Saturday, April 30, 2016

Meniscus Repair 2

The role of the meniscus in cushioning the joint and protecting the articular cartilage makes preserving them a key part of knee health. For a meniscus tear unfortunately meniscectomy (removing the torn portion) is the appropriate treatment 90% of the time. This is because in most situations a repair will not be successful. The reasons repair is not attempted is due to the lack of blood supply in 1/3-1/2 of the meniscus that precludes healing of a repair. Additionally, if the configuration of the tear is not appropriate then repair is not possible. In the 10% of situations when repair is possible it is typically highly successful in the short term with > 90% success without reoperation within the first 2 years. Our ability to predict ahead of time whether or not repair will be possible has been evaluated. In a study performed in conjunction with my partners and published in  the American Journal of Sports medicine we found we were able to predict the chance to repair a meniscus 74% of the time. This makes it easier to tell patients what to expect after surgery regarding recovery and rehabilitation. Read the Abstract HERE.

We evaluated the MOON meniscus repair results at 2 years in a study published in the American Journal of Sports Medicine and found that in 82 tears of which we were able to obtain follow up on 77 (94%) there was a success rate of 96% with no further surgery required for the meniscus within the first 2 years following repair in 74 of the 77 repairs. Read the full study HERE. In future blogs I will discuss the longer results we have noted at 5 years or more following meniscus repair.

Friday, April 29, 2016

1 Minute of All-Out Exercise May Have Benefits of 45 Minutes of Moderate Exertion

  A New York Times article reviewing studies that suggest high intensity short length interval training may give the same benefits as longer episodes of lighter exercise. Read the article HERE

Saturday, April 23, 2016

PRP for Osteoarthritis

The search for ways to improve osteoarthritis pain continues. I believe eventually we may figure out the proper use of Platelet Rich Plasma (PRP) injections to decrease pain. HERE  is a study evaluating different kinds of PRP preparations. It appears PRP containing fewer white blood cells works better when injected into joints than injections with higher concentrations of white blood cells.

Wednesday, April 20, 2016

Revision ACL Reconstruction Graft Choice Part 2

Revision ACL reconstruction Graft choice is an important Issue that impacts patient outcome.  In the AOSSM O'Donoghue award winning study published in American Journal of Sports medicine the MARS group analyzed the impact of allograft versus autograft choice on patient reported outcomes, reoperation and return to sports.Read the full study HERE In this study of 1205 patients that underwent revision anterior cruciate ligament reconstruction at 52 sites by 83 different surgeons 58% were male, median age was 26.  48% underwent autograft reconstruction and 49% underwent allograft reconstruction.  3% had a combination.  We obtained followup on 989 with questionnaires (82%) and an additional 10% phone followup for a total of 92% followup At 2 years. The IKDC Sports score improved with the use of autograft with an odds ratio of 1.33. The Knee Osteoarthritis
Outcome Score subscales sports and recreation and quality of life improved with autograft use with an odds ratio of 1.33.  37/1112 (3.3%) patients sustained a graft rerupture. Use of an autograft resulted in a 2.78 times less risk for graft rerupture.  Graft irradiation versus nonirradiated grafts did not affect the allograft failure rate.  More grafts had not undergone a radiation that ultimately failed.  Many people previously had believed that if the graft had not undergone irradiation then the results were equal to autograft. Reoperation risk was not affected by allograft versus autograft use.

Based on these findings many people now recommend if at all possible using an autograft for revision anterior cruciate ligament reconstruction.  This can involve the quadriceps, patellar tendon or hamstring grafts.  Frequently I will use a graft from the opposite knee if no other autograft options remain. 

Tuesday, April 19, 2016

Revision ACL Reconstruction Graft Choice Part 1

Revision ACL reconstruction requires careful thought about the appropriate graft to utilize.  In the revision (redo) situation a previous graft has already been used and failed.  This can force surgeons to potentially use a graft that is not their first choice.  As the basis for the MARS (Multicenter ACL Revision Study) we allowed surgeons to choose their graft that they felt most appropriate in the clinical situation.  Many surgeons believed that graft choice was a fait accompli and that they had no real choice in the matter.  They were forced to many times use a graft not of their choice based on other factors including patient's age, patient’s sport, previous graft utilized, gender etc. In a propensity study the MARS Group performed (Accepted for publication in The Journal of Knee Surgery) we analyzed a variety of factors that impacted revision ACL graft choice. Below you can see the factors analyzed and their impact on what graft the patient eventually received.

As can be seen despite a variety of factors that impact graft choice the most important factor was the particular surgeon that treated you.  Thus, a surgeon that wants to use an allograft (cadaver) for the reconstruction can do that.  Likewise, a surgeon that wants to utilize an autograft has the ability to control that decision most of the time.  The top 5 choices are expanded below and as can be seen in this table ---in fact the particular surgeon involved was 5 times higher impact on graft choice than anything else analyzed including the previous graft the patient had utilized for the primary ACL reconstruction.

Following this study we knew that if we could improve what type of graft gave the best results we could then recommend to surgeons to use that graft and impact patient outcomes.  In Part 2 I will discuss the follow-up study that analyzed outcomes depending on the patient's graft utilized in the MARS study.

Thursday, April 14, 2016

Tuesday, April 12, 2016

Meniscus Repair

The meniscus is critical for protecting and cushioning the joint. When the meniscus is torn and unable to be repaired then a meniscectomy is performed. Meniscectomy means removal of the torn tissue. When this occurs it increases the risk of arthritis. Even when performed arthroscopically the risk of developing arthritis in the future remains high. 50-75% of people that lose a moderate portion of their meniscus will develop symptomatic arthritis over the next 15 years. Since the meniscus helps protect the knee from wear and tear, surgeons try to repair the meniscus whenever possible. However, most meniscus tears are not considered repairable. Approximately only 10% are reapairable. The meniscus has a limited blood supply, and tears in areas of little or no blood flow have a high risk of not healing. The pattern of the tear is also important. It is not always possible to predict whether a meniscus tear is repairable prior to surgery.

If a meniscus tear is considered appropriate for an attempt at repair, a number of techniques can be used. The surgery is primarily arthroscopic (minimally invasive). It can involve small devices that utilize a technique completely inside the knee or small incisions, or cuts, may be necessary to perform the repair. A variety of devices or sutures can be used to perform a repair. If a patient has an ACL reconstruction at the same time as the repair of the meniscus, there is more blood present in the knee joint. Other methods can be used to improve the blood supply to a meniscus repair, for example using a portion of the patient’s own blood with a technique called platelet rich plasma (PRP).

The physical therapy following meniscal repair varies depending on a number of factors. Most patients can put weight on the knee soon after surgery, although a brace may be used. Running is usually delayed until 3-4 months after surgery while a full return to sports and squatting typically occurs after 4-6 months. The results are good following repair. In future blogs we will delve into some of the research we have performed at Washington University regarding meniscus repair, but in general 90% of repairs last a minimum of 2 years and 75-90% will last 5 years without retear.

Monday, April 4, 2016

Rotator Cuff Repair

The rotator cuff consists of four muscles that surround the ball and socket joint in the shoulder. Their

role is to initiate shoulder movement and to stabilize the joint by compressing the ball against the socket when larger muscles such as the deltoid, trapezius, and latissimus are recruited to perform heavy lifting or overhead activities such as those in tennis or baseball. Overuse and acute traumatic injuries can cause a tear in one or more of the tendons that attach the rotator cuff muscles to the bone on the ball of the shoulder. This is a common injury seen in orthopedic sports medicine clinics. The patient that presents with a rotator cuff tear typically will describe pain or inability to use their arm
away from their body. This includes reaching overhead, reaching away from their body and reaching behind the back. Physical examination will often demonstrate weakness in muscle testing of the rotator cuff. X-rays are most often normal. An MRI or an ultrasound test can be used to determine if a rotator cuff tear is present.

Depending on the individual surgery or nonoperative management may be an option. Chronic tears with a gradual onset can frequently be managed by physical therapy as we demonstrated in our MOON Shoulder study where 85% of patients over 50 years old with chronic tears were successfully managed for a minimum of a year without surgery. Future blogs will discuss this study further, but it can be found here. MOON Shoulder Study It appears that surgery is more routinely indicated in a couple of circumstances: 1.) tears in individuals less than 50 years old and 2.) acute tears with no previous history of a full thickness tear. This is somewhat controversial and strict indications for rotator cuff repair are difficult to tease out of the medical literature as Brian Wolf, Warren Dunn and I found when we performed a review on the topic in the American Journal of Sports medicine. Rotator Cuff Repair Indications 

Surgical repair involves typically an arthroscopic approach utilizing small puncture wounds where small minimally invasive instruments are used to reattach the torn rotator cuff tendon. This is done by placing anchors with sutures into the bone and stitching the tendon in place. Physical Therapy begins shortly after surgery and continues 3-4 months until strength and motion have been regained.