrid and Group 2: uncemented). The implants used in all 130 patients were the same size and shape and put in place by the same two surgeons.

Measuring blood loss isn’t exactly easy. Drains are used to catch any fluid loss (including blood) during the procedure and for several days afterwards. But the drains can’t collect all blood lost during this time. A special formula is used to calculate total amount of blood lost given all the required variables.

Blood tests are also done to measure two important values: hematocrit and hemoglobin. These two measures are another indication of how much blood loss has occurred. When the hemoglobin levels drop down too far (less than eight g/dL in this study), then a blood transfusion is ordered.

The results did not show a difference in blood loss between the two groups. The cemented implants did not produce a smaller volume of blood or lower levels of hemoglobin/hematocrit. An equal number of patients in both groups ended up needing a blood transfusion.

Based on the results from this study, the authors suggest that cementing the femoral side of the implant in place does not influence how much blood is lost during a total knee replacement. Surgeons still have to plan for blood transfusions in patients having a total knee replacement but it won’t be because of the type of fixation used. Some other factor may yet need to be discovered.

Arthritis is a well-known long-term effect of anterior cruciate ligament (ACL) reconstructive surgery. Many studies have shown that more than half the patients treated with ACL surgery end up with osteoarthritis in that knee. And that seems to be true whether the procedure was done early after the injury or later when knee instability has become chronic. There is some evidence that waiting too long can certainly make matters worse.

In this study, the question is raised: does the type of grafting done to reconstruct the torn ligament make a difference? In other words, does having a patellar tendon-bone graft contribute to more cases of knee arthritis than the 4-strand hamstring graft? Or vice versa? Or does everyone develop arthritis no matter what type of graft is done? Maybe it’s just a matter of degree — everyone gets arthritis but patients with one type of graft or the other end up with a more severe case.

To find out, a group of researchers from Norway hypothesized that there would be no difference in knee function or degree of arthritis between patients having a patellar tendon-bone graft versus a hamstring graft. Patients were randomly assigned to have one or the other reconstruction procedure. They were matched by age, gender, and activity level so the patients were very similar from one group to the other.

For surgeons interested in how the two surgical procedures were done, the authors provide a detailed description of both the patellar tendon-bone and 4-strand hamstring grafts. Harvesting and grafting techniques are provided. All grafts were autografts (tendon tissue taken from the patient) and all procedures were done by the same surgeon. Everyone followed the same postoperative and rehab program from day one through return to full activities after six months.

Over the next 10 years, the patients were followed at regular intervals. The authors summarized their findings after two years and published the results at that time. Now they are reporting their 10-year follow-up results. Activity level, knee joint laxity (looseness), muscle strength, and knee range-of motion were recorded and compared from the two year mark to the 10-year mark and between the two groups. X-rays were taken and compared with an eye toward any signs of joint arthritis.

In terms of complications, there were an equal number of graft failures in both groups requiring an ACL revision surgery. There were an equal number of patients in both groups who ended up with a torn ACL on the other side. As far as additional risk factors goes, patients in both groups gained weight and increased in their body mass index (BMI, a measure of obesity). BMI is a potential indicator of a sedentary (inactive) lifestyle. Both inactivity and being overweight are risk factors for joint osteoarthritis.

When all the data was analyzed and factors sifted through, there simply weren’t any statistically significant differences between the two groups. About half of the patients who were athletes went back to their preinjury level of sports participation. But by the end of the 10 years, most were over 30 years old and no longer engaged in competitive sports events. Competitive sports had taken a back seat to recreational activities instead.

The procedures were considered a success despite the fact that there were a large number of patients (again, in both groups) who did indeed have signs of mild to moderate knee osteoarthritis. There was a tendency for patients with patellar tendon grafts to develop arthritis more often than patients with hamstring grafts but it wasn’t considered statistically significant in this study.

The authors do point out that other similar studies have found differences in the long-term development of arthritis based on graft technique used. Taking a closer look at their own study and comparing to others’ they thought there might be three reasons why the results of this study did not match previous studies.

First, there were quite a few patients who moved, died, dropped out, or were lost to follow-up. The reduced number of patients at the 10-year point might have made a difference in results. Second, X-rays used to identify the presence and severity of arthritis are subject to interpretation. The radiologist who read the X-rays in this study might have made different interpretations compared with radiologists involved in other studies. And third, although only two types of grafts were compared in this study, there were two different ways those grafts were attached. These different fixation techniques could have had an impact on the outcomes of surgery but were not tested for.

The conclusion drawn from this study was that the choice of graft type for ACL reconstruction surgery does not have a direct effect on the development of knee joint osteoarthritis 10 years later. This problem will continue to need further study until all risk factors and predictive factors can be identified. The goal is to find a way to prevent this complication from occurring — either by changing when and how the surgery is performed or by choosing patients more carefully for each type of reconstructive procedure performed.

It’s a fact that half of all patients who have anterior cruciate ligament (ACL) surgery end up with knee osteoarthritis. Why does this happen and who does it affect? If the predictive factors and patients at risk can be identified, it might be possible to put a stop to this problem. In an effort to find some answers, a group of Australian physical therapists identify, test, and follow 56 patients who had ACL surgery. All of the patients were younger than 40 years old and had a complete ACL rupture.

They used a variety of ways to measure and track results over a period of six years. Joint laxity (looseness) was measured using a special device called the KT-1000 arthrometer. Another tool was used to measure muscle strength. The involved knee was compared to the other (uninvolved) side. Each patient filled out a survey with questions about return-to-sports. They reported on type of sports participation, level of competition, intensity (how often they played), and duration (how long they played).

X-rays were taken to confirm the presence (and severity) of tibiofemoral and patellofemoral arthritis. Joint space, presence of osteophytes (bone spurs), and any obvious arthritic changes of the cartilage-bone interface were noted. The tibiofemoral joint is located between the lower leg bone (tibia or shin) and the thigh bone (femur). The patellofemoral joint is where the patella (kneecap) moves up and down over the femur.

Other studies have shown us clearly now that aging is a factor in the development of knee osteoarthritis — and so is a previous knee injury. In fact, any time the knee ligaments (like the anterior cruciate ligament) or the meniscus (cartilage) is damaged in a knee injury, the chances that person will develop knee osteoarthritis go up by 10. That means they are 10 times more likely to have knee arthritis compared with someone the same age who never injured the knee.

Anyone with both a ligament AND a meniscus injury has a 70 per cent chance of developing knee problems later. Most of these injuries are sports-related in the younger age group. Athletes involved in cutting sports or activities that include sharp pivoting movements of the lower leg or sudden changes in direction are the group who have the highest number of ACL tears.

For this group of patients, the therapists also paid attention to what kind of ACL reconstruction was done. Some patients had a bone-patellar tendon-bone graft, while the others had a hamstrings graft. No one had a meniscectomy (removal of the meniscus cartilage. When the meniscus was damaged, a repair was done instead. Only one surgeon was involved in performing the procedures. The graft tissue was reattached exactly where the anatomical ACL pulled away from the bone. That spot is called the footprint of the ligament.

Additional information was gathered that might be linked with results such as how much time passed between the injury and the surgery, age at the time of surgery, and whether or not there was chondral damage. Chondral damage refers to part of the joint articular (surface) cartilage being pulled away with the ligament when it detached from the bone.

The good news is that 96 per cent of the patients were satisfied with the results. They had a stable knee joint and were able to go back to competitive play in their sports activities. The downside is that true to form, half the group had signs of osteoarthritis. The patients who had a hamstring graft had the highest incidence of arthritis. In fact, twice as many people in the hamstring group had developed knee arthritis compared with the patellar tendon graft group. However, the patellar tendon group was more likely to have more severe osteoarthritis (rated as moderate) compared with only mild arthritis in the hamstring group.

Dividing results by groups based on location of the arthritis, members of the tibiofemoral group who developed arthritis were more likely to have had a meniscectomy and chondral damage compared with those individuals who did not develop arthritis. Muscle weakness of the quadriceps and an imbalance between quadriceps and hamstrings had a significant effect in predicting the development of arthritis later. Patients in the patellofemoral arthritis group had more meniscal and chondral damage than those without arthritis but the arthritic group were also older at the time of surgery (30 years old and older).

It makes sense that losing the meniscus leads to problems later. The meniscus is designed to absorb shock. It also evens out the two joint surfaces so they can slide and glide against each other smoothly. Without the meniscus, the contact pressure and load on the joint increase thus speeding up degenerative changes that ultimately lead to arthritis. Likewise, disruption of the chondral surface leading to osteoarthritis is easy to understand. With pits and holes in the surface, every movement wears away the joint protection needed for normal knee motion.

The reason for hamstring grafts being linked with onset of osteoarthritis is unclear. More study is needed to understand this factor more completely. Older age might be part of the accelerated joint destruction because joint remodeling for healing and recovery are less effective as we age. It’s likely that the older adults already had a degenerative process starting even before the injury occurred. The injury and age-related decline in remodeling processes seem to be two strikes against normal healing.

The authors conclude that the biggest predictors of arthritis after ACL reconstruction surgery are meniscal damage (and removal) along with cartilage (chondral) disruption (where the joint surface meets the underlying bone). Type of graft, age of the patient at the time of surgery, and leg muscle weakness/imbalance are additional factors that can influence the final outcome of surgery. Addressing these risk factors before and after surgery may reduce the high rates of osteoarthritis following ACL reconstructive surgery.

What do high-speed runners, dancers, kick boxers, and rugby players all have in common? Hamstring injuries. The hamstring muscle along the back of the thigh is made up of three parts: semitendinosus, semimembranosus, and biceps femoris. Hamstring strains and tears can cause scar tissue that puts the athlete at risk for another injury. And often that second injury occurs within two weeks of returning to their sport after rest and recovery. And it’s more severe and more disabling.

What’s the problem here? Why are the hamstrings so susceptible to injury and reinjury? Physical therapists from the University of Wisconsin use the case of a high-speed runner to show with MRIs just how much hemorrhage, swelling, and scarring remain when the athlete returned to his sports participation. They propose ways to prevent these common injuries as well as a three-phase plan for rehabilitation of acute hamstring strain injuries.

In order to prevent musculoskeletal injuries like hamstring strains, it’s important to identify any and all factors that put the athlete at increased risk for injury. Some of these risk factors are modifiable (can be changed) while others are nonmodifiable (can’t be changed). Obviously, focusing on modifiable risk factors is the recommended approach.

Two main risk factors for hamstring injuries are age (older) and a past history of a hamstring strain. Not much the physical therapist can do about either of those! But a program of prevention and/or rehabilitation can address modifiable factors such as muscle weakness, lack of flexibility, and a strength imbalance between hamstrings and quadriceps muscles.

To begin, the therapist conducts an in-depth exam evaluating the patient’s history (including the mechanism of injury or how it happened) and symptoms (location and severity of injury). Special tests are carried out to assess range-of-motion, strength, coordination, balance, and flexibility. The therapist also evaluates the surrounding muscles for any sign of injury, inflexibility, or imbalance.

X-rays aren’t very useful in confirming a hamstring strain, tear, or rupture. Unless the tendon pulls a piece of bone away from its attachment, nothing will show up on the X-ray. MRIs are used instead because they show deep portions of the muscle, scarring from a previous injury, and location/severity of the injury (partial or complete rupture). The surgeon can use this information when deciding if surgery is necessary. Complete ruptures with tendon retraction almost always need surgical repair, especially in the athletic population.

The injured athlete is usually most interested in one thing: how long before I can go back to my sports training and/or competition? MRIs help answer that question by giving information that can be used to estimate time to recovery, which translates into time away from sports participation.

Injury location and severity are the main markers for prognosis. For example, recovery takes longer when the free tendon (nearest the attachment to the bone) is injured compared with injury to the portion of the tendon closest to the muscle (intramuscular tendon).

Patient symptoms such as pain, tenderness to palpation, loss of motion, and weakness aren’t always the best indicators. For example, intramuscular tendons tend to be the most symptomatic yet heal the fastest. Complete ruptures requiring surgery can be painless.

Once it’s decided that a rehab program is the ticket, then what? The goal is to get the athlete back to his or her level of performance prior to the injury with the least risk possible of reinjury. Studies show that there are several key ingredients needed in the rehab program to accomplish this. One is to focus on eccentric (lengthening) muscle contractions while working on flexibility during the early healing phase. Another is to include training to improve coordination of the lumbopelvic (low back and pelvis) region. And a third is the need to include neural mobilization (nerve sliding and gliding) techniques for the sciatic nerve that runs down through the hamstring muscle.

For anyone interested, the authors provide a detailed description of each phase of rehab for hamstring recovery. Online videos are available demonstrating each exercise. For each of the three phases (Phase 1, 2, and 3), suggestions are made for protection of the injured and now healing hamstrings as well as proper use of nonsteroidal antiinflammatory medicine during the early phases of recovery. Goals for each phase are also provided.

Phase 1 starts with low-intensity, pain free exercises designed to minimize pain and reduce edema while helping form a nice, clean linear scar. The hamstrings are not stretched in order to avoid a thick scar and even contraction of the hamstrings is limited to painfree motions to encourage muscle healing. All exercises prescribed during this period must protect the muscle while it is remodeling during this early healing phase.

The athlete is slowly progressed from phase one to phase two. Fiber repair is still an important phase of recovery during this portion of the rehab process. The hamstrings are not yet lengthened to their end range until strength is restored. Exercises are done that will gradually lengthen the muscle and overstretching is avoided. When full strength is present without pain and there is full motion, then phase three can begin. In this final phase, the focus is on fine-tuning everything needed for return-to-sport.

Specific exercises to help the athlete return-to-sport and the best timing for introducing that phase of rehab are suggested. The athlete will need to work on agility, sport-specific drills, and quick directional and postural changes. Muscle testing is done by the therapist to determine when the athlete is ready to progress to this last phase of rehab. They must have enough strength and stability to carry loads required by repetitive motion and needed to carry out those motions with speed. In order to return to full sports participation, they must have full strength and motion without pain and function near maximal speeds without pain.

What about prevention? What do these researchers have to say that can help athletes prevent this injury in the first place and avoid a reinjury once it does happen? Most athletes stretch their hamstring muscles thinking this will prevent injuries. But studies don’t really support hamstring stretching as a very effective method for injury prevention. Instead, there is evidence that eccentric (lengthening) hamstring exercises may be the best way to avoid this type of injury.

How is this done? First, evaluate each athlete for risk factors that can be changed and work on changing them. Then, instead of working on knee flexion to strengthen the hamstrings (that’s a concentric or shortening contraction), the hamstrings are put in their shortest (already contracted) position and slowly lengthened (e.g., moving from hip extension and knee flexion to hip flexion and knee extension). Eccentric training should be done during the pre-season period as well as during the sports season.

Other suggestions for a prevention program include improving neuromuscular control of the entire lower half of the body. This includes core training to stabilize the lumbopelvic area, postural exercises to stabilize the trunk — especially while running or moving, and movements like high stepping, explosive starts, and forward-falling running drills.

The authors tell us that there is a lack of evidence to support the current rehab programs in place. Sports and orthopedic physical therapists are concentrating their focus on evidence to support specific exercises and rehab programs for athletes with hamstring injuries. More research is also needed to predict risk of reinjury, identify when athletes can return to their sport safely, and determine prognosis.

All surgical procedures have some risks. Complications can vary from mild infection to something as serious as death. In this study, the risk of infection after anterior cruciate ligament (ACL) reconstructive surgery is calculated. Surgeons from the Hospital for Special Surgery in New York City present data from a review of over 3000 patients who had ACL surgery in their clinic.

This study helps put into perspective concerns about infection when using tendon grafts to replace the ruptured anterior cruciate ligament in the knee. There is always a niggling concern in the back of the surgeon’s mind about this problem.

Four main factors enter into the equation. There are two choices for graft tissue: taking the donor tissue directly from the patient (an autograft) or taking tissue from a donor bank (an allograft). Allografts have become increasingly popular with surgeons based on the fact that these are easy to use, come in a wide variety of sizes to choose from, decrease the time the patient is in surgery, and eliminate pain and problems at the donor site when patients use their own tissue.

But the question arises: is the risk of infection higher with donated tissue? And there are two types of graft collection sites: the hamstring tendon or the patellar tendon. The same question arises: is the risk of infection greater using one type over another?

The authors reviewed the charts of 3126 patients at their facility who had this type of surgery. They separated out these four variables and found that the overall incidence of infection is very low (less than one-half of one per cent). The rate of infection wasn’t any higher in the allograft (donor bank) tissue than for patients using their own tissue (autograft).

However, hamstring autografts do seem to have a higher risk of infection than patellar tendon grafts. This result has been reported by other researchers. There is some thought that the way in which the hamstring tendon grafts are sterilized might be the reason for an increased risk of infection with these grafts.

Even though this complication is rare, when it happens, it can still be devastating. The patient experiences fever, pain, and drainage with swelling and redness around the joint. The main danger is that the graft will have to be removed and the surgery done over. Surgeons do everything they can to save the graft and avoid a re-operation.

What can be done? Well, first the infection is confirmed by removing some fluid from the joint and testing it for bacteria. Staphylococcus aureus (staph infection) is the most common organism found. Then the joint is irrigated with a cleansing liquid called saline solution. The surgeon removes any infected tissue through a procedure called debridement. And finally, intravenous (IV) antibiotics are given for at least six weeks.

The process of irrigation and debridement may have to be repeated more than once. In this study, one-third of the patients needed this type of repeated surgery. That’s about average for what is reported in other studies of this kind. In the end, the authors were able to salvage (save) 72 per cent of the ACL grafts that got infected.

In summary, ACL graft infections are rare. Using allografts (donor tissue) doesn’t increase the risk of an infection. Most of the grafts can be saved with irrigation and debridement, though this treatment might have to be repeated more than once.

Hamstring autografts (taken from the patient) have the highest rate of infection probably due to the way the graft material is sterilized. The hamstring autograft were the least likely to be saved and kept intact. The authors suggest long-term studies now to see how well patients with graft infection and salvage procedures do over time (10 years or more).

Back in 1995 when surgeons first started using a technique called autologous chondrocyte implantation (ACI), a group of surgeons from around the United States set up a special study to track results of this treatment. They called the collection of data from patients at various clinics and surgical centers the Cartilage Repair Registry or Registry for short. The goal was to follow patients long enough to see how well this treatment worked over time.

Autologous chondrocyte implantation (ACI) refers to the filling in of cracks and holes in the knee joint cartilage with the patient’s own chondrocytes (cartilage cells). These lesions or defects occur as a result of trauma, injury, or repetitive damage to the joint. Autologous means that normal, healthy cartilage cells are taken from a place in the patient’s own knee joint. The cells come from an area that isn’t damaged and doesn’t bear a huge load when the person is upright and weight-bearing. The harvested chondrocytes have the advantage of being accepted (not rejected) by the patient’s body.

Five years ago, results from the registry were reported. An area of key interest was the durability of the implantation. At that time, results were good-to-excellent for the majority (80 per cent) of patients. There was even evidence that as time went by in the early years, patients continued to improve. Now the researchers present results after 10 years. They used the outcomes after five years and compared it with the results after 10 years to assess durability.

They didn’t just look at how well the implant held up. They also evaluated knee alignment, stability of the ligaments, and patellar tracking (knee cap moving up and down over the knee). They collected data on patients’ ages, sex (male or female), height and weight, size and location of the defect or lesion, and history of any previous knee surgeries. The data was analyzed in a number of ways trying to see if any one of these factors or variables could be linked with success or failure.

Success was defined as a confirmed defect filling, patient satisfaction with results, and no need for further treatment for the problem. Failure was determined as the need to remove the graft for any reason, the need for partial or complete joint replacement, and failure of the defect to fill in (seen on imaging studies). Most of the failures (17 per cent) occurred early on (in the first two and a half years)

Looking at patient characteristics, it turns out that most of the patients had normal knee (including knee cap) alignment before surgery. Three-fourths of the patients who ended up with autologous chondrocyte implantation (ACI) had at least one previous knee surgery (e.g., arthroscopy, debridement, meniscal repair or removal). One-fifth of the group didn’t just have an ACI procedure but also had some other procedure to improve knee alignment or repair a torn or ruptured ligament.

As far as the cartilage lesion goes, two-thirds of the patients had a sudden or acute onset of the injury. Most of the defects were located on the medial (inner aspect) on the round end of the femur (thigh bone) where it meets the tibia (lower leg bone) to form the knee joint. This is an area that takes a lot of use and abuse during weight-bearing and knee motion.

Those who improved in the first five years stayed that way — they didn’t get better or worse. The authors take this to mean that early improvement after autologous chondrocyte implantation is maintained years later. There was no indication that age, gender, lesion size, patient size (height and weight), or other knee surgeries had any effect on the final results. That’s good but what did cause those patients who had a poor outcome to fail the treatment?

Problems with knee alignment that was never corrected heads the list as possible factors linked with failure. Larger-sized defects (more than four centimeters in width and length) seemed more likely to fail. Since this is a new procedure, a lack of experience on the part of the surgeon might be a variable. Over time, statistical analysis will be able to factor for that more directly.

The authors conclude that autologous chondrocyte implantation (ACI) is a successful procedure for full-thickness (clear to the bone) holes in the articular cartilage of the knee. Pain, swelling, and knee function can be resolved in most patients who are carefully selected for this procedure. The results occur early and last up to 10 years, which is considered long-term. There are only two published studies with long-term data of this kind — this is one of them! So you can see there’s room for more results to be reported from other studies.

Cracks, holes, or other defects in the knee joint cartilage can be painful and limit function. Heath-related quality of life goes down as these patients are prevented by their symptoms from engaging in recreational and sports activities. In fact, they can be as crippled as older adults who have knee osteoarthritis that is severe enough to need a knee joint replacement.

Some experts have wondered if patients with cartilage lesions that severe should just go ahead and have the knee joint replaced. But the problem with that is that these patients are usually much younger than patients in need of a knee replacement for arthritis. Joint replacements don’t last a lifetime — they are usually good for 10 to 15 years. So that treatment option isn’t really realistic for younger adults. If that’s the case, then what’s the best treatment for cartilage defects that will yield the highest patient satisfaction?

That’s a question researchers have been trying to answer for quite a while now. So far, there hasn’t been enough agreement to support the use of one technique over another. And — too many patients end up with knee problems after treatment. In fact, some studies show that knee problems persist in both groups (those who have had treatment and those who haven’t).

We can say that younger patients with one single defect in the cartilage who have only had symptoms a short time (less than two years) seem to have the best results when autologous chondrocyte implantation (ACI) is the treatment used. Autologous means the cartilage used to repair the damage comes directly from the patient having the treatment. The cells are harvested from a place in the joint surface where there is minimal weight-bearing and where removing the cells won’t affect the load-bearing surface. Chondrocyte is another word for cartilage cell.

In order to measure patient quality of life after treatment for cartilage lesions, the authors of this study used a well-known tool called the Knee Injury and Osteoarthritis Outcome Score or KOOS. This test measures pain, symptoms, activities of living, participation in sports and recreation, and quality of life. The KOOS scales makes it possible to compare complaints for patient with different types of knee problems.

To see how patients with cartilage defects compared to other patients with knee problems, they compared three groups: patients with cartilage lesions, patients with anterior cruciate ligament (ACL) ruptures, and patients with severe osteoarthritis. The thing that made the patients in all three groups so unique was the fact that they were all scheduled for surgery. Their pain and symptoms made it impossible to cope with daily life. That places a different slant on the research study because it doesn’t include patients with mild-to-moderate cases of these three diagnoses who manage without surgery. And that’s okay — we just have to keep in mind when looking at the results that this is a specific group of patients based on severity of symptoms and doesn’t include everyone with these problems.

According to the results from the KOOS test, the patients with ACL tears were the ones most distressed by their inability to participate in physical activities. Their quality of life was more influenced by that factor than the older adults who couldn’t get around because of pain from knee arthritis. Patients with cartilage defects reported that their quality of life was affected equally by pain, inability to get around to do their daily activities, and the inability to participate in sports and recreational activities. This was true no matter what type of surgery they had to repair the cartilage.

The authors suggest that the poor results after surgical treatment for cartilage defects are made clearer when comparing these patients to those with other types of knee problems. Patients with cartilage lesions suffer ongoing pain and loss of function despite treatment. The fact that the KOOS scores were the worst for the patients with cartilage defects repaired surgically tells us that more work is needed to find better ways to treat this condition.

Despite the relatively high rate of incidence of patellofemoral
arthritis, it has traditionally been resistant to treatment. Because
of the numerous factors at work with normal functioning of the
patellofemoral joint, determining the the cause of abnormal functioning has proven difficult. Further complicating the matter, is the multitude of opinions concerning the best course of action to treatment the condition. This article reviews many ways that patellofemoral arthritis may be approached and the precise conditions that favor one treatment plan over another. It is hoped that as understanding of the condition and the complexities involved grow, so too will the ability to treat the condition.

Patellofemoral arthritis is often managed with nonsurgical treatment
initially. Therapy programs using stretching and strengthening
techniques to maintain motion and function have been shown to
effectively mitigate the symptoms of the condition. Anti-inflammatory
medications and corticosteroid injections may provide additional
support to correct the problem. Current testing is also beginning to
highlight the effectiveness of patellar sleeves, braces, or taping in
managing the condition.

For those whose arthritis fails to respond to these conservative
treatments, there exist many surgical options. Lateral facetectomy has
historically proven to be a simple, effective means of treatment for
middle-aged to elderly patients who wish to maintain their activity
level. Lateral release, though not recommended in cases of
instability, has also demonstrated effectiveness in resolving
conditions that involve patellar tilt without subluxation. Though not
fit for younger patient populations, total knee arthroplasty has
long-proved an effective way of managing the condition. The procedure
remains the most proven and predictable single procedure for older
patients with patellofemoral disease.

But recent studies have also drawn attention to the effectiveness of
autologous chondrocyte implantation. As with the other surgical
procedures for patellofemoral arthritis, implantation requires careful
diagnosis of the underlying causes and accurate identification of
positive surgical conditions concerning the architecture of the joint
space and durability of the surrounding cartilage. But with proper
suture technique and soft-tissue tensioning, implantation can restore
articular surface shape as well as normal movement and glide.

Tibial tubercle transfer is another procedure that has gained recent
attention. Though complications and concerns have traditionally
cautioned against its use, early studies are beginning to suggest the
niche role the procedure may have in cases where lesions are also
present. Younger patients have proven particularly well-suited for the
procedure as the incidence of skin necrosis and nonunion are greatly
reduced. With appropriately selected patients, tibial tubercle
transfer offers the ability to resume one’s activity level with much
less pain.

These advances offer hope that the difficulty that has surrounded the
management of patellofemoral arthritis may be minimized in the future
and may improve outcomes that have typically been less than optimal.

Can you believe it? Out of 5,000 studies published since 1990, only one compared the results of autograft to allograft reconstruction surgery for an anterior cruciate ligament (ACL) tear. That’s what orthopedic surgeons report after conducting an extensive systematic review of studies on ACL reconstruction surgery.

When a patient tears or ruptures the ACL ligament inside the knee, surgery is often needed to restore the stability that the anterior cruciate ligament (ACL) provides the knee. The best way to do this is to take tissue (usually a tendon) from some place else around the patient’s own knee (that’s an autograft) or from a donor bank (allograft) and stitch it in place.

The question these surgeons asked was, which one is better: autograft or allograft? They used measures of joint stability (e.g., the Lachman test, pivot-shift test, and KT-1000 arthrometer) as one way to look at results. They also looked at knee function and failure rates as measures of outcome.

Before starting their search, they identified a specific subset of patients to study. Only studies using live humans were included. The patients in these studies had only one knee involved and only the ACL ligament was damaged. Many times, an acute traumatic injury powerful enough to rupture the ACL will also tear other soft tissue structures in the knee. None of the patients had a previous history of other surgeries on the involved knee.

Studies included had to include only patients with a mean age of less than 41 years. The age restriction was to select out younger patients less likely to have additional arthritic changes to contend with. The studies had to follow them for at least two years after surgery.

With more than a quarter of a million ACL reconstruction surgeries performed in the United States each year, and 80 per cent of those using autografts, you would think the question of allograft versus autograft would be settled. In fact, the authors thought they would find no differences in results or outcomes between the two graft choices.

But what they found was that more time and money has been invested in studying the differences in results between two types of autografts (bone-patellar tendon-bone vs. hamstring). Second to that, surgeons have been working hard to improve and refine the way these grafts are attached, a process called graft fixation.

There were only three studies on allografts that fit the criteria used for including studies in this analysis. More of the acceptable studies were focused on autografts (a total of 54 included). Because there weren’t enough direct studies comparing one to the other, it was necessary to look at the studies for each type of graft separately and compare them that way instead. Without enough studies using a direct comparison, the level of evidence to support one or the other is less.

Given all the ifs, ands, or buts, the authors reported that allografts tend to produce a knee that isn’t as stable as joints treated with autografts. In other words, there’s greater joint laxity (looseness) with allografts when using joint stability tests described.

The KT-1000 assessment is probably the most objective way to measure stability. The device shows in millimeters how much the joint moves (slides and glides) when pressure or force is applied to the joint. The other tests (Lachman, pivot-shift) are performed by an examiner and are therefore more subjective.

There were no significant differences based on the other outcome measures (graft failure, function). The authors thought that the lack of significant differences might be more a reflection of how studies are conducted than the fact that there really aren’t differences in results between autograft and allograft.

For example, the study size (number of patients included) varies greatly from one study to the next. That factor alone can affect the results. There is also a wide range of differences among patients included based on age, activity level, and surgical technique used. Without a set standard approach with more similarities than differences in how studies are conducted, results can’t be compared from study to study.

The final conclusion from this meta-analysis was that researchers may need to direct future studies toward comparing autograft to allograft ACL reconstructive surgeries. This is important before continuing to choose autografts over allografts. Autografts have the disadvantage of causing problems at the donor site such as infection, persistent pain, and possible deformity. Allografts eliminate those problems but have their own issues with potential tissue rejection by the patient.

The authors suggest it would be helpful if comparative studies select patients carefully so that other factors don’t cloud the results. Outcome measures using valid tests like the Tegner activity score, Cincinnati knee score, Lysholm score, and International Knee Documentation Committee (IKDC) score should be used in all studies to allow for more accurate comparisons of results.

Many will remember the attack on U.S. ice skater Nancy Kerrigan when she was struck on the knee during a practice session by a hired assailant. The injury forced her to withdraw from the competition at that time. Most traumatic knee injuries are not that dramatic but can be very disabling just the same. In this review, orthopedic surgeons from the University of Colorado team up with experts from the New York University Hospital for Joint Diseases to review quadriceps tendon injuries. The assessment, diagnosis, and treatment of three problems are covered: quadriceps tendinosis, partial quadriceps tears, and complete quadriceps tendon ruptures.

The quadriceps muscle along the front of the thigh is made up of four muscles that attach to the quadriceps tendon: rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius. Together, the quadriceps muscles, patellar tendon (where the quadriceps tendon attaches around and below the patella), and the patella (kneecap) form the extensor mechanism. The extensor mechanism is the motor that drives the knee joint and allows us to walk. It straightens the knee when the quadriceps muscle contracts making it possible to climb up stairs or get up from a sitting position.

Any injury to the quadriceps muscle or tendon affects the extensor mechanism causing pain, loss of knee extension, and loss of function. You’ve probably heard of tendinitis, an acute inflammatory process affecting tendons. But what is quadriceps tendinosis? The term tendinosis tells us that the injury is chronic (been there a long time). When examined under a microscope or with advanced imaging such as ultrasound or MRI, there is degeneration of the tissue but without any sign of inflammation.

A specific type of patellar tendinosis seen in athletes who repeatedly jump is known as peripatellar tendinosis or more commonly known as jumper’s knee. At first there’s an inflammatory response to overuse or repetitive motion. Acute inflammation occurs as tiny tears called microtears develop around the patellar tendon. These microtears can occur where the tendon inserts on the patella or on the tibial tuberosity, a bump on the lower leg bone just below the kneecap. The inflammatory process ends resulting in scar tissue that replaces the destroyed tendon tissue. That’s when a tendinitis becomes a tendinosis.

Tendon tears are usually the result of an active injury either while engaged in a sports activity or from a fall. Less often, as in the case of the skater, trauma from a direct blow can cause the same kind of damage. Besides athletes, older adults are at risk for quadriceps tendon tears. For a long time, it was believed that a loss of balance and fall led to tendon ruptures. But more recent evidence has shown that weakness of the tendon from age-related degeneration causes tendon rupture first, then the fall. The fall is the result of the loss of knee joint stability from the torn tendon.

Older men, especially older black men seem to be affected most often. The injury doesn’t just come out of the blue. Other risk factors include the use of certain antibiotics (fluoroquinolones) or steroids. Having a chronic, systemic health problem like diabetes, lupus, rheumatoid arthritis, gout, or kidney disease increases the risk of quadriceps tendon rupture considerably.

Although the patient with a quadriceps tear is in pain, he or she is usually still able to contract the quadriceps muscle and extend the knee. If the entire tendon is torn, then this motion becomes impossible and the injury is declared a rupture. Without the quadriceps muscle, the patient cannot extend the knee or stand on the leg and walk. It’s clear that there is a significant problem!

To make sure the exact problem is diagnosed and the proper treatment planned, diagnostic imaging is needed. The orthopedic surgeon may begin with X-rays to see if there are any bone fractures or a change in the position of the patella. Ultrasound testing is next. The ultrasound can show any defects in the quadriceps tendon. It is a quick, easy, and painless test that is also less painful to the pocketbook (i.e., much less expensive than MRIs). But MRIs may be needed if the surgeon suspects damage inside the knee joint.

Once the diagnosis has been made, a plan of care is developed. It may involve rest and activity modification with physical therapy to help alleviate pain at first. Surgery isn’t usually required for tendinosis. The patient with this problem will progress through rehab to restore normal function, flexibility, strength, and motion of the knee (and leg). It’s only when all these things have been tried with no success that the surgeon may have to consider removing some of the degenerated tissue. Fibrosis and calcification (hardening) of the tendon may make recovery impossible without surgical intervention.

Partial tears are treated in a similar fashion. If there’s been significant bleeding into the joint, the surgeon may have to remove the fluid that has built up. The procedure helps speed up healing. The old R.I.C.E. standby (rest, ice, compression, elevation) is still used. Antiinflammatory drugs may be prescribed for some patients. But research has shown that the use of these medications can delay tendon healing, so they are no longer used routinely. The leg is kept straight in a splint for three to six weeks depending on how big the tear is.

Once the patient can contract that muscle and lift the leg up off the table, the immobilizer can be taken off and rehab begun. Failure to recover following this formula means the patient becomes a surgical candidate. The surgeon cleans up the area removing any scar tissue, debris, and frayed edges of the torn tendon. This procedure is called debridement. Then the torn layers of the tendon are stitched back together. Surgical repair of this type is almost always required for a complete tendon rupture — and usually the sooner, the better.

There are different ways to repair a complete quadriceps tendon rupture. The surgeon may use drill holes, screws, sutures, suture anchors, or wires to reattach the tendon to the bone. It all depends on the location of the rupture, the condition of the tissues, and the extent of damage. It may be necessary to reinforce the defective tendon, especially if the patient is older with obvious signs of tissue degeneration.

The leg is protected in a brace or cast that holds the knee in 30 degrees of flexion. That means the patient can’t straighten the knee all the way. This position allows the tendon to heal without any pulling on the fixation site from the muscle contracting. After surgery, patients may begin walking on the leg right away. That’s a fairly new approach based on studies that show early mobilization actually helps tendons heal. Some surgeons tell their patients to put full weight on the leg. Others recommend only partial weight-bearing for the first six weeks and then progress to full weight.

When tendon repair has been delayed long enough, the torn end of the quadriceps tendon retracts or pulls back. Scar tissue around the torn end of the tendon can make it difficult to just pull it back down and reattach it (this can be done more easily when the procedure is done soon after the injury). If the surgeon can’t get the tendon down close enough to reattach it at least near its original insertion point, then the procedure changes from a tendon rupture repair to a reconstruction procedure. This calls for some fancy footwork on the part of the surgeon.

The authors discuss various surgical options for reconstruction. It may be possible to take a piece of tendon from the hamstring muscle behind the knee and use it to make the quadriceps tendon long enough to reattach. Other options include a V-shaped turn down flap and Leeds-Keio ligament, a manmade device that promotes the formation of collagen tissue around it. In this way, the body fills in the gap with its own repair tissue. Another approach is to cut the quadriceps muscle itself to make it longer. The authors describe this technique (Codvilla quadriceps lengthening technique) for surgeons planning treatment for these patients.

A follow-up look at patients with quadriceps tendinosis and partial tears shows good results and satisfied patients. Repair or reconstruction of tendon ruptures can be more problematic. Some patients don’t get their full motion (extension) back. That means they won’t have full strength or full function of that knee and leg. Even those who do get their full motion back don’t get full strength. In fact, studies show that half of all repaired quadriceps tendon ruptures result in quadriceps muscle weakness even years later. Rerupture of the tendon is always a concern.

The authors conclude that the more involved quadriceps tendon ruptures (compared with tendinosis or partial tears) are rare but treatable. Any time a condition is rare, research to provide evidence of the best way to treat it is difficult. Currently, there are no large studies comparing treatment approaches or even outcomes from different surgical procedures. Research is needed to answer these questions, look at who is at risk for complications, and answer the question about delayed weight-bearing post-operatively (i.e., how soon can patients put full weight on the knee).

There are plenty of studies looking at the results of anterior cruciate ligament (ACL) repairs. But this may be the first to report outcomes for posterolateral knee reconstruction. Whereas the anterior and posterior cruciate ligaments hold the knee stable from inside the joint, there are other ligaments that hold it together from the outside. Three ligaments that provide posterior (to the back) and lateral (to the side) support and stability to the knee are the focus of this study.

Those three ligaments are: fibular collateral ligament (FCL), popliteus tendon (PLT), and popliteofibular ligament (PFL). The fibular collateral ligament connects the top of the fibula (bone along the outside of the lower leg) to the bottom of the femur (thigh bone). It gives lateral (side) support to the knee to keep it from bowing out too far. The popliteus tendon starts midway along the bottom portion of the femur and angles back to connect to the back of the upper tibia (shin bone in the lower leg). This tendon supports the knee and keeps it from rotating too far in one direction. And the popliteofibular ligament connects the back of the tibia to the back and side of the fibula. The fibula and tibia sit side by side as the two bones in the lower leg.

A previous study by these surgeons (one group from the U.S., the second group from Norway) reported on their success anatomically reconstructing these three support structures. Many other surgical procedures have been used to repair damage in this area. They believe theirs is the first to actually restore the natural anatomy by using Achilles tendon grafts taken from a donor bank. The surgical procedure was described in detail — how the Achilles tendon was prepared for use as a graft, preparation of the bone with tunnels for the grafts, and anchors used to keep the grafts in place.

Everything was done with the idea in mind of stabilizing the knee in the most optimal way possible — by mimicking the original, natural anatomy. In this way, patients can get full function back without fear that the knee is going to give way from underneath them or get reinjured. They should get the same kind of good results other knee patients get when the anterior or posterior cruciate ligaments are reconstructed. But instead of keeping the bones in the knee from sliding too far forward or too far backward (the job of the cruciate ligaments), these posterolateral structures protect the knee from bowing out to the side too far or externally rotating too far.

Patients came from two separate centers but with everything done in the same way so that all the data could be combined. Everyone in the study had been diagnosed with a grade-3 chronic posterolateral knee instability. The term chronic is a key factor in this study. These are people who had a significant delay between the time the knee was injured and the surgery was performed. The time interval ranged anywhere from two months up to 12 years. The patients ranged in age from 18 to 58, so it wasn’t just young, athletes who were involved in the study. And quite a few of the subjects had other knee injuries (e.g., nerve damage, previous failed knee surgery) that added to the complexity of surgery and recovery.

Clinical tests used to make the diagnosis showed a widening of the joint space along the outside (lateral edge) of the knee when pressure was applied in that direction. Likewise, there was an increase in external rotation of the tibia under the femur and a positive posterolateral drawer test. The drawer test is done by applying pressure to the lower leg (tibia) and seeing or feeling too much backward movement of the tibia under the femur. Sometimes there is even a clunk as the bone shift too far back. This occurs because the ligaments are damaged and don’t hold the tibia in place as they should.

Before the surgery was done, patients were tested using X-rays, MRIs, and rating scales to measure pain, knee range-of-motion, and function. Patient ratings of their symptoms and disability were measured using the Cincinnati scores. Function was measured using the International Knee Documentation Committee (IKDC) score.

Results of the clinical tests were also recorded. All of these tests were repeated after surgery and during the follow-up period to compare before and after results. Everyone was followed for at least two years. Some of the patients had been treated and reassessed over a longer period of time (up to seven years total). And the authors intend to continue following as many people in the study they can keep in touch with in order to gather data to judge intermediate and long-term results.

A postoperative rehab program was part of the post-surgical plan. No one was allowed to put weight on the involved leg for six weeks. They were allowed to do some specific range-of-motion and strengthening exercises supervised by a physical therapist. A knee immobilizer (splint) was used to protect the knee until they could lift the leg off the table (straight leg raise) without an extension lag. Extension lag refers to a lack of full extension of the knee when trying to straighten it all the way or while doing a straight-leg raise.

The surgeons set certain milestones to be reached during rehab such as 90 degrees of knee flexion by the end of two weeks, full knee motion at the end of six weeks, and resume weight bearing by the end of 10 weeks. It was expected that the patients would walk normally again (without a limp) by the end of four months. Athletes could return to full competitive sports action when they had full motion, strength, endurance, and proprioception (sense of joint position).

The length of time for complete recovery varied depending on the extent of surgery. Some patients only had one ligament reconstruction whereas others had all three restored. And in some cases, the surgeon had to perform a two-part procedure, first realigning the knee and then reconstructing the damaged soft tissues. Realignment was necessary for those patients who had too much varus contributing to the problem. Varus is a natural bow-legged position of the knee. Without reducing the pressure along the outside of the knee by putting it in a more neutral position, the reconstructed ligaments would be under abnormal stretch, stress, and strain again. The realigning procedure is called an opening-wedge tibial osteotomy.

So for a quick recap: we’ve got patients with posterolateral knee instability. It’s a complex instability pattern affecting two ligaments, one tendon, and two areas of the joint (side and back). It’s been there a long time, so it’s considered chronic. The surgeons have come up with a way to reconstruct the knee stability (not just repair the torn tissues). Because the procedure is meant to recreate the normal anatomy, they are calling the procedure an anatomic posterolateral knee reconstruction.

And the results? All patients in the study had a good result. This included those with only one soft tissue structure involved, patients with all three tissue structures damaged, and people with varus deformities creating alignment problems requiring additional surgery. Test results from before to after showed significant improvement in all areas measured.

The test measures used are standard in the treatment of knee injuries and can be repeated by others interested in studying results of surgery for chronic posterolateral instability. In this way, evidence can be gathered and reported to help determine the long-term results of this particular operation. And surgeons using other procedures can report their data in the same way. The comparisons will help surgeons find the best way to treat this problem.

Total knee replacement, or total knee arthroplasty is an increasingly common surgery. The authors of this article describe various issues involved in knee reconstruction, including economic, surgical and demographics. To do this, researchers reviewed 100 medical journals to ultimately find the outcome of 6,483 patients who had undergone knee replacements.

Economics
One study, by Bhattacharyya and colleagues looked at the success of pay-for-performance. They found that teaching hospitals, hospitals with higher volumes of replacement surgeries and hospitals in the Midwestern part of the United States had better pay-for-perfomance rate. The performance was judged on three issues: when antibiotics was started before surgery (preoperatively) and if it was done within one hour, when antibiotics were stopped after surgery (postoperative and if it was within 24 hours of surgery, and if there were signs of bleeding, bruising, or chances that the patient would need to be readmitted to the hospital.

Another study, however, by Bozic and Chiu that also looked at pay-for-performance, found that surgeons varied widely as to whether they stuck to certain guidelines, such as timing of x-rays before surgery, timing of referral for surgery, use of injections and physical therapy, and repeat operations after one year. Finally, a third study by Rosenberg and colleagues looked at the timing of when antibiotics were started before the surgery. To ensure that patients received the antibiotics, the institution studied used a ‘time out’ protocol, which aimed to ensure that the timing of the antibiotics was adequate. In other words, the incision for surgery would not be made until a certain amount of time had passed since the patient received the antibiotics. The authors of the study found that this time-out period improved antibiotic guideline adherence from 65 percent to 97 percent within 18 months.

Unicompartmental Arthritis

When arthritis affects one part of the knee, rather than the whole knee, this is unicompartmental arthritis. This is a common reason for knee replacements. In one study, Riddle and colleagues looked at the data from three different implant manufacturers and how often these implants were used in 44 hospitals. They found that over a seven-year period (1998 to 2005), the rate of implant use increased by an average of 32.5 percent. In comparison, there was a 9.4 percent increase in total knee replacements over that same period.

Another study that used the Swedish registry to look at knee replacements, done by Robertsson and Lidgren, looked at the short-term results of three different unicompartmental knee replacements. They found that there was a less than 10 percent risk of having a revision surgery after five years, but one particular type of implant needed revisions more than the other two.

A 12-year study, done by Emerson and Higgins, looked at 55 knees over the course of 12 years following unicompartmental knee replacement. They found an revision rate of 85 percent. Interestingly, there have been excellent long-term reports for this type of surgery, but there have also been many early failures due to mechanical breakdown. To study this aspect, Aleto and colleagues looked at 32 knee replacement revisions on patients whose average age was 66 years at the time of the revision and there was an average of 5.7 years between the initial surgery and the revision surgery. Fifteen failures were due to a collapse of the medial tibial plateau, the smooth bony surface of the two bones that join at the knee. The patients who had this complication ended up needing more screws or other hardware when their knee was replaced by a total knee replacement. As well, these patients were generally older than the others. They were, on average, 71 years old while the others were an average of 61 years old.

Surgery
As with most other procedures, there are various approaches that surgeons may use to accomplish their goal. Recently, surgeons have been focusing on trying to reduce tissue damage, reduce pain after surgery, and improve the speed with which a patient may regain full – or as close to full as possible – function.

One approach, called the midvastus involves making an incision into the joint (arthrotomy that moves away from the kneecap, to the middle of the quadracep muscle. Dalury and colleagues investigated this approach in 20 patients who had both knees replaced; one knee was done this way and the other using another approach. The results of their study showed that there was not much difference between the two knees six weeks after the surgery. Six patients did prefer the midvastus approach, but no other issues were noted.

Another approach, the mini-subvastus approach has similar results but the surgeon can avoid cutting into the quadraceps muscle and tendon. Schroer and colleagues looked at 150 total knee replacements to assess the success of this approach. They found that patients who had the mini approach were discharged from hospital earlier than patients who had the traditional approach. They were able to recover their quadriceps strength more quickly, were less likely to need inpatient rehabilitation, and had better ability to bend the knee.

Minimally invasive surgeries, those that don’t make such large incisions as traditional surgeries, are becoming more common as surgical equipment becomes more advanced. Researchers McAllister and Stepanian looked at the early results of 100 patients who had total knee replacements, either with minimally invasive surgery or traditionally. Their results showed that the patients with the minimally invasive surgery had shorter hospital stays, less complaints of pain, and better bending than those who had the traditional surgeries. However, after one year, there were not many differences between the two groups.

Computer Use
Computer navigation is becoming increasingly popular in surgery. With knee replacements, computer navigation allows the surgeons to line up the bones more accurately, improving the chances of the implant success. In one study, by Lionberger and colleagues looked at 46 total knee replacements during which the surgeons used a navigation system. After surgery, 95 percent of the patients had accurate lining up of the bones and mechanical limb alignment was 93 percent.

During Surgery
Perioperative, during surgery, management has also been improving over the years. Pain management and patient education have also significantly improved outcomes after knee surgery. Dorr and colleagues studied 35 patients who had an epidural anesthetic and 35 who had a femoral nerve block (local anesthesia), along with pain medications after surgery. The patients were encouraged to take medications before they were absolutely necessary. These patients seemed to have better pain relief than those who are managed with traditional pain relief techniques. This type of pain relief also reduced the need for narcotics.

Another researcher, Lavernia and colleagues, looked at 778 procedures where patients were managed with traditional pain relief techniques and compared them with 358 patients who followed a specific pain-management protocol. The protocol included using the medications celecoxib, controlled release oxycodone, acetaminophen, and ondansetron. These medications were given in such a way that the pain was prevented, rather than treated. The patients also received the same local anesthetic described above. The results were not surprising. Those patients who prevented the pain did better after surgery than those patients who managed the pain once they felt it.

Blood Clots
Venous thromboembolism, blood clots in the deep veins in the leg, are a common problem among many patients who undergo surgery, particularly surgery in the hips and knees. There are treatments to try to prevent it, but this is controversial among some surgeons for patients who undergo total knee replacements. Researchers Novicoff and colleagues looked at patients who received a new protocol of anti-coagulation therapy, medications that prevent the formation of blood clots. All patients who had a total hip replacement received warfarin to thin their blood and those who were considered to be high risk for developing a clot received a higher dose.

As with all medications, anticoagulants may cause side effects and the researchers found that this was no different. In this study, there was a 1.4 percent increase in bruising and hemorrhages from before the protocol was instituted. That wasn’t all. Readmission to hospital increased by 2.2 percent and there was no change in the number of patients who developed blood clots.

Another study, done by Callaghan and colleagues, looked at 312 total knee replacements, in which low-risk patients were given aspirin to try to prevent blood clots. In this study, there were no side effects noted and no readmissions to hospital.

Complications
As with all surgeries, total knee replacements do cause complications for some patients. Pulido and colleagues investigated in-hospital complications in 15,383 joint replacement in patients who had either a knee or hip replacement. They found a 0.16 percent mortality rate in the hospital. Complications involving body systems, systemic complications, included 152 blood clots that went to the lungs, pulmonary emboli; 92 rapid and irregular heart beats, tachyarrhthmias; and 36 heart attacks.

When looking at the joints, the researchers found 29 injuries involving the nerves around the joints, 25 fractures of the replacements; 18 dislocations; and 16 injuries to the blood vessels around the joints. Another researcher, Parvizi, found that 0.7 percent of 4,567 patients studied developed postoperative ileus, complications in the colon.

Infections are always a risk after surgery and knee replacements are no different. In a study by Kurtz and colleagues, it was found that those patients who had a total knee replacement had a higher rate of infection (0.92 percent) than patients who had a total hip replacement (0.88 percent). Having an infection doubled the length of hospital stay among patients with the replacement.

Five years ago, Dr. Goldblatt, orthopedic surgeon and professor at the University of Rochester School of Medicine (New York) wrote an article on meniscal (knee) injuries. It was published in the Journal of Musculoskeletal Medicine. Today, Dr. Goldblatt and two other orthopedic surgeons update that information here. More and more efforts are being made to save the damaged cartilage, first through conservative (nonoperative care) and when necessary, using surgery to repair the torn tissue whenever possible.

There are multiple levels of protective cartilage and soft tissues in and around the knee. The meniscus is one of them. Shaped like a crescent or horseshoe-shape, there are two of these thick, stiff pieces of cartilage in each knee. They are designed to help separate the joint, assist with smooth motion, transfer load, and generally, protect the joint. Modern treatment no longer just removes a torn or damaged meniscus. Long-term studies have shown over and over that this type of aggressive treatment puts the joint at risk for faster and worse wear and tear often leading to knee arthritis.

Arthroscopic surgery has made it possible to correct the problem by repairing the meniscus with a minimally invasive procedure. The updated technology has been aided by new treatment techniques such as meniscal regeneration and meniscal transplantation. Although most patients are candidates for meniscal repair, two groups must be considered separately: those who need or want a more conservative approach without surgery and those who qualify for meniscal regeneration and transplantation. Let’s take a look at the way treatment is chosen for each patient.

In the case of nonoperative care, the surgeon considers the age and activity level of the patient. Older adults who aren’t very active may do just fine with a rehab program of modified activity and strengthening exercises. The surgeon looks at how long the patient has had this problem (acute versus chronic). The chances of healing in a long-term injury (one that occurred months to years ago) are less than in a more recent injury.

What’s the condition of the joint? How bad is the tear? Could it heal on its own? Small tears along the edges of the cartilage have a better chance of healing because there is a better blood supply there. An MRI will help show how much blood supply there is and give the surgeon an additional tool when predicting who might get better with nonoperative versus surgical care. Tears on the inner aspect of the meniscus (especially large tears in multiple directions) don’t heal well and often need a little surgical help.

Sometimes patients are advised to try a conservative (rehab) program first. If symptoms are resolved and activities can be resumed, then great — surgery won’t be needed. But if after a trial of rehab lasting up to three months, there’s no improvement or pain persists with activities, then it’s time to think about surgery. The most successful operations are performed within the first 10 to 12 weeks after the injury first occurs.

When it comes to surgery, the goal is to save the meniscus but also stabilize the knee. It may be possible to repair the tear and/or reattach the torn edges. The surgeon shaves down any ragged edges in a procedure called debridement. Debridement may be all that’s needed to stimulate a healing response. In some cases, the surgeon may opt to suture loose edges back in place or even remove part of the damaged meniscus.

By taking a look at the cartilage using an arthroscope, it’s possible to see what condition the meniscus is in and how much degeneration has occurred. Too much degeneration and the meniscus won’t heal itself and can’t be saved. Likewise, if the tear is too long, too deep, or too displaced, then it might be necessary to actually remove part (or all) of the cartilage. This procedure is called a meniscectomy. No matter what, the surgeon always tries to preserve tissue and knee function.

The most difficult injuries to deal with are large tears in more than one direction (vertical and horizontal) and bucket handle tears. With a bucket handle tear, half the meniscus has pulled up away from the rest — like a bucket handle lifting up away from the bucket. One end of the meniscus can get folded back on itself.

For severely damaged menisci, meniscus repair implants may be possible. This procedure is fairly new and was first used about 10 to 15 years ago. Since then, two procedures have gained in popularity: meniscal allograft transplant and collagen meniscal implants. An allograft transplant uses meniscus donated by others (like an organ donor). Collagen implants use collagen (the basic building block of soft tissues) from animal (cow) tendons. The collagen provides a scaffold that fills in with meniscus-like tissue and fibrous cartilage cells. Collagen implants have two important advantages over allografts: they are widely available and don’t require a tissue match.

When considering which treatment approach to take, it’s important to consider the success rates (outcomes) for each procedure. That’s where researchers are working now to match the right patient with the procedure that will yield the best results. Over time with improved techniques, better patient selection, and matching each patient to the most appropriate procedure, success rates have improved dramatically.

For example, meniscal repair in young patients with a stable knee and tear in the outer portion of the meniscus is 80 to 95 per cent successful. Athletes in this group are able to get back into full sports action at a level equal to before the injury. Partial meniscectomy in someone who has good articular cartilage underneath has a 90 per cent chance of successful healing. This same procedure is only successful 60 per cent of the time when there’s damage underneath the torn meniscus or when the knee is unstable or misaligned.

Removing any portion of the meniscus will eventually result in degenerative changes in the joint. This may not happen for five to 10 years, and it is somewhat dependent on how active the patient is — more activity puts added stress on the joint and increases the risk. Hopes are pinned on meniscal transplants and implants for future successful results. It’s always better if the patient can form his or her own, durable, stable meniscus. Meniscal substitutes of this type aren’t perfect yet. Future efforts will be directed at finding alternatives that will result in normal, healthy meniscal tissue that will hold up over time under joint contact and force.

New, updated techniques used to perform osteotomies make this procedure one to consider for younger, more active patients with unicompartmental knee arthritis. Osteotomy is a surgical procedure designed to realign the knee and even out the weight-bearing forces from side to side. A wedge-shaped piece of bone is removed from one side of the bone. Then the bone above and below the space is adjusted to correct the joint alignment. The two sides of the bone can be held open with a special opening-wedge metal device screwed into the bone. Or the two sides of the bone can be collapsed down toward each other in a closing-wedge procedure.

Once the joint is realigned to create a more normal load distribution, painful symptoms go away, and the knee is stable again. The best use of this procedure is for patients who have abnormal joint alignment and uneven weight-bearing that has led to arthritis on one side of the joint. That’s what is meant by unicompartmental (one-sided) knee arthritis. Usually the medial side (or compartment closest to the other knee) is affected but lateral unicompartmental arthritis can develop instead. The type of unicompartmental arthritis that develops is based on how the knee is put together, where the alignment problem is, and how the uneven load affects the joint.

In the past, osteotomies were more commonly used with older adults. But their use in younger adults has become the focus of closer attention in the last few years. That’s why orthopedic surgeons wrote this review article from the University of Pennsylvania. They offer surgeons a second look at high tibial and distal femoral osteotomies for young patients with unicompartmental arthritis of the knee. Anyone who is too active, too young (less than 50 years old), and unwilling to protect the total knee replacement by modifying and limiting activities might be a good candidate for an osteotomy.

High tibial osteotomies are done in the upper portion of the tibia (the lower leg bone) — usually just below the knee joint and above the shaft or long portion of the bone. Distal femoral osteotomy is done along the lower portion of the femur (thigh bone) — above the knee joint but below the long shaft of the femur. Tibial osteotomies are done much more often than femoral osteotomies.

The surgeon based on X-rays and clinical observations of the bony alignment determines the exact location of the procedure and whether an opening-wedge or closing-wedge approach is used. Full-length hip to ankle X-rays are recommended. MRIs may be ordered to give surgeons a better preoperative idea of the condition of the surrounding soft tissues (ligaments, cartilage, other knee compartments) Each patient is evaluated individually. There’s no set formula of X, Y, Z to guide the surgeon.

There are some general guidelines based on the results of studies done so far. For example, anyone who has had the meniscus (knee cartilage) removed from the knee or who has severe degenerative disease on the other side of the joint is not a good candidate for an osteotomy. Osteotomy buys the patient some time before having a total knee replacement. During that interim, activities are not restricted. The person can be as active as he or she would like.

With newer, more modern surgical techniques and follow-up protocols, results are far superior to the old way of doing osteotomies.
The osteotomy shifts the weight away from the arthritic side of the joint. Surgeons have available now tools to make precision cuts in the bone. The device used to hold the bone in a specific position is called a distraction plate. This is a fairly new feature in osteotomy surgery. The authors present detailed instructions for surgeons in using these new tools and while performing tibial or femoral osteotomies.

The results of osteotomy can be somewhat unpredictable. Various degrees of success are reported. But the new technology, new surgical techniques, and new instrumentation (opening-wedge distraction plates, locking closed-wedge plates) have increased the accuracy of correction bringing this procedure back into the limelight.

The benefits don’t last forever. Breakdown and deterioration of the joint is to be expected over the next 10 years or so after osteotomy. At that point, a total knee replacement is the most likely next step in treatment. But if an osteotomy can delay joint replacement while still giving patients an opportunity to stay as active as they like, then it may be well-worth it. Young patients with arthritis from malalignment of the knee are the best candidates to consider for this treatment approach. Surgeons must be skilled in the technique in order to minimize complications and maximize results.