News Category: Knee

In this study, surgeons from the Netherlands (Belgium) present long-term results of a study previously published comparing two methods of treating knee articular cartilage damage. Articular cartilage refers to the fibrous structure directly over the bone protecting the joint and helping produce smooth gliding action. What makes the research of this Belgium group so unique is the use of a cell therapy product in one of the groups. Cell therapy is designed to prevent breakdown of the repair. Here’s a little background on the subject.

Knee articular cartilage doesn’t repair well by itself. There isn’t a lot of blood supply to the area. So left untreated, patients with this problem often develop knee pain, early osteoarthritis, loss of function, and eventually disability. In the last 10 years, joint resurfacing techniques such as microfracture (MF) and autologous chondrocyte implantation (ACI) have been developed to address this problem. But there are problems with these procedures.

The authors of this study are addressing the problems associated with autologous chondrocyte implantation (ACI). In this procedure, normal, healthy articular cartilage cells are removed from the patient and taken to a lab. In the lab, scientists use the cells to grow more cells — enough to fill the hole or defect in the patient’s joint and repair the damage. But surgeons have discovered that over time, the lab grown chondrocytes (cartilage cells) seem to lose their ability to remain chondrocyte cells. They start to become unstable and lose their form and structure, a process called dedifferentiation. The end-result is joint breakdown again and early arthritis.

The solution to this problem may be a new method called cell therapy. With cell therapy, the autologous cells (harvested from the patient) are treated (processed) in a special way to preserve the cells’ ability to remain stable and unchanged after implantation into the knee. This cell therapy procedure called a characterized chondrocyte implantation (CCI) is a slight variation of the autologous chondrocyte implantation (ACI).

In the first part of this study, patients with painful cartilage defects on the femoral (upper or thigh) side of the knee joint were divided into two groups. The first group had the microfracture procedure (tiny holes drilled into the joint surface to create bleeding and stimulate a healing response). The second group had the characterized chondrocyte implantation (cell therapy). Short-term results were reported after 12 months. The same two groups of patients were followed an additional 24 months for a total of 36 months (three years). This report provides the results after three years for those two groups.

The authors were watching for several things during follow-up. They wanted to see how patients compared symptom-wise (pain, swelling, knee function), but they also wanted to see if there was a difference in outcomes based on how long patients waited before getting treatment. They used serial (repeated) MRIs and a special test called the Knee Injury and Osteoarthritis Outcome Score (KOOS) to measure results. The KOOS gives information on overall knee function including pain, stiffness, activity level (daily activities and sports or recreational activities), and quality of life.

The MRIs showed that patients having a microfracture procedure showed improvement in the cartilage for up to 18 months. But the characterized chondrocyte implantation group had ongoing biologic growth and repair for much longer. Not only that, but there was evidence of bone overgrowth and degeneration of the repair tissue with microfracture that wasn’t present in the cell therapy group. Likewise, KOOS scores of knee function were better for the cell therapy group, especially for pain and quality of life. There were fewer adverse effects of treatment and fewer treatment failures in the characterized chondrocyte implantation (CCI) group.

All in all, the long-term results of this first published study using cell therapy products to stabilize cartilage implantation seem to point to characterized chondrocyte implantation as a better treatment procedure than either autologous chondrocyte implantation or microfracture. The procedure is not without some potential problems. Overgrowth of cartilage and joint crepitus (crunching sound made by rough joint surfaces rubbing against each other) occur more often with implantation than with microfracture.

But as a technique to repair damaged articular cartilage in the knee and provide long-lasting, normal movement of the joint, autologous chondrocyte implantation treated with cell therapy to form characterized chondrocyte implantation seems to be an improvement in joint resurfacing. And the sooner it’s done the better because the patients who had the best results had the surgery done early after injury (within the first 18 months). Previous research has shown that patients have up to three years from the time of injury to the time of treatment before it may be too late for a safe and effective repair using these techniques.

What’s the best way to treat damage in the knee joint articular cartilage? In this report, surgeons from the Netherlands summarize the current evidence for repair versus restorative procedures. The articular cartilage is a smooth, fibrous covering over the two bones that form a joint. If you were to look at this structure on a chicken leg, it is the equivalent of the gristle at the end of the drumstick.

The purpose of the articular cartilage is to protect the bone while making it possible for the knee joint to slide and glide as it bends and straightens. Damage to this part of the joint can create cracks and even holes called defects that must be treated to prevent erosion of the underlying bone. Without treatment, the eventual outcome is painful knee osteoarthritis.

Don’t confuse the articular cartilage with the meniscus. Torn meniscus is a common injury among sports athletes. The meniscus is a C-shaped disc of dense cartilage that also protects the joint, helps create smooth movement, and transmits load placed on the joint. The focus of this report remains just on the articular cartilage, which lies underneath the meniscus (between the meniscus and the bone itself).

There has been some suggestion that surgeons treat articular defects based on their training, not based on the evidence. That’s why a systematic review of this type is important — it helps surgeons see what works best and when to use a variety of techniques. With this information, they can seek additional training and provide best practice (evidence-based) procedures to all their patients.

To perform a systematic review, it is necessary to search for all studies published on a single topic. Each study must be carefully reviewed for research methods and quality. Small studies with only a few patients or case studies featuring only one patient are not included. Finding studies that measure the same things in order to compare the results is always a challenge in a systematic review. Finding studies that follow patients for the same (or similar) lengths of time is also important.

As part of this systematic review process, articles had to be in English, French, German, or Dutch (languages the researchers could read or translate) and compare at least two of the three techniques listed. Studies were limited to those that included patients with articular cartilage lesions that had not yet progressed to damage to the bone and defects that did not include damage to the meniscus.

In this case, the authors were able to find 865 articles on the treatment of articular cartilage lesions. But only four were randomized controlled trials (RCTs) that would qualify as sufficient evidence on this condition. Randomized means the patients were assigned to their treatment group based on computer selection, not based on any particular characteristic such as age, activity level, or type of damage. Three treatment techniques were included: osteochondral autologous transplantation (OAT), microfracture (MF), and autologous chondrocyte implantation (ACI).

Microfracture is a way to repair the defect. The surgeon drills tiny holes through the articular cartilage into the bone. This causes bleeding and the formation of tiny blood clots to fill the defect. The body then sets up a healing response that releases growth factors and causes new chondrocytes (cartilage cells) to form. Transplantation and implantation are restorative techniques. The surgeon uses a plug of cartilage and bone taken from a healthy area of the patient’s own knee for the transplantation procedure or the patient’s own normal, healthy cartilage for implantation procedures to fill in the hole.

After analyzing all the data and comparing results, the authors made the following observations:

Here’s a unique research dilemma for orthopedic surgeon: how can they study what works best for traumatic knee dislocations when there are so few and the injuries are so different? Most of the time, knee injuries severe enough to cause the joint to dislocate also cause significant soft tissue damage. Multiple ligaments are torn or ruptured requiring surgery. There can also be damage to the nerves and blood vessels in the knee creating even more complications.

Surgeons are searching for the answers to the following questions regarding these patients: 1) How soon should surgery be done? 2) Should they reconstruct the knee fully all at one time or is it better to stage the procedure (i.e., one step at a time)? and 3) How aggressive should rehab be?

A systematic review of the orthopedic literature was done to find some answers. Just as they thought, the authors reported it was difficult to find enough patients with the same combination of knee dislocation and soft tissue injuries to study. There weren’t very many high quality or large studies — mostly single case reports or case series (a group) of patients. It’s difficult to consider the results of those studies evidence on which to base treatment recommendations.

By taking a look at all of the studies from 1950 to 2008, they found 24 studies for a total of 396 knees that qualified for inclusion in this review. Results of treatment were assessed using objective measures such as patients’ return-to-work or return-to-sports status.

Tools used to test for function included the International Knee Documentation Committee (IKDC) subjective knee-evaluation form, the Lysholm scale, Meyers ratings, the Cincinnati knee-rating system, and the Taylor criteria. You can see by the wide range of tests used to measure outcomes that there isn’t even one method used so that comparisons can be made from one study to another. That adds another level of challenge in finding some answers to guide the treatment of traumatic knee dislocations.

It was possible to see a pattern of treatment times. These were divided into acute treatment (first three weeks following the injury), chronic treatment (three or more weeks after injury), and staged treatment. Staged repairs often take place throughout the time periods. The first surgery in a staged procedure is done during the acute phase with follow-up operations during the chronic phase.

Rehabilitation corresponded with these same time periods and could be divided into two major groups: mobilization (early movement) and immobilization (no movement). Data for all patients was put together and analyzed to compare each treatment option with each phase of treatment.

The results were summarized based on measures of joint laxity, joint motion, patient report of satisfaction with results, return-to-work or play, and finally, need for manipulation. Manipulation refers to an operative procedure under anesthesia. The surgeon moves the joint through its full range of motion, gently breaking any adhesions or scar tissue that are keeping the joint from moving and causing severe stiffness and pain.

They found that patients who had acute (early) treatment were more likely to end up with knee instability (joint laxity/looseness) or the opposite: joint stiffness requiring manipulation. Acute treatment followed by immobilization had the worst results. These patients were the least likely to get back-to-work or back-to-athletics.

Patients in the chronic treatment group (treatment three or more weeks after injury) regained their knee joint motion better than the other two groups and were less likely to need a joint manipulation. But results for this group varied and couldn’t be predicted. Staged surgeries seemed to have the best results. Patients who had staged treatment were also more likely to rate their results as good-to-excellent. However, they did have just as much stiffness as the acute group requiring manipulation later.

In terms of the rehabilitation programs, getting patients up and moving rather than putting them in an immobilizing splint or brace didn’t seem to cause joint instability. In fact, in some cases it prevented instability. But it didn’t prevent joint stiffness later.

The most significant findings regarding postoperative treatment involved that acute treatment group. Patients treated surgically in the acute phase (within three weeks of the injury) who also had early mobility had fewer problems with joint stability. This combination (acute treatment with early mobilization) was more likely to get patients back to work. The results suggest that early aggressive rehab after acute treatment may be advised.

The authors state that this was the first systematic review to look at treatment for traumatic knee dislocations. Timing of treatment and post-operative rehab were the two areas of focus. They concluded that even if a review of this type doesn’t find all the answers surgeons need, it does bring to light the need for more research and more reporting of these cases. Eventually with enough data, it might be possible to pool the results and make some firm recommendations based on results rather than on the outcomes of a few small studies or case series.

As an adult, you’ve probably never known that your patella (knee cap) wasn’t always a single, round bone. But, in fact, we are born with a knee cap that starts out as a piece of cartilage. Eventually, it hardens and forms the bone that glides up and down over the knee.

The patellar bone doesn’t develop into one unit right from the start — it is either two or three peices that eventually ossify (harden into bone). By age six, most children have the pieces necessary to form a single, hard patellar bone. Between ages six and 12, all the pieces join together and fuse into one bone that forms the adult patella.

But in about two to six per cent of children (boys more often than girls), fusion doesn’t take place. The patella may remain in two pieces called bipartite patella or three pieces called tripartite patella. The patella remains that way into adulthood. Most of the time, the person isn’t even aware that there’s a problem.

It’s only if the knee is injured and an X-ray is taken or (more rarely) the knee becomes painful slowly over time that the diagnosis is made. What should be done about this? What can be done? Current guidelines for the management of this problem are the topic of this article from the United Kingdom. The authors present an algorithm for the conservative and surgical treatment when the condition is painful.

An algorithm is a very useful way to solve a problem using a specific set of instructions. The algorithm for bipartite patella begins with a patient who is having knee pain that started after trauma to the knee, from overuse (e.g., cycling or hill climbing) or more gradually with no known cause. Bending the knee is the main aggravating factor.

Treatment begins with rest, the use of nonsteroidal antiinflammatory drugs (NSAIDs), and physical therapy. The therapist prescribes stretching exercises, a dynamic patellar brace, and possibly low-intensity pulsed ultrasound to stimulate a healing response. Steroid injections administered by the physician may also be helpful.

If there’s no response to treatment or an inadequate response (i.e., patient still can’t participate in sports or tolerate daily activities), then surgery is the next step. But it’s not that simple. There are many more decisions to be made regarding the most appropriate surgery. The algorithm continues.

In the algorithm, patients who are surgical candidates are divided into two separate groups. The first group is made up of those with test results that show the surface of the patella is scarred and irregular and the bone is in pieces that move. The second group has a healthy surface and the patellar pieces are stable (not moving).

In the surgical treatment of the first group, the surgeon removes the moveable fragments. This can be done with arthroscopic surgery but in some cases, an open-incision procedure may be needed.

For patients with the healthy, immobile bone fragments, small fragments can be removed. Or instead of taking the extra bone out, the soft tissues still attached to the fragment can be cut to release the pull on the patellar piece. There are different ways to do this — each one has some disadvantages (e.g., muscle weakness, muscle imbalance, abnormal patellar tracking up and down).

Larger pieces can be wired back in place but there’s always the risk of stiffness from the long period of immobilization needed to foster healing. Fortunately, not very many people end up needing surgery for this problem. When they do, the results are usually pretty good.

The key to a successful outcome is to choose the right treatment for each patient individually. The algorithm helps guide this decision-making process. The goal of treatment is to provide pain relief, return to full activity (including sports participation for athletes), and protection of the remaining knee cap.

Even with this nicely laid out algorithm, there are many unknowns about the best way to treat bipartite patella. If the larger fragments are wired in place, will the knee develop arthritis later? What size fragment responds well to this type of fixation? Where does the surgeon draw the line on what size fragments can be removed versus which ones can be preserved? These are just some of the many questions that remain to be answered in future studies on this condition.

Research has shown that better pain control immediately after a total knee replacement reduces time in the hospital (and costs), improves function, and gives an overall improved result for the patient. Surgeons have gradually increased the use of drugs to control pain so that it is now common to follow a multimodal pain-control protocol.

Multimodal means many ways or methods to achieve pain control. This protocol started with periarticular injections (around the joint) of a combination of numbing agents and pain relievers. That worked well but in order to reduce the need for narcotic drugs after surgery, intraarticular injections (right into the joint) with the same agents was added. Then a steroid was added to the injection to help control inflammation. But there’s an increased risk of infection with steroids, so surgeons started wondering if that steroid added in was really needed.

That’s how this study came into being. Surgeons at the Lexington Clinic in Lexington, Kentucky raised the question of whether adding a steroid gains the patients any additional pain relief. They decided to compare two groups of patients having a total knee replacement. One group had the injection with the steroid (steroid group). The second group had the standard injection without the steroid (no-steroid group). No one in either group knew what type of injection they were getting. Their surgeons didn’t even know what type of injection was being given. That research method is called a double-blind study.

Over 300 patients were invited to participate in the study. All were adults between the ages of 18 and 95 who were planning to have a total knee replacement of one knee. But for various reasons, 200 of those patients either didn’t qualify or didn’t want to join. Some of the patients invited into the study decided not to have the surgery after all. A few had allergies to the medications being used. When the study got started, there were 76 who were randomly assigned to one of the two groups. Everyone was followed for 12 weeks after the surgery to get an idea of the effects during the early postoperative recovery period.

All surgeries were performed by one surgeon who had advanced training in joint reconstruction. The pharmacy prepared the injections and placed them in covered syringes so no one else knew which injection was being used on each patient. A periarticular approach was used for all injections. This means a little bit of the contents of each syringe was squirted around the knee ligaments where they attached to the joint, around the synovium (lining of the joint holding lubricating joint fluid), and along the back of the knee where the joint capsule (fibrous cartilage) can be reached.

Results were measured by looking at levels of pain, how much narcotic medication was needed/used during hospitalization, and how long each patient stayed in the hospital. They measured range-of-motion of the knee and performed a test called the Knee Society score to gain an idea of knee function. These two tests of motion and function were done before and after surgery. Any problems or complications were also recorded.

The authors thought the steroid group would do better and show shorter hospital stays, improved motion, better function, and no real increased problems afterwards compared with the no-steroid group. What really happened was the steroid group got out of the hospital faster, but there wasn’t any difference in their pain levels, joint motion, or function. And there were some serious complications in the steroid group that did not develop in the no-steroid group. Each of those patients had unique circumstances contributing to the complications. The role of the steroid in those complications wasn’t clear, so can’t be ruled out entirely.

The authors concluded that adding a steroid to the periarticular injection given during total knee replacement surgery isn’t necessary. There was no clear benefit to it and safety concerns remain. Comparing the results of this study with other similar studies showed the authors that the other medications used in the no-steroid group are really effective and better than steroids at controlling pain.

Some people may criticize this new study because there was no control group (patients who don’t receive any injections). But there have been plenty of studies to show that these injections do provide pain control and improve outcomes. The authors did not think it was ethical to withhold valuable treatment from anyone that could ease pain after surgery.

They did point out that there is still much room for further investigation. Would it make a difference if intraarticular injection (inside the joint) were compared? Remember, this study looked at periarticular (around the joint) injections. Does the severity of disease (i.e., osteoarthritis) at the time of surgery alter how patients respond to the injections? How about the role of physical therapy? Would different types of physical therapy after surgery change pain levels? And what about discharge? Do patients who go directly home from the hospital do better than those who have to go to a transitional (step-down) unit or skilled nursing facility? The answers to these questions are outside the scope of this particular study but need to be addressed in future studies.

Six risk factors for patellofemoral pain syndrome (PFPS) in young athletes have been identified in this study. Some of them are modifiable, which means they can be changed. And that means this painful knee condition may possibly be prevented. That’s good news since PFPS is one of the most common painful and chronic knee problems faced by military recruits and athletes elsewhere.

What is patellofemoral pain syndrome? The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. This produces pain, weakness, and swelling of the knee joint. Several different problems (including PFPS) can affect the patella and the groove it slides through in the knee joint.

It is believed that PFPS occurs because of altered biomechanics between the patella and the femur (thigh bone). The patellofemoral joint is where the kneecap moves up and down over the lower end of the femur. If the patella doesn’t track up and down over the femur where it should, uneven wear and tear can occur. The protective cartilage behind the patella can get torn and shredded. Patellofemoral pain syndrome is most noticeable when kneeling, squatting, or during other activities that require bending the knee. That’s because altered hip and knee motion increase the pressure from contact between the patella and femur during these motions.

Patterns of movement like this are referred to as kinematics. With patellofemoral pain syndrome altered kinematics is a key problem. Stress on the patellofemoral joint is made worse by rotations of the lower leg during weight-bearing activities. And altered kinematics combined with repetitive actions during weight-bearing load (e.g., running and jumping-landing) can result in patellofemoral pain syndrome.

To find out what might put some people at risk for this problem, athletic trainers studied over 1500 military recruits (men and women) at the United States Naval academy. They collected baseline data about these individuals the summer before their freshman (first) year at the academy. Three-dimensional (3-D) motion analysis was done during jumping and landing, leg muscle strength was tested, and two tests of postural alignment were evaluated and measured (navicular drop, Q-angle).

Navicular drop refers to the position of a bone (the navicular) in the foot. A drop in the position of this bone reduces the arch of the foot, which can then change the angle of the knee. Q-angle is the angle of pull of the quadriceps (thigh) muscle on the patella. If either of these anatomical alignments are off, it changes how the patella tracks and how the knee moves. And that may contribute to the development of patellofemoral pain syndrome.

That all sounds so very technical. The bottom-line is that the pain can be severe enough to limit physical activities. And if you are a military recruit or athlete in training, you need to be able to run and jump without thinking about it and certainly without being in pain. The midshipmen who participated in this study were all required to participate in military training including daily physical conditioning exercises and intramural or varsity sports.

Using special computer software, the researchers analyzed joint angles, peak vertical ground-reaction force, and internal joint movements for the hip and knee. These values were compared using body weight and height for comparison of one recruit to another. Then the authors looked at kinematics, muscle strength, and alignment variables for recruits with and without patellofemoral syndrome (PFPS). They found six risk factors for PFPS: 1) decreased knee flexion angle, 2) decreased vertical ground-reaction force, 3) increased hip internal rotation angle when landing jumps, 4) decreased muscle strength (quadriceps and hamstrings), 5) increased hip external rotator strength, and 6) navicular drop.

Even one change in postural alignment or knee angle or the way a person moves can set of a chain of reactions or responses that make the problem worse. Muscle weakness or imbalance changes the stress points on the patella as it moves up and down over the femur. Other muscles may step in and try to compensate for the loss of function in the weak areas. The result may be a slight improvement in the knee angle but less ability to handle the ground reaction-forces when landing a jump. Hip muscle weakness can alter the knee alignment from above, again changing the contract stress on the patellofemoral joint.

Finding risk factors has been the focus of many other studies. Figuring out why some people develop PFPS while others don’t could help prevent some folks from developing this problem. Other studies have identified factors that are mostly nonmodifiable, which means there’s nothing that can be done to change them. But this study was able to identify some biomechanical factors that can be changed. Of course, the next step in research will be to see if changing any of these factors (and which ones) makes a difference.

For now, the authors suggest a good place to start is strengthening the quadriceps and hamstring muscles and teaching proper techniques for activities that are painful. Active young adults such as military recruits and athletes can be assessed before engaging in physical activities that could potentially lead to the development of patellofemoral pain syndrome. Anyone with modifiable risk factors can be trained to change the way they move and perform dynamic tasks such as knee flexion and jump/landing. Changing the hip angle (less internal rotation) and knee angle (more knee flexion) might make a difference in these active groups of people.

Research has shown that corticosteroids injected into the joint work for reducing knee pain caused by osteoarthritis. But how long does the effect last? Osteoarthritis is a chronic problem, so long-term solutions are needed. Just how well do steroid injections work? According to the results of this study: the pain reducing effect lasts about one week. Steroid injections offer short-term pain relief but they aren’t advised for more than that.

Since we know that almost half of all adults age 80 and older will have osteoarthritis of the knee, finding ways to decrease the painful symptoms is important if these folks are going to stay active and independent. Not only that, but almost one-quarter of the entire U.S. adult population have some symptoms of arthritis. That’s a staggering statistic and a significant one given the focus on physical activity and exercise as the best way to stay healthy, avoid weight gain, and manage diseases like osteoarthritis as well as diabetes and high blood pressure.

The authors did an extensive electronic review of the published articles on the subject of corticosteroids for joint osteoarthritis. They were specifically looking for data that would show if corticosteroid injections work for this problem. And if so, how well do they work, and how long does the effect last? While they were compiling the data, they also decided to take a look at the various steroids used (e.g., betamethasone, methylprednisolone, triamcinolone) and see if one was better than the rest.

There weren’t very many studies: only six trials reported in five different papers compared a corticosteroid to a placebo. And only four separate studies compared results using different types of corticosteroids. This type of review is called a systematic review. It is a good way to look at the evidence supporting or refuting any kind of treatment, including steroid joint injection. Individual doctors, clinicians, and even patients (consumers) just don’t have the time to comb through all the literature looking for answers. Or in the case of consumers, they may not really know how to analyze and interpret what they read. Systematic reviews like this one do the leg work for us.

So, here’s what they found out. Besides showing that knee pain was reduced for at least one week, there was also evidence that the pain was decreased by 30 per cent. Triamcinolone came out as the front-runner in providing the best results. But not all corticosteroids were included in comparative studies and the use of validated outcome measurements was very limited. Outcome measures refers to the way results are measured such as the visual analog scale (VAS) as a clinical indication of pain and change in pain. Other validated tests that could be used also include the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short-form-36 (SF-36).

For those who are interested, the authors do provide some details about the studies included in this systematic review. A discussion of research methods, results, weaknesses of the studies, and tables to show how they were compared are provided. Each study design such as single-blind, double-blind, crossover was listed along with the type of corticosteroid used, dosage, and similar information regarding the placebo used.

It’s always helpful when doing comparative studies to also compare patient demographics. Demographics refer to patient characteristics such as age, sex, education level, socioeconomic status, and type of diagnosis. For this study, an additional measure (duration of disease) was also included. Results were primarily measured in terms of pain relief and patients were followed anywhere from one to 24 weeks (six months). The idea that corticosteroid injections provide only short-term pain relief at best is supported by other studies. When a longer period of time for pain relief was reported, the differences between steroid group and placebo group were not considered significant.

Other studies have investigated whether or not physicians can really deliver the injection into the joint space. The overall conclusion of studies looking at this factor is that properly trained medical staff can deliver the medication into the knee joint with no problem at all. Other joints such as the hip or shoulder may be more problematic requiring the use of fluoroscopy, a special real-time (3-D) X-ray that allows the surgeon to see what her or she is doing.

Fortunately, even though steroids only give short-term pain relief, there are other effective treatments patients can use as well. Physical activity and exercise, nutritional supplements, antiinflammatory drugs, braces, topical creams, and if necessary, surgery are all acceptable treatment choices. Finding the most optimal single treatment or combination of treatments may be an individual decision. More research is clearly needed in comparing different steroid injections, the timing and dosage of the injections, and factors that predict which patients are most likely to respond.

The verdict is in on the subject of meniscectomy (removal of the meniscus) — don’t do it unless it’s absolutely necessary. And sometimes there is no way around it. But whenever possible, surgeons repair the damage and save as much of the natural meniscus (knee cartilage) as possible.

The menisci (plural for meniscus) sit between the femur (thigh bone) and the tibia (lower leg bone). These structures are sometimes referred to as the cartilage of the knee, but the menisci differ from the articular cartilage that covers the surface of the joint. The menisci support the knee joint, help distribute and transfer the load, and provide nutrition and lubrication to the joint. Without it, the concentration of force into a small area on the articular cartilage can damage the joint surface. Research clearly shows early osteoarthritis from joint degeneration is to be expected.

There are different ways to approach the treatment (and prevention) of this type of joint degeneration after meniscectomy. One of those has been around for the last 25 years: the allograft meniscal transplantation. Allograft means the patient is receiving meniscal tissue donated by someone else (after death). The menisci are harvested and preserved by freezing them until needed. The patient receiving the graft is carefully tissue-typed to find a match with donor (allograft) tissue.

This study from the Netherlands reports on the long-term results of this procedure. How long does it last? Does it provide long-term pain relief and improvement in function? Can it delay the need for a total knee replacement? Fifty-seven (57) men and women between the ages of 26 and 55 participated in the study. They all received a meniscal allograft transplantation after meniscectomy. Some had just part of the meniscus removed. Others had a complete meniscectomy. The allograft procedure was done anywhere from two to 33 years after the meniscectomy. It was usually performed because the patient had developed painful and disabling knee osteoarthritis.

The authors have been studying the results of this treatment method since 1995. Patients are not reevaluated in a clinical setting, but rather, fill out several surveys sent to them by mail. The questions they answer come from three standard tools used to measure knee function and assess level of disability. The instruments used included the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Score, and the International Knee Documentation Committee (IKDC) scoring system.

The results of the study provided some valuable data. First, the overall failure rate of the allograft procedure was 29 per cent. That’s almost one-third of the total group. Failure meant the graft had to be removed surgically. Graft failure occurred four to 14 years later, so you can see the graft did buy the patients some time before having a total knee replacement. And scores from the tests showed that there was a significant improvement in pain and function from before to after the allograft procedure. So, the procedure may have failed, but all was not a complete loss.

A closer look at the data revealed a few other interesting and important findings. It didn’t seem to matter which side of the meniscus (medial or lateral) was removed and replaced with an allograft. The final results didn’t differ among patients. That was a bit of a surprise because the two sides of the menisci have slightly different shapes and different functions. Patients who wait too long and have too much damage to the articular cartilage under the meniscus are not good candidates for this procedure. They would do better to just go ahead and have a joint replacement.

The authors found that the transplanted menisci don’t last indefinitely, even though they attach well to the joint surface and regain a blood supply. But they concluded that allograft meniscal transplantation is an effective treatment following meniscectomy for young patients (younger than 55 years old). The survival rate of the transplanted tissue is enough to delay major surgery (i.e., total knee replacement). And that’s good news because knee replacements don’t last forever either. And for younger adults facing severe degenerative arthritis, having a stop-gap measure between meniscectomy and joint replacement buys them some pain free time with improved daily function.

The best candidate for an allograft meniscal transplantation is a younger adult (less than 50 years old) with an intact anterior cruciate ligament (ACL) needed for good support and stability. Without a healthy ACL, the meniscus is subject to even higher demands. The allograft is more likely to detach and fail when the knee is unstable because of a deficient ACL. The ACL should be repaired first before doing the allograft. Normal knee alignment is necessary for a good result. The allograft is done when meniscectomy patients develop painful and limiting unicompartmental arthritis (affecting one side of the joint).

Future studies are needed to determine the best time to perform the allograft transplantation. There is some evidence that men and women have different results, maybe because of different activity levels. This sex-based difference should be investigated further. The authors intend to continue evaluating long-term results as well as compare results based on various surgical techniques used to attach the implants.

Injuries of the anterior cruciate ligament (ACL) of the knee are common among adults of all ages. Athletes seem to be the primary patient population but they are not alone. Adults of all ages but especially between 20 and 40 are among the most common patients to present with traumatic or degenerative injury of the ACL. Physical therapists who help rehab these folks are making every effort to find the most optimal postoperative program — one that will reduce pain and restore function, neuromuscular control, and stability.

In this study from Norway, two types of exercise were compared after ACL reconstruction. The first was a traditional program of strength exercise training. The second was neuromuscular exercise (NE) training. Both programs were carried out for a period of six months. Results were measured for up to two-years, which is much longer than other studies. Most other studies have reported outcomes after only six months.

There’s been agreement among researchers that ACL rehab requires two important ingredients in order to regain normal knee function: quadriceps muscle strength and neuromuscular control. The quadriceps muscle is the large muscle along the front of the thigh. It helps straighten the knee and hold it in an extended position. Neuromuscular control is achieved through a combination of physiologic functions within and around the knee. Without neuromuscular control, the knee buckles, twists, or gives way, potentially causing another knee injury (or reinjury of the ACL). Recent research efforts have shown conclusively that neuromuscular training is beneficial following ACL surgery.

The question posed by these physical therapists was: which program gives the best long-term results — strength training or neuromuscular exercise? They used a computer program to randomly assign patients to one of these two programs. All patients were adults between the ages of 16 and 40. They all had arthroscopic surgery to reconstruct a torn ACL using a bone-patellar tendon-bone graft. In this technique, a bundle of tendon fibers from the quadriceps muscle as it inserts just below the patella (knee cap) is harvested and used as a donor graft to replace the ruptured ligament.

The rehab programs were conducted on an out-patient basis starting two weeks after surgery and running for six months (two to three times each week). Physical therapists instructed and supervised each patient throughout the process. Strength-training for the muscles of the leg included progressively increasing repetitions and weights. Targeted muscles were the quadriceps muscle, hamstrings (behind the thigh), gluteus medius (buttock muscle), and gastrocnemius (calf muscle). Stationary biking was used early on to help improve range of motion and decrease joint swelling.

Patients in the neuromuscular training group did balance exercises, exercises to increase dynamic joint stability, and plyometric exercises. Plyometrics helps individuals regain the ability to make sudden changes in direction of movement with speed. The neuromuscular exercise program also included agility drills and specific exercises geared toward individual sports athletes were involved in (e.g., soccer, basketball, volleyball, running). These sports require athletes to make sudden starts and stops as well as quick changes in direction. The knee must be able to do so without hesitation, without pain, and without giving way or wobbling even the slightest bit.

Each program was divided up into phases based on the patient’s tolerance, ability to handle increased loads, and time. The neuromuscular exercise program was divided into six phases lasting three to five weeks per phase. The strength-training program was made up of four phases and was directed more by how the patient was doing than by a set amount of time.

Outcome was measured by comparing before and after test results. The Cincinnati knee score of overall knee function measured swelling, giving way, general activity level, walking, stairs, running, and jumping or twisting actions. Pain was measured using the standard Visual Analog Scale (VAS) rating pain as a single number from zero (no pain) to 10 (worst pain). Muscle strength was tested with a specific machine used by physical therapists called the Cybex 6000. The Cybex is used both to test strength at various speeds and to train muscles (speed and strength).

Another machine called the KT-1000 arthrometer gave the therapists an idea of how stable (stiff) the knees were. And the Short-form 36 questionnaire was used to assess overall mental and physical health. All of these tests are well known in rehab and research. Using them makes it possible to compare one study to another so that results can be compiled for greater statistical analysis.

After following the patients for two full years, they discovered a pattern of differences in the benefits provided by each program. The neuromuscular program had the most benefit in the first year. Patients in this group had better overall knee function and less pain compared with the strength-training group. The strength-training program was more effective in improving knee flexion muscle strength after two years. It really looks like both exercise approaches contribute something a little different at different times in the recovery process. Therefore, both should be used together for the best total results.

This study is important because previous (short-term) studies showing the benefit of neuromuscular training made it seem like that’s the direction therapists should go without continuing the more traditional strength-training approach. Without a long-term study to show that both work together over time, changes might have been made in future rehab programs that wouldn’t have given patients the best in both short-term and long-term results.

There’s no doubt that rehabilitation is key to the success of ACL surgery. Regaining normal function, strength, and motion as quickly as possible after ACL surgery is the goal of most athletes. Strength-training without paying attention to neuromuscular reeducation and vice versa (abandoning strength training in favor of neuromuscular exercise) would be a mistake. It should be noted that not everyone in the study got full function. At the end of the first year, more patients in the neuromuscular group had better overall function. By the end of the second year, the overall functional results were equal between the two groups. The authors suggest future studies combining the two techniques compared with each individual treatment protocol are needed in this ongoing effort to find the best way to optimize ACL rehab.

Knee replacements are common among older adults with painful joint arthritis. It has been assumed that the decrease in pain after recovery from joint replacement surgery translates into improved motion, strength, and function. But physical therapists working with these patients have noticed problems with climbing stairs and a slower walking speed long after recovery and rehab.

Rehabilitation researchers around the world have confirmed these observations. Measures of muscle strength, CT scans showing muscle cross section, walking speed, and time to complete stairs have provided quantifiable evidence to back up this finding. Now similar results have been observed in patients who have a unilateral knee replacement (UKR). Unilateral knee replacement refers to an implant for half of the joint. Usually the medial side of the knee (closest to the other leg) is replaced most often because that’s where most of the wear and tear occurs in many patients.

In this study, physical therapists from Finland take a look at just how bad is this muscular weakness and loss of power. Being in the business of rehabilitation, they need to pay attention to this problem in their patients. They measured strength of flexor and extensor muscles of patients who had a unilateral knee replacement within the last 18 months. Adults in good health between the ages of55 and 75 years old were selected to participate.

A special tool called an isokinetic dynamometer was used to measure muscle strength at different speeds (60 degrees of motion per second, 180 degrees per second). The operated knee was compared to the nonoperated side. Some, but not all, of the patients did have arthritis in the nonoperated knee, which could affect the results.

In addition to analyzing peak muscle power, CT scans were taken of the muscle cross section. These pictures allowed the researchers to measure muscle bulk. Loss of muscle bulk called atrophy can result in weakness and loss of joint stability. Walking speed over a 10-meter distance and time negotiating 10 stairs (up and down) were also recorded. In all of the statistical analysis, the researchers calculated to see if age, sex, or time since the surgery made a difference in the final results.

Everyone had a loss of strength in the operated leg compared to the nonoperated side. Both the knee flexor muscles and the knee extensors were weaker. When the extensor muscles on the operated side and the flexors on the nonoperated side were both weak, patients had a more difficult time going up stairs. This was true for all ages (men and women alike). Weak flexors and extensors on the operated side meant greater difficulty going down stairs. And anyone with significant weakness also had smaller cross-section of the affected muscles indicating muscle atrophy.

These findings so long (months) after the primary surgery are of concern. The risk of falls increases when there are deficits in muscle power. Even recoverying from a stumble can be a problem because muscle power and coordination are linked together. Decreased power means altered coordination, which can result in an inability to regain balance. When muscle weakness occurs after a unilateral knee replacement, walking speed can be affected but not as much as stair climbing, which seems to suffer the most. The nonoperated leg seems able to help compensate with the walking but more power and force are needed in the extensor muscles of the operated leg for stair climbing. Even with help from the other side, it may not be enough for the task.

Physical therapists can use this information to screen patients more carefully after unilateral knee replacement. Discovering persistent muscle weakness and loss of muscle power can be addressed with an exercise program. Improving mobility and function for these patients while preventing complications and disability from falls is an important goal for all knee joint replacements — whether it is a complete replacement or a partial replacement with the unilateral implant.

Before a surgical technique can be conclusively declared a success, many studies must be done to look at treatment effects, long-term results, patient satisfaction, and function. One study (no matter how large) is never enough to satisfy the need for evidence to prove the benefits of the procedure. In this article, a systematic review is conducted of the long-term results for microfracture cartilage repair of the knee. Systematic review means a number of studies were examined. The results of any study looking at the ability of this procedure to repair cartilage and improve knee function were included.

The success of this repair technique was evaluated by looking at scores on tests of knee function, quality of the repair, and other findings on MRI studies. The microfracture technique is used for patients with defects in the articular cartilage of the knee joint. The articular cartilage is the smooth surface of the joint just above the first layer of bone. Fractures in the cartilage can lead to fragments of the cartilage breaking off leaving holes in the joint surface.

The microfracture method of repair involves several steps. First, the surgeon removes any ragged edges along the tear. This is called debridement. Then the layer of calcified (hard) cartilage is removed to expose the subchondral bone. Subchondral just means the bone is right below the articular cartilage — like subflooring in a house. Next, the surgeon takes a special tool and forms tiny holes (microfracture) in the subchondral surface.

Microfracture works by stimulating a bleeding and healing response. Blood from inside the bone marrow seeps up through the holes and fills the hole or defect in the cartilage with a clot. The articular cartilage doesn’t have much of its own blood supply or an ability to heal itself. That’s why the surgeon tries to help it along with techniques like microfracture. There are other methods used to stimulate healing but microfracture has become popular with good short-term results and that is the only focus of this systematic review.

The question is: do the benefits of this treatment last? For how long? Six months? A year? Five years? The authors found 28 studies assessing the microfracture technique. Over 3,000 patients were involved in the combined analysis. Some studies followed patients for one year. Others extended beyond that to two years. Only five studies followed patients for five or more years but those studies accounted for over half of all the patients who had this procedure.

Not everyone used the same measuring tools to assess outcomes. Pain, swelling, level of athletic activity, and ability to perform strenuous work were used as the primary measures of results in five studies. Some researchers used the well-known Western Ontario and McMaster Universities (WOMAC) index while others used the equally well-known Cincinnati knee score. Other tools used to measure before and after knee function included the Tegner activity scale, Baumgaertner score, Japanese Orthopaedic Association knee score, and the Knee injury and osteoarthritis outcome score (KOOS). In fact, there were a total of 15 different scales used to measure knee function. So you can see there wasn’t a uniform method of studying results, which could make it more difficult to get a handle on how well this procedure does work.

They also found that the type of lesions studied wasn’t always the same from study to study. Many studies included patients with both acute (new) and chronic (old injuries) of varying sizes and depths. Very few studies recorded whether the patient had previous knee surgeries or repair for other injuries at the time of the microfracture procedure. Most of the studies did not record the patients’ body mass index (BMI), an indicator of overweight or obese status. Any of these features could really affect long-term results.

The final analysis suggests that microfracture helps improve knee function in the early months to year following surgery. But many patients experience deterioration over time. In other words, the benefit of the procedure doesn’t seem to last so the durability of microfracture is questionable. When the defect filled in nicely, patients had the best results.

But not everyone got a nice even and full healing response. A closer look at that showed some possible (predictive) risk factors. For example, younger patients (less than 40 years old) with smaller cartilage defects and lower BMIs had the best results. Not surprising, the more active, athletic patients who went back to full levels of activity had poorer results. Patients who had the microfracture technique first before any other treatment approach did better than those for whom the microfracture was a salvage procedure when other treatment failed.

The authors conclude that with no systematic evaluation of the benefits of microfracture, this systematic review was timely and helpful. It showed that short-term improvement following microfracture for articular cartilage defects is a certain benefit for most patients. The technique is safe, minimally invasive, and effective even when it doesn’t produce normal cartilage. Decline in function is to be expected with time but even so, the final results in terms of activity and function are still better than before surgery.

Further studies are needed to find out why microfracture fails, the optimum time to perform the surgery, and which patients can benefit the most from this technique as a first-line approach. The authors also suggest taking a look at why some patients have poor fill volume of the defect after microfracture and which factors are the most significant in those patients who end up with deterioration over time. Using arthroscopic examination is one way to take a look inside the joint and possibly identify what’s going on and why. The authors suggest that second-look arthroscopic studies are needed at various points along the way (e.g., after six months, 12 months later, and beyond the two-year mark) — possibly even 10 (or more) years later.

Anytime a common surgical procedure is done, it is important to follow-up and make sure the operation was done safely and had the intended outcomes. In this study, the results of anterior cruciate ligament (ACL) reconstruction were evaluated. The three areas of interest were: 1) number of ACL reconstruction surgeries done between 1997 and 2006, 2) how often these patients need another surgery later, and 3) risk factors to predict readmission and revision rates.

A statewide hospital database from New York was used to gather information. Using hospital identification numbers and physician license numbers, the researchers were able to calculate annual volume for both the 263 facilities and the 1513 surgeons involved. Basic information about over 70,500 patients who had an ACL reconstruction was collected (e.g., age, sex, type of insurance coverage, and the presence of other health problems).

About one-third of the ACL reconstructions were the only procedure performed. But the majority (two-thirds) of the patients had other repairs done to damage in the knee, most often meniscal (cartilage) repair or removal. A small number of patients (45 of the total 70,500) had a total knee replacement at the same time as the ACL surgery. The coding process did not record which knee was being operated on, so the authors were unable to tell if subsequent surgeries were on the same knee or the other knee. For this study, they just gathered information for either knee.

What they found was that most of the procedures were performed on an out-patient basis. Reconstruction procedures done on an inpatient basis were usually for patients who had other health issues that put them at increased risk requiring closer follow-up surveillance. Surgeons who performed at least one ACL reconstruction procedure each week (labeled high volume) had the best results. High volume was defined as at least one ACL reconstruction per week (more than 52 per year). Only doing one procedure every two months for a total of less than six per year placed the surgeon in the low volume category. Likewise, the results were better when the surgeries were done in a high volume hospital (defined as one ACL procedure every other day for a total of at least 125 each year).

Statistically, 2.3 per cent of the patients were readmitted within 90 days of the ACL reconstruction. That is considered a fairly low rate. The reasons for readmission were usually infection, stiffness, or need for further rehab. Less often, the problem was more of a medical (health) issue such as appendicitis or heart attack. More patients (6.5 per cent) ended up having another knee surgery (on either knee) within the first year after the ACL reconstruction. And although this study couldn’t report on which knees needed surgery later, other studies have shown that the opposite knee is involved most often. The reasons for subsequent knee surgery ranged from knee pain, to infection, to scar tissue build up.

The patients who had the highest readmission rate (within 90 days) were older men (more than 40 years old) or those who had other health problems. Patients were also more likely to be readmitted for problems if they were operated on by a lower-volume surgeon in a lower-volume hospital. The risk of having a subsequent ACL surgery (within one-year) was highest among patients who were younger than 40 (especially those who were younger than 20 years old). That may be because they are more active and less likely to follow guidelines on restrictions following surgery. One other risk factor for later problems requiring additional surgery was having a meniscectomy (meniscus removal) at the time of the initial ACL reconstruction procedure.

The authors say that ACL reconstruction is still a safe and effective procedure. But it is not without its problems. With the overall number of ACL procedures on the rise each year, it’s a good idea to take a look and see how results can be improved. Although the results of this study were reported for patients in just one state (New York), there is no reason to suspect they don’t represent the overall picture for outcomes of ACL reconstruction. It may be necessary to take a closer look at the results between patients who have an isolated ACL procedure and those who have other (called concomitant) procedures at the same time.

There are a few other challenges in a study of this type. The finding that younger males are more likely to have subsequent surgeries bears further investigation. Given the fact that younger adults (college age and early 20s) tend to move around, there may be a higher number of revision and second surgeries than was reported here. Age as a factor (older and younger) was the central finding of this study, but other similar studies have not confirmed these results. There seems to be a wide range of results reported when age is analyzed as a predictive factor of outcomes.

Anterior cruciate ligament reconstruction is a technically demanding procedure. The complexity of the procedure is a risk factor of its own. Surgeon and hospital volume are important but there are many other possible risk factors yet to be explored when trying to isolate what it is that causes patients to require readmission or subsequent surgery. Type of injury, time between injury and surgery, presence of concomitant injuries in either knee, and general health history need to be explored further. Future studies are needed to look at technical failures versus additional injuries as risk factors.

For now, we know ACL injuries are common, the number of ACL surgeries is on the rise, and reconstructive surgery is challenging but safe and effective. Finding ways to reduce complications, improve outcomes, and eliminate the need for subsequent surgeries will remain key features of ongoing studies such as this one.

After years of using pain pumps to control joint pain after surgery, surgeons are getting an inkling that the drug used (bupivacaine) may be the cause of cartilage damage called chondrolysis. Chondrolysis refers to the loss of articular cartilage, the smooth cartilage that allows the two joint surfaces to slide and glide against each other easily. Thinning of the cartilage narrows the joint space, putting more pressure on the joint and causing painful symptoms that eventually lead to joint arthritis.

Chondrolysis doesn’t develop until many months to years after the use of the pain pump, so the connection hasn’t been made until just recently. By the time the patients develop joint pain and swelling, it is so far after the operation that no one has ever linked the two events together. Now, as a result of several case reports, there has been a published recommendation against the use of intraarticular pain pumps until this problem can be studied further.

How do we know for sure it’s the pain pump that’s causing the problem? How do we know it isn’t the screws used in repairing ligament damage? Or maybe the patients who develop chondrolysis had some cartilage damage before the operation that just got worse over time. Well, some animal studies done way back in 1985 were the first to point out that bupivacaine kills chondrocytes (cartilage cells). And more recent studies on human joints removed during total joint replacements showed cartilage damage after only 30 minutes exposure to bupivacaine.

And now, a series of three patient cases reported in this article seem to support the idea that chemical trauma can occur when joint cartilage is exposed to this drug. Not only does bupivacaine kill cartilage cells, but it also seems to inhibit (prevent) new chondrocytes from forming. In all three patients, there was a continuous infusion of bupivacaine for 48-hours after knee surgery. Surgery was done to repair a torn anterior cruciate ligament. In two cases, young female athletes had a pivoting injury while playing basketball. The third case was an older adult woman (41-years-old) who had a skiing accident.

Preoperative X-rays, MRIs, and arthroscopic exam were used to make the diagnosis and determine the best plan-of-care. Only the 41-year-old showed any signs of mild articular cartilage thinning and joint narrowing before surgery. The two young athletes had completely normal, healthy cartilage before the procedure was done. In all three cases, it was months after the surgery before the patients returned to their surgeons with reports of knee pain and swelling. And even more time before the first obvious signs of cartilage damage could be seen on imaging studies.

At first, there was no change in pain and swelling despite the use of antiinflammatory medications. After months of conservative care, changes in the cartilage could be seen on MRIs or during arthroscopic exam. The cartilage was fragmented in all three compartments of the knee. That includes the top and bottom and both sides (medial and lateral) of the femur (thigh bone), tibia (lower leg bone), and patella (kneecap). And the cartilage was worn down to the bone in all three areas. The most severe case was in the older woman with the skiing injury who already had some early signs of joint degeneration.

Taking a closer look at these three cases, the surgeons surmise that perhaps the pain pump caused problems in the knees because it is a small area with less capacity compared with the shoulder or hip where pain pumps have been used with fewer problems. The articular cartilage tends to be thinner in the knee compared to other joints as well. So, that might have been an additional factor. Where does this leave these three patients?

Treatment has not been successful in stopping the degenerative process. Rest, steroid injections, microfracture, activity modification, and the use of antiinflammatories have not helped. The 41-year-old was told that further surgery won’t help. She will have to manage her symptoms for as long as possible and expect to have a total knee replacement at some time in the future. Efforts to use viscosupplementation (injection of a slippery fluid into the joint) have also proven unsuccessful. Successful treatment options are limited at the present time, once again pointing to the need for further research in this area.

The authors advise watchful awareness of any joint symptoms after post-operative pain pump use. They advise against the intraarticular use of these pumps until further notice.

There are many different types of braces on the market for the knee. Prophylactic braces are used to prevent or decrease the risk of a knee injury. Functional braces stabilize a wobbly knee when the anterior cruciate ligament (ACL) is deficient or after surgery to repair the ligament. Rehabilitative braces limit the amount of knee motion that’s allowed during recovery and rehab after knee surgery. But the focus of this article is on the unloader (sometimes called offloader) brace used to give patients with osteoarthritis pain relief.

The off-loader brace just got rated an A for consistent, good-quality patient-oriented evidence based on a review of the literature. All evidence points to the use of off-loader braces as a good way to improve knee stability while reducing knee pain. How do these braces work? Well, first of all, they are meant to be used by patients who have unicompartmental knee osteoarthritis. Unicompartmental arthritis affects one side of the joint (usually the medial side — the side closest to the other knee).

Unicompartmental knee osteoarthritis is a common problem associated with alignment problems, obesity, and aging. Some people have a slightly inward angle at the knee that results in more weight being placed on one side of the knee. It could be a valgus angle, which is more toward a knock-kneed position that leads to lateral unicompartmental osteoarthritis. Or (more commonly), it could be a varus angle, a bow-legged position resulting in medial unicompartmental osteoarthritis. Either of these two malalignment problems causes cartilage degeneration and ligament laxity, bringing the joint surfaces closer together. The result is an increased load on one side of the joint.

The unloader or off-loader brace uses adjustable straps and pads to apply an external force to distract the involved compartment. It’s a mechanical intervention meant to reduce pain, which in turn, increases function. The long-term goal is to keep the arthritis from getting worse. By improving the alignment of the knee, compressive force and load are shifted off the already damaged area of the joint.

It’s expected that with an estimated 27 million adults with osteoarthritis, that this brace will used by more and more patients in an effort to avoid (or put off) a knee replacement. There are predictions that nearly half of the American adult population will develop knee pain from osteoarthritis. The rising rates of obesity make this almost a certainty. With no cure in sight, every method shown to benefit osteoarthritis is worth knowing about.

The last time the effectiveness of off-loader bracing was reviewed (2005), there weren’t enough good quality studies to provide evidence that this treatment was safe and of any benefit to patients. Since that time, new evidence has shown a much higher percentage of evidence for their effectiveness.

Who should use this type of brace? Management guidelines published by the American Academy of Orthopaedic Surgeons (AAOS) suggest that adults with pain and activity limitations because of pain should be considered for an off-loader brace. X-ray evidence of unicompartmental knee osteoarthritis is required. Patients who meet these criteria who have not been helped with standard medical care are likely good candidates for this type of bracing. Standard first-line medical treatment includes nonsteroidal antiinflammatories, steroid injections, and viscoelastic supplementation.

Age is another important criteria in the use of off-loader bracing. Adults 65 and older are the main target group. Younger, more active adults may be better candidates for a surgical procedure called a tibial osteotomy. In this procedure, a wedge-shaped piece of bone is removed from one side of the tibia (lower leg bone) and inserted on the other side of the tibia. This realignment procedure shifts weight away from the diseased side. By doing it when the patient is younger, there’s a better chance that unicompartmental disease can be avoided.

What are patients saying who are using this brace about their results? Questionnaires evaluating knee pain and function show that the majority of carefully selected patients who use the off-loader report significant improvement in pain and function. They can walk longer and climb stairs with greater ease. Many patients were able to double their pain free walking time from an average of 51 minutes before bracing to 138 minutes with bracing. Improvements in daily function continue throughout the first year of wear. Patients were also able to reduce the amount of pain medication taken each day when using the brace.

There were some studies that did not show an overall benefit from bracing. Patients were able to get some pain relief but their function and quality of life did not improve over time. Others found that the benefits only lasted as long as they wore the brace. Patient compliance dropped over time, possibly contributing to a decline in perceived benefit.

There’s still plenty of room for further study in this area. Research is needed to find the optimal knee alignment using the brace. Should the knee be exactly in neutral? Or is that too much stress in the opposite direction from where the natural knee rests? If neutral isn’t used, how many degrees of valgus or varus would give the best results? Does wearing the brace for 12 months put off surgery by an equal number of months? Is it necessary to wear the brace during all daily and sports activities? Or can it be worn just during periods of increased physical activity and exercise? These are just a few of the many questions yet to be answered.

The authors conclude that there is new evidence that supports the use of an off-loader brace as a cost-effective way to treat unicompartmental knee osteoarthritis and delay surgery. Patients report decreased pain, better stability, and fewer falls. The overall level of evidence from analysis of all the updated data puts the strength of this recommendation at 76 per cent for the success of off-loader braces treating unicompartmental knee osteoarthritis. The higher the percentage, the higher the strength of the recommendation based on scientific evidence.

Patients with chronically dislocating or otherwise unstable kneecaps have a condition called patellar instability. This condition poses a treatment challenge because of the unique and complex anatomy and biomechanics of the patellofemoral joint (where the kneecap articulates or moves against the leg bones). And this problem is fairly common, especially among the young, athletic population.

That’s why the American Academy of Orthopaedic Surgeons (AAOS) has put together this instructional course lecture for orthopedic surgeons. The authors present current recommendations for treatment with intraoperative and arthroscopic color photos of surgical techniques provided. The goal of surgery is to restore the normal anatomy of the patellofemoral joint. But there are many ways to approach this. The authors propose a three-step procedure to treat patellar instability when surgery is called for.

Before any attempt is made to surgically repair or reconstruct the patellofemoral joint, an understanding is needed of the basic mechanics and functional anatomy of this joint and just what it is that causes patellar instability. The patella slides and glides up and down over the front of the leg through a track called the trochlear groove. The quadriceps muscle along the front of the thigh and the medial patellofemoral ligament are two important soft tissue structures that help hold the patella in place, thus providing patellar stability.

Other important anatomical features contributing to patellar stability/instability include the surrounding fascia (connective tissue), shape of the patella, depth of the trochlear groove, and other ligaments (e.g., meniscofemoral ligament, posterior oblique ligament). Most of these soft tissue structures provide restraint, a force known to hold the patella in place where it belongs. Change in any one of these factors can result in rotation or translation of the patella away from the trochlear groove. When that happens the patella can sublux (partial dislocation) or fully dislocate.

Sometimes athletes experience a traumatic patellar dislocation that is reduced (relocated) spontaneously (on its own) and that’s the end of the episode. But for those athletes who have an anatomical predisposition to patellar dislocation, the condition can become chronic. If the structure of the patella is flat instead of curved to cup the femur or if the muscles or ligaments are unbalanced in some way, the patella may slip off the groove with or without spontaneous reduction.

The patient with patellar instability may feel like the knee is going to give out from underneath him or her. Sometimes, the leg just collapses out from underneath them without any warning. Painful symptoms may develop over time. More than one patellar dislocation is considered a major patellar instability. It’s at this point that most athletes seek professional help.

A sports medicine physician or orthopedic surgeon examines the patient, performing necessary tests to document patellar instability. Knee range-of-motion and quality of patellar motion are observed and measured. The various ligaments can be palpated and/or tested for integrity or deficiency. The strength and quality of muscular contraction are assessed for the quadriceps muscle. The Q-angle, which is the angle of pull of the quadriceps muscle on the patella is measured. An increased Q-angle results in pulling the patella laterally (toward the outside of the joint away from the other knee). With enough pull and not enough restraint, the patella can be pulled so far over that it pops out of the groove and dislocates.

Sometimes imaging studies can be helpful. X-rays have the least value in this area. Unless the patella is fractured or there are bone spurs, X-rays don’t really show any problems that would confirm a diagnosis of chronic patellar instability or offer information as to why the problem is occurring. CT scans can show an abnormal tilt of the patella and give some information about the bony prominence (the tibial tubercle) that inserts into the trochlear groove. MRIs can show ligament damage and even bone bruises from a recent patellar dislocation.

Although the first-line of treatment is nonoperative with activity modification, taping, bracing, and exercises, the major focus of this review article was on the operative management of patellar instability. Surgery is indicated when conservative (nonoperative) care fails to improve symptoms and/or the patella continues to dislocate.

There isn’t one specific surgical procedure that can be done on everyone with patellar instability. The surgeon takes into consideration the age of the patient, activity level (and specific sports involvement), anatomical factors, and the overall condition of the patellofemoral joint. If there is generalized joint laxity or congenital changes (present at birth) in the shape of the patella, further reconstruction may be necessary before patellar stability is fully restored.

The authors describe the three-step procedure advised for this condition. First, patellar tracking up and down the trochlear groove must be restored. Then everything necessary to keep the patella tracking normally must be done. This step usually involves restoring the soft tissue restraints needed to prevent a lateral pull on the patella. It may be necessary to perform a tendon graft or shave off some of the bone that is preventing normal trochlear tracking. And finally, the Q-angle must be corrected. Exactly how the Q-angle is corrected depends on the underlying pathologic (abnormal) anatomy and altered biomechanics.

The authors offer a detailed description of repair and realignment procedures. They start with the surgeon’s decision whether to repair or to reconstruct the joint. Again, this is an individual decision made on a case-by-case basis. Repairing the medial patellofemoral ligament requires the surgeon to find where it has torn away from the patella and reattach it. Different types of incisions and sutures are used depending on the location of the rupture. After making the repair, the surgeon checks knee motion to make sure the patella is tracking properly. Getting just the right amount of tension is important to avoid tightening the structures too much.

Reconstruction procedures are used more often when there is chronic instability, not from a traumatic injury, but from malalignment, laxity, and poor restraint mechanisms. Tendon grafts from the hamstrings are often used when the patient’s own ligament is deficient. Soft-tissue grafting techniques are described including where to drill holes for pins and buttons used to hold the graft in place.

Fluoroscopy, a special real-time X-ray allows the surgeon to make sure placement of the graft and hardware is accurate. The authors note that there are many ways to reconstruct the patellofemoral ligament. Both graft choices and fixation methods vary depending on what alignment problems are present and how much tension is needed. Less commonly used procedures described in this article include medial imbrication and vastus medialis obliquus advancement, lateral retinacular release, the Fulkerson procedure (tibial tubercle transfer), and trocheoplasty.

Following any of these surgical procedures, patients wear a protective (hinged) brace for a period of time and enter into a rehab program. The brace limits both the amount of weight that can be put on the knee and the motion. Motion is gradually increased every two weeks for six weeks. Quadriceps strengthening is the main focus of rehab but the physical therapist will also make sure the patient’s posture, joint proprioception (joint sense of its own position), and kinesthetic awareness (leg sense of movement) are fully restored as well. Sports specific exercises enable the athlete to return to sports approximately 12 weeks after surgery.

The authors conclude that more studies are needed to compare the results of the various repair and reconstructive procedures that are done for patellar instability. Currently, success rates for the different methods range from 71 to 93 per cent. Long-term results at the 10-, 15-, and 20-year mark are also needed. For now, having review articles like this one give surgeons an idea of what other surgeons are doing, the rationale for selecting one procedure over another, and individual patient factors to consider when making the decision to treat surgically.

In this article, the American Academy of Orthopedic Surgeons (AAOS) presents a Clinical Practice Guideline for the nonoperative treatment of knee osteoarthritis. Guidelines like this help all health care professionals treating patients with knee arthritis using noninvasive approaches. Patient education, self-management techniques, physical therapy, and exercise are just a few ways this problem can be approached conservatively.

The 22 guidelines offered are based on an extensive review of published studies on this topic. A panel of 16 orthopedic surgeons, physical therapists, athletic trainers, sports specialists, and research analysts conducted the review of publications. Besides the recommendations, they also mention areas where research is lacking and ways future studies can be directed. The goal is to help health care practitioners guide patients in finding ways to treat knee arthritis short of having the joint replaced.

The authors make it clear that these guidelines are recommendations only. Each patient must be evaluated on his or her own merits, given the past history, current symptoms, past treatment and treatment results, and any important individual patient factors. When looking at the final guidelines as a whole, there are eight major groups or categories including: changes in lifestyle, rehabilitation, mechanical interventions, alternative therapies, pain relievers, joint injections, joint debridement (cleansing), and surgery (other than knee replacement).

The panel carefully reviewed the evidence for each guideline and graded the quality of that evidence as Level I (good), Levels II and III (fair), and Levels IV and V (poor). Once the 22 recommendations were developed, they were reviewed and commented on by various committees, patients and the public, as well as the AAOS Board of Directors. Here’s a brief summary of the major findings. If you have knee osteoarthritis:

If you watch much sports on television, you know that a torn knee cartilage (meniscus) can put a player on the bench. Injuries to the meniscus occur most often in athletes when they injure other parts of the knee (e.g., knee ligament tears, fractures around the knee). But did you know that most meniscal tears actually occur in older adults as a result of aging? That makes the diagnosis and treatment of degenerative meniscal tears an item of interest for many older adults and the doctors who treat them.

In this review article, three orthopedic surgeons bring us up-to-date on patient evaluation of meniscal injuries. Their focus is on the anatomy, biomechanics, and function of the menisci (plural for meniscus).

Taking a quick look at the anatomy of the meniscus, we find that it is a C-shaped disk of fibrous cartilage between the tibia (lower leg bone) and the femur (thigh bone). There are two menisci: one on each side of the knee joint. The medial meniscus (along the inside of the knee closest to the other leg) is torn most often. The lateral meniscus (along the outside of the knee away from the other leg) is injured less often.

The menisci have several functions. They help spread the load from forces directed from the foot up through the knee and into the hip. They act as mini-shock absorbers while lubricating the joint and helping the joint surfaces slide and glide smoothly against each other. Without these fibrocartilage disks, the knee is less stable and more likely to give way underneath the person. An unstable knee is at increased risk for another injury.

Diagnosis is made by history, physical exam, and imaging such as X-rays and MRIs. The patient’s history will reveal his or her activity level, lifestyle, previous injuries, goals for recovery, and any other health concerns or issues. During the physical exam, the surgeon looks for loss of joint motion, tenderness along the joint line, and any swelling that may be present.

The patient’s report of traumatic injury or the onset of popping, catching, locking, or buckling of the knee is suggestive of a meniscal tear. The patient who reports loss of knee motion and says it feels like the motion is blocked may have a torn and displaced meniscus. Limping while walking is a common clinical presentation when the meniscus is torn because the patient cannot put full weight on that leg.

X-rays show any fractures or loose fragments in the joint. X-rays also help the physician see what kind of shape the joint is in, how much degeneration has occurred, and any signs that the joint is thinning. MRIs show the pattern of meniscal tears. This helps the surgeon plan treatment. The tear could be across the meniscus (vertical), the length of the meniscus (horizontal), or at a diagonal (oblique). The severity of the tear can also be assessed with MRIs (mild, moderate, severe). Any other features such as the shape of the tear (e.g., flap tear, parrot-beak tear, or complex configuration) can be seen as well.

It is now recognized that removing a torn or damaged meniscus isn’t always the best idea. With all of their functions to disperse load, absorb shock, stabilize the joint, and give controlled joint motion, it’s no wonder the knee degenerates faster without the menisci. Early, degenerative arthritis is common in those patients who have a meniscectomy (surgical removal of the meniscus) after an injury. Every effort is made now to save these important cartilaginous disks.

Understanding the anatomy, biomechanics, and function of the menisci is important when trying to repair rather than remove them. The surgeon must be knowledgeable about the direction of the collagen fiber bundles that make up the menisci. Understanding microanatomy, blood supply, and location of nerve fibers is necessary when trying to surgically restore this important part of the knee.

Likewise, understanding motion of the meniscus as it is guided by ligaments and joint capsule and where and how the meniscus attaches to the bone are key features needed by orthopedic surgeons repairing torn menisci and restoring normal anatomy and function as much as possible. All of these aspects of the meniscus are discussed in detail with color illustrations and MRI photos to aid the surgeon in making a correct diagnosis.

A discussion of treatment for meniscal tears is not included in this article. The authors say this is an update of a previous article they published in 2005 on the diagnosis and management of meniscal injuries. A second article will be published in The Journal of Musculoskeletal Medicine later with a similar type review of treatment approaches to this problem. Both conservative (nonoperative) and surgical treatment will be discussed at that time.

It’s clear now that unrepaired anterior cruciate ligament (ACL) injuries are often accompanied by damage to other soft tissue structures of the knee. Patients are advised to have surgery sooner than later. And surgeons are advised to carefully evaluate the joint for any additional ligament or cartilage tears before doing surgery for the ACL. But sometimes patients opt out of surgery and decide to wait before having the operation. In those cases, without the stabilizing force of the ACL, do patients end up with meniscal tears that weren’t present at the time of the ACL injury? That’s what the authors of this study set out to find out.

They studied 31 patients who delayed having surgery after an acute ACL injury that resulted in a complete tear of the ligament. To be included in the study, each patient had to have at least two MRIs done and a delay of a minimum of six months before surgery was done. With a chronic ACL-deficient knee, the meniscus becomes even more important as a supportive and stabilizing structure within the joint. The medial meniscus is the focus of this study. The medial side of the knee is the side that is closest to the other knee.

The meniscus is a tough, rubbery C-shaped piece of cartilage that acts like a shock absorber in the knee. It forms a gasket between the tibia (shinbone) and the femur (thighbone) to help spread out the forces that are transmitted across the joint. Walking puts up to two times your body weight on the joint. Running puts about eight times your body weight on the knee. Besides protecting the joint surface, the menisci (plural for meniscus) also help the ligaments stabilize the knee.

The medial meniscus was the main area of interest because previous studies have shown that lateral meniscal tears don’t seem to get worse over time like medial meniscal tears do. There are two basic types of meniscal tears: bucket handle and longitudinal. Bucket handle tears mean the tear follows the C-curve shape of the meniscus and goes all the way through the cartilage. If you could pick the tear up, it would look like a bucket handle over the remaining meniscus. A longitudinal tear also goes the length of the meniscus but it only extends along one side of the cartilage. It doesn’t go all the way through to the other side of the cartilage.

At the time of the initial ACL injury, only half the group had a meniscal tear. When the next MRI was done, only five of the 31 knees no longer had a medial meniscal tear. Not only that, but of the patients who did have a meniscal tear right from the start, almost half of them had a worse meniscal condition when the second MRI was done. Longitudinal tears became bucket handle tears and more people who started out with no tears now had bucket handle tears.

Once the authors confirmed that medial meniscal tears were made worse by an unrepaired and deficient ACL, they started analyzing other factors that might make a difference in the outcomes. First, they looked at age. Maybe the older the patient, the more likely it is that the meniscus will tear over time. The patients in this study were fairly young (between 18 and 47 years old). It turned out that there was no relationship between patient age and whether or not a meniscal tear occurred over time.

Then they looked at activity level. Maybe more active patients are more likely to tear the meniscus with an unrepaired and deficient ACL. Nope — patients who were more active didn’t have more meniscal damage (or greater severity of meniscal tears). In fact, even those people who had repeated knee injuries didn’t have more meniscal tears than those individuals who didn’t reinjure the knee.

What they really found was that medial meniscal tears occur more often the longer the patient delayed ACL reconstructive surgery. That begs the question: when it comes to protecting the status of the medial meniscus, is there an ideal time to have ACL surgery? Other researchers who have looked at this issue have concluded from their studies that reconstruction should take place between three and 12 months after the injury. And the results of this study not only confirm that conclusion, but also offer the knowledge that the earlier the better. Delaying reconstruction surgery puts the medial meniscus at increased risk for tears.

There was one other finding from this study that is important to note. MRIs don’t always show meniscal tears or places where the meniscus separates from the joint capsule. That means it’s possible to have a meniscal tear and not know it. Surgeons find these unknown tears when they either do an arthroscopic exam or at the time of the ACL reconstruction. Tears along the backside of the meniscus are especially difficult to see on MRI. Even with arthroscopy, posterior tears can be missed unless the surgeon takes a probe and double-checks the integrity of the meniscus all the way around.

In summary, patients with ACL tears who want to delay surgery should be advised about the possibility (probability) that ACL deficiency contributes to medial meniscal tears. This is true even for patients who have an intact medial meniscus at the time of the acute ACL tear. A delay of more than six months increases the risk of further damage and degeneration of the involved knee. The exact reason(s) for this development still aren’t clear. If it’s not age or activity related and it’s not a direct result of a repeated injury, then what? The authors suggest that further research is needed to identify risk factors that might be preventable.

The authors of this study provide us with some long-term information about the results of autologous chondrocyte implantation (ACI) for large lesions in high-demand patients (athletes). Autologous chondrocyte implantation refers to using the patient’s own cartilage to repair the problem.

This study follows a long line of other studies that have led to the current standard of care for hyaline or articular cartilage injuries of the knee. The affected cartilage covers the ends of bones. It is made up of cartilage cells called chondrocytes. Damage to this structure can cause holes called defects or lesions. Continued daily use of the joint puts pressure on the damaged area leading to pain, swelling, and sometimes locking or catching of the knee.

When these symptoms result in loss of function, the surgeon can perform a debridement or microfracture procedure. Debridement removes any loose fragments and smoothes the cartilage surface of the joint. Microfracture is the drilling of tiny holes through the cartilage to the joint surface. This technique stimulates bleeding and sets up a healing response.

A third treatment option for first-line care of cartilage injuries is an osteochondral autograft transplantation. This involves harvesting a layer of cartilage and bone from a healthy area of the same patient’s joint and transferring it to fill in the hole. Any of these first-line treatment approaches work well for inactive or low-demand patients with a small lesion. But for active patients with large defects, a different procedure might work better. That’s the autologous chondrocyte implantation (ACI).

To perform an ACI, the surgeon first removes healthy cartilage cells from the patient and sends them to a special lab where they grow more of the same type of cells. When there are enough cells to fill the hole, the surgeon performs the second part of the procedure. The hole is prepped for the new cells, which are then placed in and around the defect. The implanted area is then covered over with a patch of periosteum, the outer layer of bone (also harvested from the patient). The patch fits over the repaired defect like a manhole cover.

The surgeon doesn’t just repair the defect. It’s also important to take a look at the patient’s alignment and correct any problems that contributed to the cartilage damage in the first place. Many times, the cartilage wears down through all its layers because the bones forming the knee joint are angled unevenly. The surgeon can correct this by performing a procedure called an osteotomy. A wedge of bone is placed along the side of increased pressure in order to shift the point of weight-bearing contact over toward the other side of the joint. This helps even out the weight-bearing surface of the knee.

Although autologous chondrocyte implantation has good results, it is not the first treatment of choice for this type of cartilage damage. As mentioned, it is reserved for patients with large defects and who are very active. There are some potential problems with this treatment method. Removing cartilage cells and periosteum needed for the implantation always leaves the donor site at risk for subsequent problems. And the implanted chondrocytes don’t always fill in with good, solid cartilage. Sometimes, the new growth is just a fibrous type of cartilage.

So, how well does it hold up with everyday function and under the pressure of sports participation? Is it possible to predict who will have a good (or poor) result? How often is another operation necessary due to failure of the ACI? These are the questions the authors tried to answer with this study. They followed 137 patients who had ACI of the knee and reported on results measured by symptom improvement and function.

Everyone was treated by the same surgeon and followed the same postoperative rehab protocol. They wore a hinged knee brace for two weeks after the procedure. The brace kept the knee straight and the patient was not to put any weight on the leg. Knee movement (bending and straightening) was accomplished using a continuous passive motion machine. Weight-bearing was added after six weeks with gradual progression from partial- to full-weight bearing by the end of 12 weeks.

The patients filled out several different surveys answering questions that could help evaluate the results in five areas: pain, symptoms, daily activities, sports function, and quality of life (related to knee function). They found a significant improvement in all areas. The implant was durable and 83 per cent of the patients said they would have the same surgery again if they had to do it all over. A small number of patients ended up with some arthritic (degenerative) changes in the joint but they still were better off than before surgery. Two factors that are linked with an increased risk of failure with this procedure included increasing age and worker’s compensation status.

Having only one surgeon involved in the study offers a unique advantage in research. Consistent care and follow-up was possible, reducing the chances that different surgical techniques or rehab efforts would affect the overall results. The authors believe that autologous chondrocyte implantation (ACI) should be considered for large or irregular full-thickness cartilage lesions. This type of implantation works well, no matter which part of the knee joint has been affected. It should still be used after the standard first-line treatment has failed. Properly selected patients can expect the good results to last for many years as shown by this study. Patients older than 40 are less likely to have chondrocytes with active growth factors and more likely to have fewer new, healthy cartilage cells form.

All drugs come with benefits and possible side effects or adverse events. For anyone suffering joint pain from osteoarthritis, nonsteroidal antiinflammatory drugs are often used to reduce pain from inflammation and improve function. But since osteoarthritis is a chronic condition, that can mean taking these medications for a very long time. And that increases the risk of problems or complications.

One way around this is with the use of topical (lotions or gels applied to the skin) NSAID formulations. The results of this study show that one topical NSAID in particular may be helpful for those people who have mild to moderate knee arthritis. Diclofenac in a topical form was compared with oral diclofenac and with a placebo (pretend) topical solution.

Over 700 patients with bilateral knee osteoarthritis were included in the study. Bilateral means both knees were affected. The diagnosis was confirmed with X-rays. They were divided into five groups. One group received treatment with topical diclofenac administered through a liquid you may have heard of: dimethyl sulfoxide or DMSO. By combining the topical NSAID with DMSO, the active NSAID agent could be absorbed faster and more effectively without altering its effects. This group was also given an oral placebo tablet. Placebo means there was no active drug in the tablet.

The second group received a topical placebo (they thought it was the NSAID), but it was just the DMSO. They also took a placebo tablet. The third group received a placebo topical solution combined with DMSO at a lower level of DMSO concentration (2.3 per cent instead of 45.5 per cent) and they took an oral placebo tablet. The placebo solution with the higher percentage of DMSO was included to help show (or rule out) the effect of the DMSO as a possible treatment agent. The lower percentage DMSO solution was meant to be a test without DMSO’s effects; a small amount of DMSO was added because this substance normally causes a garlic taste or odor that patients expect. Without it, the group would know they weren’t getting the real NSAID.

Group four was given a placebo solution plus oral diclofenac (a slow-release pill form of the topical NSAID being tested). And the last group received both the topical and the oral forms of diclofenac. Anyone who used any of the topical solutions tested applied 40 drops of the prepared solution around the whole knee. They did this four times a day without rubbing it in.

Patients in the groups receiving a topical agent only had one knee treated. This provided a nice control group (the untreated leg). Everyone was followed for 12-weeks. They were told not to take any other antiinflammatory medications. They could take Tylenol for pain and/or any other necessary medication already prescribed before the study began (e.g., antidepressants, blood pressure medication). Before and after measures were taken of pain, stiffness, physical function, vital signs, and overall health. Routine blood and urine samples were analyzed before and after as well. And because there have been reports of vision changes with the use of DMSO in animals, a visual exam was also performed before and after treatment.

After all the data was collected and analyzed, here’s what they found. First, topical diclofenac is clearly better than the topical placebo (with or without DMSO). Although pain and function were improved with the true topical diclofenac, there was no change in knee joint stiffness. Second, topical diclofenac caused fewer adverse events than the oral form. There was a little skin drying in the topical group because of the DMSO. Of particular interest was the fact that the placebo (oral) group had more gastrointestinal reactions than the topical group. The authors suspect this is as a result of the power of suggestion. Patients in the placebo group were told (just like everyone else was told) that there could be some gastrointestinal symptoms develop when using NSAIDs.

One other important finding was the fact that the DMSO was not an effective treatment itself for active, painful, and limiting knee osteoarthritis. This result helps negate commonly held (but erroneous) beliefs that DMSO is useful treatment all by itself for knee arthritis. It simply functions as a penetration enhancer assisting the NSAID in crossing through the skin.

The authors conclude that topical NSAIDs and in particular, diclofenac, can be used as the first-line treatment for patients with painful, symptomatic knee arthritis without the usual adverse effects that occur with oral doses of NSAIDs. This knowledge gives patients another treatment option early on in the sequence of events that accompany chronic knee pain from osteoarthritis. Future studies will investigate optimal solutions and doses for the topical treatment using diclofenac as well as what happens past the 12-week mark used in this study.