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Limitations Exist in Examining the Cost-effectiveness of Surgical Treatments for Lumbar Spine Disorders

For the past few decades different surgical techniques including spinal
decompression and spinal fusion have been used to successfully treat lumbar
spine conditions. Typically benefits of these surgeries are measured in pain
relief, low rate of complications and return of function. But there is new
emphasis placed on quantifying the value of surgery in terms of cost to
patients and society. Unfortunately, as recent systematic review
demonstrated, there is limited evidence available in examining cost-
effectiveness.

Lumbar stenosis (narrowing of the spinal canal) and
spondylolisthesis (forward displacement of a vertebra) are two common degenerative spine conditions. In addition to non-operative strategies, surgical decompression and arthrodesis (fusion) are accepted options for these conditions. The aforementioned systemic review was performed to examine the cost-effectiveness of these procedures. The review ran into
several limitations including scarce literature available, the inconsistency
and variability present in what literature was present and that many of the data was based on mathematical modeling algorithms versus actual patient data.

In terms of operative treatment versus non-operative treatment, it is expected that surgical techniques will have a higher upfront cost secondary to the possible hospitalization, anesthesia and invasive nature of the procedure itself. Some may argue that if there is permanent removal of the neural compression through a surgical technique the upfront costs should
dissipate over time by allowing the patient prolonged relief of symptoms and return of function and contribution to society. At this time, due to the
limited amounts of literature, there are too many limitations to support this argument one way or the other. The systemic review brought up the concept of delayed gratification being very important to analyze in a procedure that may have a prolonged course of action. There are differing opinions on when in the process this analysis should be made. A two-year time window was used by several of the studies used in the review but it was stated that this may not be a long enough period to see an effect thus reinforces the difficulty in drawing definitive conclusions on the cost-effectiveness of surgical
techniques versus non-operative treatment.

Assessing Cost-effectiveness of Surgery for Cervical Degenerative Diseases

Value based health care is swiftly becoming a thing of the present and substantiation of treatments for spinal conditions will be necessary. Optimal treatment options need to be identified in value-based health care, where optimal can be defined as greatest gain in quality of life at the lowest cost to the patient and society. Overall there are very limited cost-effectiveness studies in spine surgery literature with cervical conditions being most neglected. A recent systematic review looked to identify if there is evidence present on the cost-effectiveness of operative treatment of cervical degenerative disc disease (DDD) conditions. Ultimately they stated that no definitive conclusion can be made secondary to the great limitations present in the small amount of current research on this topic.

Answers to four questions of interest were sought in performing this review to examine cost effectiveness of surgical treatment for cervical degenerative conditions. The first question looked at whether there was evidence present to suggest surgical intervention is cost-effective as compared with non-operative treatment for degenerative spinal conditions specifically cervical myelopathy (compression of the spinal cord within the neck) and cervical radiculopathy (compression or irritation of the spinal nerve roots in the neck). It was found that no full economic review existed relative to this question. The second question focused on evidence to suggest anterior cervical discectomy and fusion (ACDF) is cost-effective compared to cervical disc arthroplasty (CDR) for cervical myelopathy or radiculopathy. Only two economic evaluations were available which demonstrated that CDR is more cost-effective than ACDF for a patient with single-level cervical DDD and radiculopathy or myelopathy. The third question looked at whether evidence is present to suggest that surgeries based from the front of the neck were more cost-effective as compared to surgeries performed using a technique from the back of the neck for cervical myelopathy. Again only two economic evaluations were available. Surgery performed from the front did demonstrate increased cost-effectiveness at one-year postsurgery for patients with cervical myelopathy. The last question examined if evidence was present to suggest that surgeries performed from the front of the neck were more cost-effective as compared to surgical techniques performed from the back of the neck for cervical radiculopathy. In this case only one economic evaluation was available for analysis and this demonstrated that surgical techniques from the back are less costly than ACDF for patients with single-level radiculopathy.

There were several limitations found in this systematic review. Drawing conclusions off of only one or two studies is challenging and thus it was concluded that these questions must be further validated by additional high-quality investigations. Different types of surgical techniques (i.e. performed from the front or back) typically have a different subset of patients thus any conclusion made on cost-effectiveness may be influenced by patient demographics. Recent studies have further defined health utility indices in the study population as well as long-term complications. A repeat cost-effectiveness comparison utilizing this new information is still lacking.

Overall it was suggested that further analysis should adopt a standardized cost-utility methodology, which should include both comprehensive long-term follow-up costs and valid quality of life outcome questionnaire data. The authors of this review also recommended that the analyses should directly compare either non-operative versus operative intervention or two different surgical interventions using a cost-effectiveness ratio and being specific about whether it is a patient with myelopathy versus radiculopathy versus neck pain alone receiving treatment. They also felt that other surgical interventions should be explored and lastly that longer-term follow-up is necessary so that aspects such as adjacent level surgery, failure rates and clinical outcomes can be further defined.

Treatment Options For Posterior Heel Pain From Repetitive Overuse Injury

Overuse injuries from repetitive ankle plantar flexion stresses can be attributed to Os trigonum syndrome. The Os trigonum can be the result of fracture of a bony tubercle in the back of the ankle or it can occur when there is an unfused ossicle in childhood. This condition may also be known as posterior ankle impingement. Ballet dancers and soccer players have an inherent risk of this condition secondary to the amount of time in a forced plantar flexed position. This occurs with push off procedures and while dancing on pointe (dancing performed on the tip of the toes with the ankles in maximal plantar flexion) and demi-pointe (dancing performed on the balls of the feel with the ankle in maximal plantar flexion).

This condition is typically asymptomatic until an overuse injury or trauma occurs. Symptoms can include stiffness, chronic pain and swelling behind the ankle. Because pain and stiffness can occur with activities involving plantar flexion, compensations can occur leading to faulty positions which additionally may lead to other ankle conditions such as ankle sprains, tendonitis or tenosynovitis (inflammation of the fluid-filled sheath that surrounds a tendon). Initial conservative management of Os trigonum syndrome includes rest, ice, anti-inflammatory medication and, of course, avoidance of aggravating activities. One study demonstrated 84 per cent of patients received relief from an ultrasound-guided corticosteroid injection.

If a three to six month course of conservative treatment fails, surgical intervention may be appropriate. Resection of the Os trigonum can be performed via three methods; posterior endoscopy, arthroscopy, or an open procedure. Most studies report outcomes that posterior endoscopy and arthroscopy can allow for faster return to sport but these techniques tend to be more complex and demanding. The author of this review article argues that a careful open approach may produce long term results that are equal to that of arthroscopic and endoscopy techniques while possibly being safer. Overall, surgical outcomes show that all three techniques provide improved function and high rate of return to sport.

Assessment and Treatment of Ulnar Fracture with Elbow Dislocation or Subluxation

The elbow joint consists of three bones, the upper arm, or humerus, and two bones in the forearm ,the ulna and the radius. The ulna forms the tip of the elbow, also known as the olecranon process. It is at the point where the ulna meets the humerus that an elbow dislocation or subluxation can occur; the dislocation can be with or without fracture of the ulna. Six major patterns have been described as causes of an ulnar fracture with subluxation or dislocation of the ulnohumeral joint.

The first is dislocation with radial head or neck facture, in which there is also injury to the lateral collateral ligament, LCL, and possibly the medial collateral ligament, MCL. A second injury is termed the terrible triad in which there is a fracture to the coronoid and radial head as well as injury to the LCL. Third is the varus posteromedial rotatory instability which involves fracture of the anteromedial facet of the coronoid with either LCL injury or olecranon fracture causing varus subluxation of the elbow. Fourth is an anterior olecranon fracture-dislocation when the proximal part of the ulna is fractured and an anterior dislocation of the forearm relative to the distal humerus occurs with no radioulnar dissociation. A fifth category is termed posterior olecranon fracture-dislocation in which the proximal ulnar fracture includes a posterior dislocation of the forearm. The two olecranon fracture-dislocations can be commonly misdiagnosed as a Monteggia fracture in which the fracture also results in a dislocation of the proximal radioulnar joint. The sixth and final category of ulnar fracture with dislocation is a dislocation with capitellar or trochlear fracture. The capitellum is fractured, with or without extension into the trochlea accompanied by injury to the capsule and ligamentous support resulting in ulnohumeral instability.

It is imperative to understand the categories of acute injury to the elbow in order for surgeons to anticipate what structures may be affected, particularly when assessing in a nonacute setting. Of the structure affected, understanding the coronoid fracture fragment is the most important when identifying the patterns of elbow instability with imaging, as research shows as significant association between the type of coronoid fracture and the type of fracture-instability pattern. There are three types of coronoid fracture: type I is a transverse fracture of the tip of the coronoid associated most commonly with terrible triad injuries, type II is a fracture of the anteromedial facet of the coronoid associated most commonly with varus posteromedial rotatory instability, type III is a fracture at the base of the coronoid associated most commonly with olecranon fracture-dislocation.

There are several factors that influence the outcome of an ulnar fracture with dislocation. Though it is uncommon to have an elbow fracture with persistent ulnohumeral subluxation or dislocation that has been left untreated for more than two weeks, it is clear that time from injury to treatment will effect outcomes. Patients treated within two weeks of injury have significantly better outcomes than those treated more than two weeks after injury when assessing range of motion, pain, and outcome measures. With this evidence, the acute period for treating elbow fracture with dislocation is within 2 weeks . If surgical management cannot take place in the first two weeks, an alternative is to reduce the joint and apply an external fixator. Type or extent of instability will also effect outcomes. Most acute simple dislocations are stable once the joint has been concentrically reduced, the ligaments will heal and function with early controlled motion. A nonacute simple dislocation, persisting beyond two weeks, can still be successfully treated with concentric reduction and early motion, however longer standing dislocations can also require surgical repair as the LCL is not successfully healing to the lateral epicondyle. These instabilities result in less favorable functional outcomes.

There is no consensus on what the optimal solution is for assuring stability of an elbow that has dislocated or subluxed. Temporary immobilization with either cross pinning or external fixation is most commonly used to help maintain elbow congruency while healing. An external fixator, however is difficult to apply, cumbersome to wear, can sometimes still allow the elbow to dislocate and can cause pin-site infection, pin breakage and/or radial nerve injury. Cross pinning of the joint is better at maintaining reduction, but the arm must be casted and there are risks of pin breakage and septic arthritis.

There are many side-effects to the treatment of ulnar fracture with dislocation or subluxation, Contracture and stiffness, particularly with weeks of immobilization, can co-exist with instability and heterotropic ossification, and can impede concentric reduction. Methods available to treat excessive contracture or stiffness include an open capsular release and excision of heterotropic ossification with or without radiation. One must be careful with these procedures as the contracture or ossification may be masking latent instability. Arthrosis develops in almost all patients with these injuries, though extent and symptoms are highly variable. Ulnar neuropathy can develop and negatively affect outcomes as can osseous and chondral erosion.

Aside from addressing the main injury to the ulna and humerus, there are other factors to consider with these an elbow subluxation or dislocation. It is most likely that both the LCL and MCL are damaged in an ulnar fracture with dislocation, thus it becomes important to assess and properly treat the radial head. The radial head can act as a secondary stabilizer when the MCL is insufficient and helps maintain valgus stability at the elbow to allow soft tissue structures to optimally heal. Prior to fracture healing, repair or prosthetic replacement of the radial head, depending on the number of fractures, is an important consideration. The coronoid must also be assessed. Research demonstrates that when more than fifty per cent of the coronoid is excised, or a combination of at least thirty per cent cornoid excision with radial head excision and lateral ulnar collateral ligament damage, there is a significantly greater chance of consistent dislocation. To repair these injuries, the radial head can be replaced and the discarded radial head bone can be used to repair the coronoid. The success rates largely depend on the original instability pattern and the size of the coronoid defect.

It is apparent that there is a lot to consider when assessing an ulnar fracture with an elbow dislocation or subluxation. The initial questions to answer should be what is the original mechanism of injury, whether past surgical procedures were performed, what the state of the radial head may be, and where the ulnar nerve is located. The surgeon should be prepared to remove any implants and should know how they are affixed, location of heterotropic ossification must be noted, the ulnar nerve must be protected throughout the procedure, collateral ligaments should be preserved when possible, and the surgeon should be prepared to perform any necessary capsular release to treat joint stiffness. These many factors and considerations will direct the surgical procedure performed and success rate for favorable long term outcomes.

A Review of Posterior Lumbar Fusion Techniques

Posterior lumbar fusion is a relatively common surgical procedure for pain in the low back. In this surgery two or more levels of vertebra are stabilized with bone grafts, or bone graft substitute. Then movement at those levels is limited to encourage the natural processes to grow bone in the space between the vertebra and subsequently stop all movement at this level. There are many options when planning for such a procedure and there is some debate over the best techniques. This article is a review of some of the more recent research and longer term studies in this area.

In 1991 there was a landmark study by Herkowitz and Kurz which showed that patients with degenerative spondylolisthesis had a better outcome with the combination of a fusion and a laminectomy than with the laminectomy alone. In this research it was noted that some successful outcomes were had even with pseudarthrosis, which means that the fusion was not complete and still allowed slight movement. Due to this study, for several years it was felt that full fusion was not necessary for successful outcome. In 2004 Kornblum et al detailed the long-term results of this same group of patients and found that for long term positive results (five to 14 years follow up) a solid union was more effective. Kornblum showed that the clinical outcome for those with a solid fusion was excellent in eighty-six per cent of patients compared with only fifty-six per cent excellent outcome with a pseudoarthrosis. The evidence presented in this longer term study suggests that gaining a complete fusion improves the clinical outcome for the patients in the long term.

The considerations are many when planning a surgery for a lumbar fusion. The first is whether to use instrumentation, additional hardware such as screws and rods, or not. Some surgeons argue that for older adults non instrumented fusion decreases time of procedure and loss of blood which may be preferable. However, in 1999 a Cochrane review by Gibson et al found that there was strong support in the research for better fusions when instrumentation was used. Newer studies have shown very slight benefits including decreased use of pain medication, and cost versus quality of life measures with instrumented fusions. In this authors opinion a solid fusion from instrumentation is the best choice for the positive long-term outcomes.

Some techniques also use more bone placed between the vertebral endplates, also called inter body fusion, to increase chance of a solid fusion. This technique has been shown by Ito et al to have a fusion rate as high as ninety eight per cent. However a recent systematic review by Lee et al of randomized trials using the Cochrane system of standards found that there is moderate evidence that there is no difference in complete fusion rates between posterior inter body fusions and posterior lateral fusion.

Often a bone graft is also used to improve likelihood of a solid fusion. Currently the gold standard is the use of an iliac crest bone graft (ICBG) due to evidence of between forty per cent and eighty nine per cent successful fusion rates. However with ICBG there is increased blood lost from a second surgical site as well as increased operating time and increased hospitalization time.

Each alternative has some advantages and disadvantages and these must be considered on an individual basis. When a decompression is performed in conjunction with the fusion, this removed bone from the lamina is routinely used with good results in the literature. The drawbacks may include a minimal amount of bone available, and often surgeons elect to increase the amount of bone by adding bone marrow aspirate (BMA) or ICBG. Another option is an allograft which is tissue from a different individual, however there is lots of variability in the research with this technique.

Another substance that has been hypothesized to improve fusion is the presence of bone morphogenetic proteins (BMP). In 2012 Kang et al found eighty six per cent fusion rate with use of BPM from demineralized bone matrix plus laminectomy bone compared to ninety two percent fusion rates for ICBG plus laminectomy bone. In yet another study by Schizas et al these two same procedures showed equivalent fusion rates. There are some recent studies which are shining some problems on BMP, and are focused on the safety of this substance. There has been some concern with increased rates of retrograde ejaculation in men and a recent association with recombinant human bone morphogenetic protein-2 and an increased risk for cancer.

There has been further research in the area of ceramics, platelet gels, and electrical stimulation to aid in fusion surgeries. In animal studies it has been shown that ceramic substrates can have osteopromotive (meaning they attract bone growth) properties and be a substitute for autograft in posterior lumbar fusions. In clinical studies ceramic materials have successfully been used as a bone graft extender with ICBG and fusion rates range from eighty two per cent to ninety six per cent over several different studies. However, it is interesting to note that some of these fusions were assessed with CT scan, and bone and ceramic material have the same density as viewed in a CT scan, so there may be some argument about whether a true fusion is the outcome vs unfused ceramic material. As a bone graft substitute ceramics have mixed results including longer time to achieve radiographic fusion and needing a larger area of bony surface to achieve fusion. There has been some promising animal research with platelet gels, however they have not translated into effective clinical adjuncts for fusion with two studies showing a decrease in fusion rates greater than nineteen per cent compared to fusion without platelet gel. Electrical stimulation is an adjunct to enhance fusion rates and in the research the results tend toward small percentages of benefit or no change.

There are some circumstances which put patients at risk for non union, or pseudarthrosis and they include smoking and increased motion during the healing phases. It is due to these findings that patients are counseled to cease smoking prior to a fusion procedure. A clinical study of two level fusions with laminectomy showed that there was a forty per cent pseudarthrosis rate in smokers compared to eight per cent in non-smokers.

The author of this review study makes the conclusion that the iliac crest autograft remains the best option for gaining a solid fusion, but it’s use can be reserved for long multilevel fusions. There is good evidence that for shorter fusions use of autograft of laminectomy bone in adjunct with cancellous allograft chips and simple BMA is effective without the sequela of a second surgical site. The author feels that there is not sufficient evidence to utilize foreign or man-made proteins or manufactured ceramics due to concerns of complications of unexpected immune reactions. Lastly this author recommends use of electrical stimulation be reserved for problematic cases as a safe and effective adjunct to increase likelihood of a solid fusion.

A Closer Look at Elbow Replacements

Elbow fractures, specifically radial head bone fractures, make up about five per cent of all fractures and are frequently caused by falling on an outstretched arm. If the fractured bones are aligned enough that they can heal on their own, the elbow is protected for a period of time, followed by physical therapy for full return to function. If the fractured bones are not well aligned then surgeons must go in and stabilize the bones with hardware.

The elbow joint is made up of three bones, the ulna, radius (both forearm bones), and the humerus (your upper arm bone). The end of the radial bone is shaped like a disc and articulates with the end of the humerus at a divot called the capitulum. Because of the unique shape of the radial head and the combined movements of the ulna and the radius, our elbows not only bend and straighten but our forearms are able to rotate as the radial head spins.

Advancements in technology and surgical techniques now allow for actual replacement of the radial head. This is appropriate in cases where the radial fracture is so bad that it cannot be reconstructed, incidences of elbow instability, poorly healed fractures, elbow arthritis, or when there is a combination of elbow dislocation and radial head fracture.

Several types of radial head implants are now available. Loose fitting prosthesis anatomically mimic the original radial head and are placed “loosely” in the radial bone. They are thought to stabilize the joint by acting as a block between the joint. The loose fitting prosthesis is not believed to be able to further loosen or cause pain from implant placement and has a full arc of articulation with the capitulum. Out of 13 patients with a loose fitting prosthesis placement queried at 38 months after surgery, eight reported excellent results, three good, and two fair results. Press-fit stems are another option. These are also modeled after the radial head in design. They are fitted as tightly as possible in the radial bone. Press fit stems tend to have good to excellent results but there is greater chance of implant loosening than with a loose fitting prosthesis. A bipolar implant consists of a fixed stem but a mobile head, which melds the two previously mentioned implants. The greatest benefit of a bipolar implant is the improved arc of contact between the implant and the capitulum, however the greatest complication is the implant can dislocate.

Complications from radial head replacement can include elbow stiffness, nerve damage, bone deposition in soft tissue, and pain. Authors point out, however that most of these reported complications are most likely due to the original trauma and not the elbow replacement surgery. Wear and tear on the neighboring bone, the capitulum, is a long-term complication that is currently unavoidable.

Rehabilitation following surgery focuses on restoring functional motion. The elbow is splinted for seven to 10 days followed by full active and assisted movement of bending and straightening the elbow. Elbow rotation (supination, pronation) is allowed with the elbow bent to 90 degrees. If patients are lacking full range of motion at the six-week mark, then physical therapy is prescribed. Elbows with instability are only allowed to move through a specific range prescribed by the surgeon for three weeks, followed with unrestricted movement after that time period.
As implants and surgical techniques improve, success rate of radial head replacement surgery ultimately lies with the skill and knowledge of the surgeon and an excellent understanding of implant designs and indications.

Management and Treatment Options for Children with Flat Feet

People with flatfeet make up about 20 per cent of the adult population. A flat foot deformity is defined as a foot lacking the normal arch of the foot and a sinking inward of the heel. A good indication of if you have flat feet is to look at your footprint after walking in water–the lesser the curve on the instep, the flatter your foot is. Infants are born with flat feet and arches do not typically fully develop until around age five. Flat feet are more prevalent in males and the obese population. Normally flat feet are very flexible and the tiny foot muscles work well.

Rarely do people with flat feet have foot pain because of the shape of their feet, however there is a small group of people (less than one per cent) who present with a stiff flatfoot and a short achilles tendon which have an increased prevalence of pain and dysfunction in adulthood.

Often flat feet are brought to an orthopedist’s attention in childhood or adolescence, primarily out of concern for cosmetic reasons, future pain or dysfunction in adulthood. However, the latest evidence suggests that because only a small portion of the flat foot population has pain no treatment is necessary, orthotics or otherwise. If a child does present with pain, then they do need to be treated but it is important to find out the cause of the pain. In a flexible flat foot when long term orthotics are indicated, over the counter orthotics helping to create an arch are sufficient. Custom orthotics should only be utilized when over the counter orthotics or other nonsurgical treatments do not work. Orthotics correcting the arch for a rigid flatfoot or for a flexible flatfoot with a shortened achilles tendon will actually exacerbate the problem. Conservative treatment for a shortened achilles tendon typically involves a specific daily stretching program.

In the very rare case where pediatric surgery for flatfeet is indicated, standards are strict for eligibility and prior to surgical correction all other conservative treatments must be attempted. Soft tissue corrections, like achilles tendon lengthening, are rarely successful. Ankle fusion to a more neutral position will speed arthritis and decrease overall function and mobility. Restriction of the primary joint causing the flat foot, called an arthroereisis, shows poor promise and is not well studied. Osteotomy, or the lengthening or shaving of certain foot bones, is the gold standard treatment and has excellent outcomes with well-trained surgeons.

Motor Vehicle Collisions and Thoracic Disc Injury

TDHs (Thoracic disc herniations) have a variable presentations and can mimic other diseases and many are misdiagnosed because of this. A TDH is thought be relatively rare compared to cervical or lumbar herniation. A traumatic origin has been estimated in up to 25 per cent of TDHs.

Whiplash injury has an estimated occurrence of 300 per 100,000 adults in western countries and is associated with pain, disability and cost. The symptoms of whiplash injury vary widely and can range from mild to severe but in most patients no specific pathology is identified.

In this study, 10 patients were found to have severe upper back pain after a motor vehicle collision (MVC) and a TDH at the level of pain. The study demonstrates that pain caused by TDHs may be relieved by surgical decompression.

All 10 patients underwent thoracoscopic microdisectomy. At one year after the operation results were excellent in seven, good in two and poor in one. One year after the operation, four patients returned to full time work, from being unable to work; two patients increased their hours at work; one did not return to work due to another medical issue but reported an excellent surgical outcome; the final patient had a poor outcome and the reason for her persisting pain remains obscure.

Many people that have MVCs have persistent pain that is difficult to diagnose and regarded as nonspecific. This study has found that some of MVC victims experience a TDH. The TDH may have been present before the accident without causing symptoms but accident triggered symptoms.

Facet Joints Related Pain and Radiofrequency Denervation

Low back pain affects 60 per cent to 80 per cent of people worldwide. One of the sources of back pain can be the facet joints of the spine. They have been implicated in up to 15 per cent to 45 per cent of back pain cases. Facet joint-related symptoms could be presented with lumbar pain radiating down toward the buttock and posterior thigh.

FJRD (Facet joint radiofrequency denervation) for the treatment of facet joint related pain was first described in 1975 and has been used in as a minimally invasive procedure for pain relief. Radiofrequency denervation for the treating facet joints uses energy in the radiofrequency range to kill off specific nerves that innervate the facet joint, blocking the transmission of pain. The purpose of FJRD is for pain relief and decrease the possibility of recurrence. This study was a systematic review, meaning that it examined past studies done on radiofrequency denervation for facet joint pain. The systematic review assessed the treatment effects of FJRD for patients with facet joint related chronic LBP. Pain, quality of life, cost-effectiveness and complications were some of the outcomes examined. Studies are searched based on certain criteria and then narrowed down to the most applicable. The initial search found 329 studies and through the filtering process nine were considered to be acceptable studies to review.

Findings:
Pain reduction was demonstrated with most studies assessed in this review. Meta-analysis also suggested that there was a benefit in pain control with FJRD up to one year after the intervention.

Results for functional status improvement favored FJRD against placebo. Only one study suggested that better results were obtained for radiofrequency then for a steroid injection but the study did not use a measurement device that had been validated. There was no significant difference for quality of life through the studies examined.

There were no comparisons for cost-effectiveness of FJRD against physical therapy or steroid injection.

Conclusions:
The available evidence reviewed in this study should be read with caution. Most studies complied for this review had low to moderate methodological quality, only a few evaluated functional status, quality of life with validated scales and none controlled for other health factors. Findings indicated that FJRD is more effective then placebo in pain control and functional improvement. Comparing FJRD to steroid injections was inconclusive and it is possible that FJRD is more effective the steroid injections for pain control. Complications and adverse effects were not reported sufficiently to accurately compare. Cost-effectiveness was not examined in any studies, so no evidence is available.

Recognizing and Repairing a Rotator Cuff Tear

Your rotator cuff is comprised of 4 muscles the supraspinatus, infraspinatus, teres minor and subscapularis. The muscles attach to the bones via tendons. They are responsible for motor control and stability of the shoulder and are active in every motion of the shoulder. Rotator cuff tears happen when one or all of the tendons in the shoulder are torn away from their attachment to the head of the long bone of the arm in the shoulder joint. These tears can cause a significant degree of pain and loss of function. Surgical repair is sometimes necessary to reduce pain and regain the function of the shoulder. With advancements in imaging of the body and surgical techniques rotator cuff tears are now better recognized, classified and treated. This allows a more planned and precise surgery and hopefully and more accurate prognosis.

A high quality MRI can be used to predict specific tear patterns that will be encountered in arthroscopy. Studies have been done that now allow surgeons to detect three-dimensional tear patterns using high-resolution MRI, select an appropriate repair method and estimate prognosis at a consultation visit before entering the surgical site. Three-dimensional tear pattern recognition is used to as a standard method of evaluation in patients with posterosuperior rotator cuff tears. However, arthroscopy still allows for better visualization than an MRI.

When a repair is being performed the reestablishment of the normal anatomy is the goal as it is thought to enhance healing and restore normal muscle function. When a rotator cuff tear is present it is classified in multiple planes because of the three-dimensional recognition. The recognition of tears takes into account the anterior-posterior dimension (front to back), how much the tendon is retracted from the normal site of attachment, number of muscle/tendon tears, health of the muscle/tendon. The classifications are: crescent tears, U-or L-shaped, massive, contracted, and immobile. The prognosis of each depends on the above factors and is something that will vary.

Repair techniques will depend on the surgeon and all of the above qualities that a rotator cuff tear can have. Repairs can be full or partial, have one or two rows of sutures and use different anchoring or fixation methods. The goal though of any repair is to obtain the best functional outcome that is possible taking into consideration the quality of the rotator cuff tear.

ACL Tear Treatment Outcomes: To Have Surgery or Not Have Surgery

An ACL tear does not necessarily mean surgery. A recent study found that surgical and nonsurgical treatment for ACL tears have about the same outcomes at a two year follow-up. The study took 143 participants with ACL tears less than three months old and followed them through their treatment over a two year period. They measured initial strength and functional capabilities, then had them participate in a five week rehabilitation program emphasizing strength. Participants were then counseled on recommended treatment–surgical or non-surgical. Of this group, 100 went ahead with the surgery and 43 opted to not have surgery. The decision to have surgery hinged on the additional tear of the medial meniscus, the desire to return to a pivoting type sport (such as soccer or basketball), as well as incidences of “giving out” of the knee. The non-surgical group had an additional two to three months of rehabilitation. Following surgery, the surgical group had six to 12 months of rehabilitation consisting of strengthening, plyometrics, and neuromuscular training.

Overall, there were no significant differences between the two groups at the two-year follow up, with the majority of both groups reporting significant improvements in their self-reported knee function and having comparable strength. Of the entire participant population one-fifth did have knee re-injury and one-third had muscle strength deficits, neither of which were correlated with either treatment option. These results must be interpreted with caution however, because the surgical group was significantly younger and more likely to be participating in pivoting type sports than the non-surgical group.

Nonsurgical Options for Disc Pain: Effectiveness of Available Treatment Options

Low back pain costs the U.S. about $100 billion dollars per year. While there are numerous causes of back pain, “discogenic,” or pain caused by a disc, makes up about 39 per cent of all low back pain cases. Diagnosis of the disc as the cause of pain is challenging as the gold standard diagnostic, “provocative discography,” is known to frequently misdiagnose disc pain. Additionally, discogenic back pain is difficult to treat due to psychological and emotional factors affecting the perception of the pain and often surgery does not alleviate symptoms.

If surgery is not the most effective treatment for discogenic pain, then what is? Researchers recently had this question and combed the research to find evidence to back up available treatment options. They found 11 quality studies investigating traction therapy, ablative techniques (either via methylene blue injections to deaden nerve endings or by heating them to destroy them) and injections.

Lidocaine injections were found to be just as effective as steroid injections in six of the studies. There was also no difference in reported pain with traction therapy versus placebo traction. Methylene blue injections proved effective in one study for two years after the procedure. (This was the only quality study that the authors could find on the topic, however, so more research is needed to see if the same results are obtained.) Nerve ablative therapies, with either radio frequencies or electricity, was found to not be effective for the general population because of the coinciding disability that comes with it. There also still remains a debate over which portion of the nerves to destroy for greatest benefit.

Overall, the two take-home points from the evidence review are that methylene blue injections are showing promise but there is more research needed and that there are no notable differences between steroid and lidocaine injections with pain relief. Discogenic pain remains allusive both diagnostically and with treatment, but hopefully with further research future treatments can be more specific and effective.

Diagnosis and Treatment of Scapular Winging

Scapular dyskinesia is a term used to describe poor movement patterns of the shoulder blade. The shoulder blade, or scapula, moves in multiple planes and must be coordinated with the glenohumeral joint in order to allow full range of motion of the shoulder. When the length, strength or timing for firing the scapular stabilizing musculature is not optimal, scapular dyskinesia occurs. One type of scapular dyskinesia is winging of the scapulae.

Scapular winging can result from either weakness or stiffness of multiple muscle groups, including serratus anterior, trapezius, rhomboid major and minor, and/or levator scapulae. Of these muscles, serratus anterior is the most common muscle contributing to winging. It is a flat muscle that originates on the upper eight or nine ribs and inserts on the medial border of the scapula. Its primary action is to stabilize the scapula against the rib cage, then laterally rotate the inferior angle of the scapula during overhead activity. The trapezius muscle may also be involved with scapular winging. This muscle helps retract, elevate and rotate the scapula and is most often injured with surgeries in the cervical area. A third muscle group that may be involved is the rhomboid major and minor, which together retract, elevate and medially retract the inferior angle of the scapula. Injury to these muscles can be a result of entrapment of the C5 nerve under a hypertrophied scalene muscle.

As previously mentioned, the cause of scapular dyskinesia is a muscle imbalance of the scapular stabilizers that can either be neurogenic in nature or inherently muscular. With scapular winging in particular, traction or stretch injuries to the long thoracic nerve can be a primary cause. The long thoracic nerve passes between the anterior and middle scalenes then travels along the chest wall to the serratus anterior. Positions in overhead sports can easily stretch the long thoracic nerve resulting in repetitive or traumatic stretch injuries to the nerve and resulting in neuropraxia that inhibits the serratus anterior. Neuropraxia can occur with increases in nerve length of only ten per cent. Aside from long thoracic nerve injuries, spinal accessory nerve injury can also lead to scapular winging as it inhibits trapezius muscle activity.

Iatrogenic injuries to the long thoracic nerve or spinal accessory nerves can also occur. These may include invasive procedures such as first rib resections, lymph node biopsy, mastectomy, surgical treatment for pneumothorax and infraclavicular plexus anathesia. Atraumatic causes of scapular winging may include Arnold Chiari malformation, Guillian Barre syndrome, lupus, and Lyme disease, all of which can cause shoulder girdle weakness.

The clinical presentation of an individual with scapular winging typically includes report of posterior shoulder pain that may radiate down the arm or up the neck. The pain can either be associated with an event or insidious in nature. The individual may experience loss of range of motion into forward flexion or abduction, weakness and a sensation or clicking or catching of the shoulder joint with movement. A skilled clinician will look at scapular position at rest and identify any scapular dyskinesia present with active range of motion of the shoulder or weight bearing on hands in a push up type position. A patient with serratus anterior palsy with exhibit winging at rest and may have pain at rest in periscapular muscles that are attempting to compensate for the weak serratus. Winging is typically accentuated in a wall push up position. If trapezius palsy is involved, wasting or atrophy of the muscle will be visible at the neckline and shoulder drooping will be present. Weakness will be present in overhead positions and winging will become apparent with resisted abduction or external rotation. Winging associated with rhomboid dysfunction is the most difficult to identify. Patients may report medial scapular pain and demonstrate mild winging at rest that increases as they lower their arms from forward flexion.

With many possible causes and clinical presentations, the incidence and prevalence of scapular winging is unknown as it is often misdiagnosed. Common misdiagnoses include rotator cuff tendinopathy, shoulder instability, cervical radiculopathy, acromioclavicular joint disorders and nerve disorders. EMG testing is the only definitive diagnosis for serratus anterior, trapezius, rhomboid and levator scapulae dysfunction that may contribute to scapular winging, however the extent of nerve damage or recovery potential cannot be identified unless serial EMG tests are performed. Furthermore, it is important to understand that patients presenting with symptomatic winging may not show EMG dysfunction, thus clinical findings are equally as important. Identifying scapular dyskinesias and the muscle length and strength relationships involved is key to proper diagnosis of scapular syndromes. More importantly, early identification of scapular winging as a component of shoulder dysfunction is important for maximizing outcomes and minimizing continued pain or secondary injury to the shoulder.

Nonoperative treatment is the most common for scapular winging, whether the cause be neurogenic, muscular, or both. Physical therapy should focus on range of motion and periscapular strengthening to correct scapular winging associated with serratus anterior, trapezius, rhomboid and/or levator scapulae imbalance . Palsies are also initially treated conservatively with the same physical therapy focus. Traumatic serratus anterior palsies typically resolve in six to nine months, nontraumatic palsies may take up to twenty four months. Chronic palsies that do not resolve with conservative care can be treated with surgical techniques including muscle transfer from the sternal head of the pectoralis major to the inferior scapular pole, facial grafts, slings, and scapular fusion to the rib cage. Trapezius palsy, though initially treated similarly to serratus palsy with conservative physical therapy treatment, does not have the same success rate with recovery. Maximum function is typically gained after just one year of conservative physical therapy, after which surgical techniques are considered. The Eden Lange dynamic muscle transfer procedure involves using rhomboid major and minor and levator scapulae to mimic the trapezius muscle function. Success rates are relatively high for improving function and decreasing pain, ranging from 71 to 92 per cent. Nerve transfer procedures can also be performed for iatrogenic or traumatic spinal accessory nerve injury.

Nonoperative Treatment Options for Achilles Tendon Ruptures

The Achilles tendon is the thick tendon that connects your calf muscles to your heel. Injury to this structure can range from a simple, but painful, tendinopathy to full rupture where the calf muscle can no longer act to plantarflex the ankle. Rate of Achilles tendon rupture is on the rise and can be quite debilitating, preventing participation in sports and limiting walking ability. Despite the rising prevalence, treatment for Achilles tendon rupture is not consistent. Most research shows that surgical repair results in significantly lower rerupture rates at three and a half percent compared to non-surgical repair, which has a rerupture rate around twelve and a half percent. More recently, however, research has indicated that a functional non-operative protocol results in rerupture rates similar to those who have undergone surgical repair, with one study reporting seven percent and another reporting eight percent rerupture rate.

Functional non-operative management is a relatively new bracing concept that involves early weight-bearing and range of motion. These two rehabilitation factors have shown to prevent detrimental alterations in muscle characteristics and increase maturation of collagen fibers during the tendon healing process. There is some difficulty with beginning early range of motion, in that the brace or orthosis must be removable which is more costly and requires patient compliance. Simply adding weight bearing to the early rehabilitation protocol, however is much easier, and involves changing casts to one that has a weight bearing device, such as a Bohler iron, added.

A recent study looking at long-term outcomes and rerupture rates of the Achilles tendon using a weight-bearing cast fit with a Bohler iron found that only one in 37 patients suffered a rerupture two years after initial injury. Some of the potential side-benefits of early weight bearing may include earlier return to work, higher self-reported functional testing scores, faster gains in ankle plantar flexion strength, and less pain or weakness after cast removal. These side-benefits have not been significant effects reported in the literature, but that is likely due to the lack of research looking at this relatively new nonsurgical approach. At this time the protocols for early weight bearing and early range of motion for non-surgical Achilles tendon repair and very inconsistent and are not research supported. As previously mentioned, basic science supports the concepts of early weight bearing and early range of motion for the beneficial effects it has on the muscle composition and tendon healing.

It is clear that more research is warranted to help surgeons and patients justify their choice of surgical vs. nonsurgical repair and decide to participate in rehabilitation that incorporates early weight bearing and early range of motion. At this time, research does show that non-surgical repair with early weight bearing is a viable option that does not seem to increase risk of rerupture rate or other complications.

An Option for Sternoclavicular Joint Reconstruction

Pain and dysfunction of the sternoclavicular (SC) joint, which is where the collar bone attaches to the sternum, is rare but can be quite problematic. This joint is important for normal arm movements and when it becomes unstable it is usually in the anterior direction. Excess movement here is usually the result of a traumatic event but can also be due to degenerative changes, or general laxity. There are several surgical techniques in use if conservative treatment is not effective, and this study looks at the results of one of these techniques. The specific technique researched in this study uses the tendon of the sternocleidomastoid (SCM) muscle to anchor the collar bone to the sternum.

This technique takes a part of the tendon from a large neck muscle, the SCM, loops it through a tunnel created in the end of the collar bone and then anchors it down to the sternum. The purpose is to provide stability to prevent excess movement, pain and dysfunction of the arm.

In this retrospective study there were thirty-two patients who underwent this surgery from 2005-2010. Fourteen patients had pain in the SC joint following a traumatic event, mean age twenty four; seven presented with generalized laxity, mean age of twenty three; and eleven had evidence of osteoarthritis mean age of fifty one. The duration of symptoms prior to surgery for all the patients was over two years, for the patients with degenerative changes it was just over four years and for the patients with hyper laxity they had symptoms for over six years before surgery. All patients were followed for forty-four months following their procedure.

The clinical scores and the pain rating for all three groups improved significantly and to the same extent for each group. There was persistent instability in two patients, both of which declined further intervention. There were no other complications reported.

Numerous surgical techniques for treatment of this problem have been described in the literature, but this is the largest study performed on one single technique to date. Fortunately it appears that this is a highly successful technique, with good clinical and functional outcomes and minimal to no complications. This technique also appears to be equally effective for the multiple causes of SC joint pain. The results of this study suggest that SC joint reconstruction with the SCM tendon graft is a safe and reliable technique for patients with debilitating instability at the SC joint.

A Closer Look at Lumbar Spinal Surgical Errors and the Consequences

Any surgery has the chance for mess-ups. Some of these mistakes can be more detrimental than others. A “sentinel event” is the worst kind of mistake– mistakes that could be avoided that result in death, the risk of death, physical or psychological injury. A recent study took a closer look at the prevalence, type of surgery error, and the overall results of these sentinel events in regards to lumbar spinal surgery.

Researchers tapped into a national database that approximately represents 20 per cent of all patients sent home from U.S. hospitals. It looked at a window from 2002 to 2011 and identified all patients who had a lumbar spine surgery, eliminating patients younger than 18 and only using data of patients who were admitted for degenerative conditions, with a total of 543,146 lumbar spine surgeries identified. They then flagged sentinel events occurring in this population, totaling 414. Of these, 30 were bowel or peritoneal injuries (i.e. puncture), 82 were vascular injuries (i.e. cutting a vein or artery), 108 were nerve injuries, 54 were foreign objects left inside, and 142 were wrong-sided surgeries.

Some specific surgeries were found more likely to have errors associated with them. With a posterior (back) approach the risk for wrong-sided surgery increased and with an anterior (front) approach the risk for peritoneal, vascular or bowel injuries increased. The chance of death in correlation to a sentinel event for this population was found to be 20 times greater than in patients not having a sentinel event and the possibility of a further post surgical complication like a blood clot or heart problems significantly increased.

Authors concluded that patients who had a sentinel event had longer hospital stays and incurred more costs and have overall poorer outcomes following a lumbar spinal surgery. Sentinel events are avoidable and if they do occur procedures should immediately be mitigated to prevent future occurrence.

Total Ankle Replacements Offer a Good Solution to Ankle Arthritis

Ankle arthritis is ranked as debilitating as end-stage kidney disease. It often strikes at an earlier age than other arthritic joints, frequently due to after-effects of trauma, and is extremely painful. Previously arthrodesis, or ankle joint fusion, was the primary treatment to help stop the pain. But ankle fusion was not a great long-term answer because it additionally caused further joint break down and significantly limited function, such as walking, because the ankle bones no longer moved. Unlike ankle joint fusion, ankle joint replacement allows for a more natural walking pattern and thus allows for people to do more following replacement.

Thanks to technological advances, there are now two types of total ankle joint options, a mobile joint and a fixed joint. The mobile implant has a ball-bearing type function that allows for improved ankle motion and increased walking speeds. The hardware shows promising survival rates up to 10 years. The fixed joint replacement allows for lesser movement from side to side than the mobile implants. There is less research surrounding this type of joint replacement but the replacements are associated with improved function and a return at the 2-year mark to “moderate exertional activities.”

Ninety patients with end-stage ankle arthritis participated in a recent study, comparing these two implant types. Authors collected gait analysis, performed a physical exam, x-rays, and functional tests prior to surgery, and at both one and two years following surgery. Participants also filled out several questionnaires self-assessing their function and satisfaction with their surgical outcomes throughout this time period. Forty-nine participants received the mobile bearing implant and forty-one receive the fixed-bearing implant. Results found both of the implants to either maintain or improve function. The fixed-bearing implants had better walking qualities than the mobile implant group, however the mobile implant group reported better improvements in pain. Authors concluded that the implants can be rated as equal when choosing ankle joint replacement type and prove a better option than ankle fusion.

Surgical Outcomes for Spinal Stenosis

The United States has the greatest number of spinal surgeries performed per year even when compared to other countries with the same amount of people with spinal stenosis. Because of the high cost, need for more surgeries and complications associated with fusions, authors of a recent study recommend a decompression surgery to address spinal stenosis. If a fusion is required, they suggest that a noninstrumented fusion is performed.

Spinal stenosis is a narrowing of the space surrounding the spinal cord. It naturally occurs as we age, however it can become bothersome if the narrowing starts to pinch on nerves that exit the spine. Often it can be managed with changing movement patterns, but sometimes surgery is warranted. While there are several options for surgery, the optimal technique is still being determined. A decompression surgery removes bone that is encroaching on these nerves and is named for the piece of bone that is removed. For example, a laminectomy removes a piece of vertebrae adjacent to the spinous process (or pokey part of your back). A fusion is another type of surgery in which hardware or bony tissue is placed to prevent the spine from moving and encroaching on nerves. An instrumented fusion utilizes actual metal hardware, like screws and rods, to stabilize the spine. A non-instrumented fusion relies on bone tissue harvested from elsewhere in the body, which is then transplanted to stabilize the spine. Sometimes surgical treatment includes a combination of the two and both a fusion and decompression surgery are performed.

Authors of this study tapped into a large database and analyzed patients who had treatment for spinal stenosis from 2002 to 2009. The number of people in the database with a spinal stenosis diagnosis was 12,657. Of those, 2,385 people had a decompression surgery and 620 patients had a fusion along with data that followed up longer than five years. They were interested in the surgical complications, (such as infection or failure of the surgery to provide relief) the need for another surgery, and the overall cost effectiveness of the surgery, which they gauged by looking at how many resources, like cost of initial surgery, emergency room visits and medication charges, occurred after the surgery.

The study found that surgical complications were significantly higher for patients who had both a laminectomy and a fusion than for patients who just had a laminectomy immediately after surgery and at a 90-day check up. Both of these patient populations however did not have a difference in the re-surgery rate, even five years after the first surgery. Authors also discovered that by the five-year mark the total costs of treatment were similar between the patients who had decompression surgery and those who had a fusion. The two types of fusions (instrumented and noninstrumented) cost-wise had a slight difference (~$7,000) with noninstrumented fusion being the cheaper of the two at around $100,471 in total care cost at a five year follow up.

Should I Get My Sciatica Relieved Surgically, Or Should I Wait? The Verdict Is In on the Best Treatment for Lumbar Disc Herniation.

The incidence of “slipping a disc” in your low back or herniating an intervertebral lumbar disc, in the medical vernacular, while attempting to move that heavy filing cabinet is not all to uncommon. The ensuing low back pain and often accompanying radiating leg or buttock pain from a bulging disc putting pressure on your spinal nerves is also unfortunately, quite common. Dr. Jon Lurie and a collaborative team of researchers based out of Dartmouth’s Department of Medicine, Orthopedics, Health Policy and Clinical Practice set forth to assess the data of eight years of outcome research from operative versus non-operative treatment for this debilitating back issue.

Decompression surgery to relieve disc-related spine pain is a well-researched and a highly-accepted indication for spine surgery. While in the throws of an episode of raging low back pain, the quick fix of going under the knife seems like a logical decision, but spine surgery comes with plenty of costs and risks. The questions Dr. Lurie’s team set to answer was: why does the rate of surgery vary so greatly geographically in the U.S, if the surgical option is more effective and faster to provide relief? They also aimed to add to the body of knowledge of high-quality, multiple-testing sites, with randomized controlled trials of prospective surgical (or conservatively managed) effects on patients over the long term.

This study was considered a ‘concurrent prospective randomized and observational cohort study’, as each of the 1,991 eligible participants chose either a route into randomized study (surgery vs. nonsurgery) at one of 13 spine clinics participating in this Spine Patient Outcomes Research Trial (SPORT) or the observational group. The observational group got to choose their not-so-random, treatment route of surgery vs. nonsurgery. There was plenty of lenience in the eight-year study for either group to opt in or crossover to the other group as their back issue and provider deemed necessary. The nonoperative group was tracked over the course of the study and received the “usual care” recommendations. These treatments were customized to the individual and included at least: physical therapy, back pain education and counseling, and medication management.

All of the enrolled participants received thorough screenings and imaging tests for eligibility (such as >6 weeks of radiating low back pain with a confirmatory MRI), outcome measures and assessments on a regular basis (six weeks, three months, and six months, and annually thereafter). Most surgical participants had the standard bulge trimming or ‘open discectomy’ and exam of their pinched nerve root. The study gets highly complicated statistically, as the analyses were multifactorial and convoluted to best capture the longitudinal comparisons of the randomized and observational groups. Lurie et al. provided plentiful and excellent flow diagrams cited in the original paper for those that want to peruse the detailed statistical intricacies behind such analyses as “intent-to-treat” versus “as-treated” groupings.

The results reiterated the hypothesis that usually, effective and selective surgery relieves radiating low back pain. Over the course of this 8-year study, more measurable improvements were “clinically significant” in all of the main outcome measures (ie. bodily pain, physical function, perceived disability) for the surgical group than those who remained nonoperative. However, both groups experienced heavy amounts of statistically challenging “crossover”, as humans tend to change their mind on the question of: Should I Get My Sciatica Relieved Surgically, Or Should I Wait? The common exception for both groups was neither returned to prior work status. Or once you ‘blow a disc’ hoisting that filing cabinet up the stairwell, you’re less likely to return to moving heavy office equipment regardless of choosing surgery or conservative care for your back. The study goes on to throw the conclusive bone to those deliberating this costly surgery, that “even among patients with strong surgical indications, many (34 per cent) remained in the nonoperative group out to eight years”. Take comfort in conservative rehabilitative care and do your core stabilization exercises and spine stretches if surgery doesn’t sound like your calling, as improvements in “sciatica bothersomeness” happened in both groups.

Uninjuried Knee Joint Laxity May Be An Indicator For Success Of ACL Repair

It is known that knee joint laxity is a risk factor that predisposes a knee to an anterior cruciate ligament (ACL) tear and a late failure of ACL reconstruction. Knee hyperextension and a large amount of tibial outward rotation are risk factors for poor outcome after ACL reconstruction. Reseachers have noted that anteriorlaxity (hyperextension) of the uninjuried knee may be able to give an indication of how successful an ACL reconstruciton would be on that persons’ injured knee. This study went back through medical records of 163 patients who had undergone ACL repair from January 2002 to August 2009 and split the patients into groups based on how much laxity was in the non-operated knee. The purpose was to evaluate the association between postoperative outcomes of ACL reconstruction and the anterior laxity (how much the tibia slides forward in the knee joint) of the uninjuried knee. There were three groups as follows: Group 1 had 7.5mm. Each pateint had bone-patellar tendon-bone graft. Functional outcomes were assessed with a Lysholm score (an assessment used for ACL reconstruction that asks how the knee functions with daily tasks) and the International Knee Documentation Committee (IKDC) score (assess ligament reconstruction function).

The three groups did not differ significantly in age (avg. 28.6 years), male to female ratio, injured side, dominant limb involvement, time between injury and operation, the Lysholm score, or IKDC score. The difference between injured in laxity in the groups was not significant in a clinical regard but, for comparison of laxity the preoperative side had 4.1 +/-0.7mm in Group 1, 6.3mm +/- 0,7mm in Group 2, and 8.6mm +/- 0.8mm in Group 3.

The postoperative stability of the knee did differ substantially between groups. Group 1 had 2.1mm +/- 1.3mm, Group 2 had 2.2mm+/- 1.3mm and Group 3 had 2.9mm+/- 1.4mm of anterior laxity. The study focused on the anterior laxity of the uninjuried knee, to examine the innate characteristic that could be related to anterior laxity of a knee that has undergone a surgical ACL reconstruction to stop excessive anterior laxity. The primary finding of the study was that patients who had >7.5mm of anterior laxity on the unijured knee and greater postoperative anterior laxity and worse functional outcomes after ACL reconstruction then those patients who had <7.5mm of laxity. However, caution should be used interpreting the results. While there were differences in the functional outcome scores they were not so great as to be considered of minimal clinical important difference (MCID). The MCID are patient derived scores that reflect changes in a clinical intervention that are meaningful for the patient. So while the scores were worse for Group 3 that Group 1 it may not carry much impact on the function. Another caution to the study is that a persons knee laxity can differ from side to side; the anterior laxity of the injured knee was not able to be assessed PRIOR to the ACL tear, so the injured knee may have had more anterior laxity to start with.

With all that, in conclusion, there does appear to be an association between anterior laxity of the uninjured knee and stability of other knee following ACL reconstruction, how much impact it has is difficult to say. It should be noted that anterior laxity of the unijured knee may be an indicator of success following ACL repair.