Saturday, February 28, 2009

ACL Reconstruction with Different Techniques

Studies Evaluate the Anatomy and Stability of ACL Reconstruction with Different Techniques

An improved understanding of the anatomy of the anterior cruciate ligament (ACL) in recent years has generated a renewed interest in the evaluation of surgical techniques to repair the knee ligament. In a study to be presented at the 2009 American Orthopaedic Society of Sports Medicine Specialty Day in Las Vegas, researchers analyzed various aspects of two of the most common ACL reconstruction techniques.

“Studies have demonstrated improved movement and stability with restoration of the native anatomy of the knee. However, the surgical technique to achieve the best movement and stability outcomes remains controversial”, says lead author Asheesh Bedi, MD of the Hospital for Special Surgery in New York City.

Bedi worked with senior mentors Dr. David W. Altchek and Dr. Riley J. Williams on studying the anatomy and stability of ACL reconstructions using transtibial versus anteromedial portal drilling techniques on 19 cadaveric knees. Femoral socket position was characterized using high-resolution 3D-fluoroscopy with transtibial and anteromedial portal drilling. “While anteromedial portal drilling allows for excellent access and restoration of the femoral ACL footprint, there is a significant learning curve. There can be an increased risk of shorter femoral tunnels and wall blow-out intraoperatively” says Dr. Riley Williams, the senior author and Associate Attending Surgeon at the Hospital for Special Surgery.

Follow-up studies have evaluated the biomechanical stability of ACL reconstructions completed with transtibial and anteromedial portal techniques. “The anteromedial portal drilling technique allowed for better restoration of native ACL anatomy and knee stability compared to conventional transtibial techniques. We also found that re-reaming of the tibial tunnel is a bigger issue than has been previously recognized with transtibial drilling” says Dr. David Altchek, senior author and Co-Chief of the Sports Medicine Service at the Hospital for Special Surgery.

Bedi and Altchek will be presenting the second part of their study at the 2009 AOSSM Annual Meeting in Keystone, CO. “Continued research into the best techniques for ACL stabilization are ongoing and a vital part of getting athlete’s back into play at a quicker rate. We are working to define these techniques in the lab and have them translated into the operating room” says Altchek.

Tuesday, February 10, 2009

Exercises To Prevent ACL Injuries

The nation’s first – and only – program aimed at taking a wide-scale community prevention approach to decrease non-contact anterior cruciate ligament (ACL) tears among female high school athletes is working, and as a result, is being expanded in Rochester, New York. The program, called PEP (Prevent injury, Enhance Performance), targets the prevention of one of the most serious knee injuries that can sideline athletic careers among females, who are at six to nine times greater risk than males to sustain an ACL tear.

Organized by University Sports Medicine (USM), the PEP program is being rolled out to 119 high schools in Section V, an area that covers all Monroe, Ontario, Seneca, Livingston, Allegany, Steuben and Wayne counties in upstate New York. The expansion, made possible by a $161,000 grant from the Greater Rochester Health Foundation (GRHF), will cover junior varsity and varsity female athletes playing soccer, volleyball and basketball – the three main sports with high incidences of ACL tears. USM officials expect to train about 11,180 athletes on nearly 700 teams during the two-year program.

GRHF provided the seed money for USM to introduce the program to Monroe County high school athletes in January 2007. Since that time, USM athletic trainers have worked with 1,137 female athletes on 71 teams, and preliminary results are promising.

“We would typically expect to see about two ACL tears per 100 participants, or about 58 non-contact ACL tears for the 2,900 athletes we have been working with,” Michael Maloney, M.D., director of USM, said. “To date, we’ve seen only 10 non-contact ACL tears, so this data is very promising. I’m grateful that with additional funding from the Greater Rochester Health Foundation, we are able to significantly expand the reach of our program, and help even more female athletes stay in the game and attain their goals, whatever they may be.”

The program has steadily been gaining national attention. In 2008, the NCAA posted an interactive segment on ACL injuries to its website, which included a feature on USM’s PEP program.

Mystery Surrounds Female ACL Tears
The numbers on female ACL tears are astounding. Over 1.4 million women have been afflicted in the past 10 years alone — twice the rate of the previous decade. It is estimated that more than 30,000 high school and college age females will rupture their ACL every year. In the last 15 years, ankle sprains have decreased by 86 percent while knee ligament injuries have increased by 172 percent.

Much speculation exists on the cause of the higher non-contact ACL injury rate in females, with hormones, biomechanics and environment some of the common culprits named. While researchers have been unable to definitively pinpoint the exact cause for the increased incidence in females, they have been able to develop a series of specific stretching, strengthening, flexibility and balance exercises that have been shown to significantly reduce injury rates.

“PEP works by retraining the nervous and muscle system in female athletes to be more efficient, and as a result, reduce the potential for non-contact ACL tears,” said Andy Duncan, P.T., A.T.C., director of sports rehabilitation at USM.

It consists of a specialized warm-up program that must be completed two to three times a week, and includes exercises and training to increase muscle strength, plyometrics (active strengthening like jumps), agility, balance and flexibility. The program takes about 20-25 minutes to complete.

“We stress quality versus quantity with the girls. These exercises are so precise that they must be done properly or they will not receive any benefit at all,” Duncan said. “In effect, we are re-teaching the muscles how to fire and respond to signals from the nervous system. At the end of six weeks, if the program is done correctly and consistently, these athletes will have a much better chance at preventing an ACL tear.”

Beginning in the summer of 2009 USM athletic trainers will use a “train-the-trainer” approach to educate team coaches/representatives on the benefits and components of the PEP program. The sessions will be interactive, including demonstration and participation. Videos detailing each exercise will be given to each team to help guide the athletes through the program.

Sample PEP Exercises
• Warm-ups: Jog, slides, backpedals
• Strengthening: Lunge walk, ball bridge, calf raise
• Plyometrics: Lateral, front/back and single leg hops, rebound jumps, scissor jumps
• Agility: Shuttle and pivot runs
• Stretching Hamstrings, quads, calves, groin and hip flexors

Tuesday, February 3, 2009

Exercises to strengthen your quadriceps

It may be uncomfortable at first, but doing exercises to strengthen your quadriceps after you’ve had knee replacement surgery due to osteoarthritis is critical to your recovery. In fact, it can boost the function of your new knee to nearly that of a healthy adult your age.

That’s the finding of a University of Delaware study published in the February issue of Arthritis Care & Research.

The authors include Lynn Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at the University of Delaware, Stephanie Petterson, clinical faculty at Columbia University, Ryan Mizner, an assistant professor at Eastern Washington University, Jennifer Stevens, an assistant professor at the University of Colorado at Denver, and Drs. Leo Raisis, Alex Bodenstab, and William Newcomb of First State Orthopaedics in Newark, Delaware.

“It sounds logical that exercises to strengthen your knee should be a component of your post-operative physical therapy after a total knee replacement, but it’s not the convention at all,” says Snyder-Mackler.

“There are all of these old wives’ tales that strength training is a detriment to the patient and that the new knee should be treated delicately,” Snyder-Mackler notes. “Our study demonstrates that intensive strength exercise as outpatient therapy is critical to begin three to four weeks after surgery.”

Nearly 500,000 knee replacements, also known as total knee arthroplasties, are performed every year in the United States to treat severe knee osteoarthritis, the loss of the cushiony cartilage padding the knee. The joint disease leaves its sufferers with persistent pain and limited function, resulting in an overall diminished quality of life.

While knee replacement alleviates the pain of osteoarthritis and improves function, patients exhibit impaired quadriceps strength and function for such activities as walking and climbing stairs, and the levels remain below those of healthy people of the same age.

In a randomized controlled trial at the University of Delaware’s Physical Therapy Clinic conducted between 2000 and 2005, 200 patients who had undergone knee replacements were given six weeks of progressive strength training two or three times a week starting four weeks after surgery. Half of the group also received neuromuscular electrical stimulation (NMES).

Their function was compared to that of 41 patients who received conventional rehabilitation and home physical therapy. Quadriceps strength, knee range of motion, and gait were measured in such tests as timed up and go, stair climbing and a six-minute walk.

The group in the progressive strength-training program showed significant improvement in quadriceps strength and functional performance. They also demonstrated substantially greater quadriceps strength and functional performance after 12 months than the group that underwent conventional rehabilitation.

“This study clearly demonstrates the importance of surgeons encouraging their patients to be compliant with progressive quadriceps strengthening during their rehabilitation to enhance their clinical improvement and function post-total knee replacement,” notes Dr. Leo Raisis, a total joint surgeon and adjunct associate professor at the University of Delaware.

“Why undergo a $25,000 elective surgery and then not do as much as you can to get the most out of it and improve your quality of life?” Snyder-Mackler says. “Older people are incredibly motivated—they hurt after the surgery and they want to be better. They need to do this.”