Athletes who experience an ACL injury are 30 to 40 times more likely to sustain a second ACL injury

Researchers at The Ohio State University Wexner Medical Center found that regaining full function after an anterior cruciate ligament (ACL) injury is more than just physical -- it requires retraining the brain.

A new study, published in the Journal of Orthopaedic & Sports Physical Therapy, shows parts of the brain associated with leg movement lagged during recovery from an ACL injury. Through comparing brain scans, researchers could see the differences in brain activity in healthy adults, versus those recovering from ACL injuries, when extending and flexing the knee.

"The brain fundamentally changed in how it processes information from an injured knee," said Dustin Grooms, a researcher who conducted the study at Ohio State and is currently employed at Ohio University. "We think those changes play a big role in why people who recover from ACL injuries don't trust their knees entirely and tend to move them differently."

The brain scans showed that instead of relying on movement or spatial awareness, people who had suffered an ACL injury relied more on their visual systems in the brain when moving their knee and didn't move it as naturally or instinctively as those who had not been injured.

"It's like walking in the dark, you don't walk as fast, you don't move as confidently," said Jimmy Onate, a health and rehabilitative sciences researcher at Ohio State Wexner Medical Center. "These individuals may, in a smaller sense, be doing the same thing -- not moving as confidently and constantly using visual feedback from the world around them when they really don't need to."

Consistently depending on the brain's visual systems for movement can cause complications when participating in complex sports. To help patients overcome that, therapists are using strobe glasses to include motor learning and visual-motor compensations in rehabilitation.

"The idea is to use these glasses to visually distract these patients, so their brains will rewire back to their original state," said Grooms. "That will allow them to once again move their knee based on natural instinct instead of relying on visual cues."

Individuals who experience an ACL injury and attempt to return to activity are 30 to 40 times more likely to sustain a second ACL injury relative to those in the same sport that have not experienced an ACL injury.

Women report more pain than men after knee replacement surgery

Researchers find gender, age of patient, type of anesthesia and surgical technique play a role in postoperative pain

Middle-aged women with rheumatoid arthritis or arthritis resulting from an injury are among the patients most likely to experience serious pain following a knee replacement, researchers from Hospital for Special Surgery (HSS) in New York have found.

One of the biggest concerns patients have is the amount of pain they will have after knee replacement surgery. Although it is a very successful operation overall to relieve arthritis pain and restore function, persistent postoperative pain can be a problem for some patients. Researchers at HSS set out to determine which groups were at highest risk for increased postoperative pain based on demographic and surgical variables.

"There is no question that pain after total knee replacement is greater than that after total hip replacement," says senior study author Thomas P. Sculco, M.D., the hospital's surgeon-in-chief. "Many factors play a role, and our studies found that younger female patients, particularly those with post-traumatic or rheumatoid arthritis, had the highest pain scores."

In two companion studies to be presented at the annual meeting of the American Academy of Orthopaedic Surgeons in New Orleans on March 11, Dr. Sculco and colleagues also found that surgical factors like having general anesthesia or a longer tourniquet time during knee replacement also can contribute to pain following surgery.

For the studies, the researchers reviewed hospital records for 273 patients who underwent total knee replacement from October 2007 to March 2010. For the first study, investigators looked at demographic data such as gender, ethnicity, age, height, weight, type of knee arthritis and co-existing medical conditions. They also looked at the knee's preoperative range of motion, how well the patients could walk and the amount of pain they had before surgery.

The strongest predictors for severe postoperative pain during rest included being female; being between the ages of 45 and 65; having post-traumatic arthritis spurred by an injury, rheumatoid arthritis, or osteoarthritis; being obese; and having a higher level of pain at the time of hospital admission. Patients with avascular necrosis, a disease that causes cell death of bone components due to a decreased blood supply, had significantly lower postoperative pain.

During periods of activity, obesity, a higher pain level during hospital admission and being between the ages of 45 and 65 were the strongest predictors of postoperative pain. Patients who were Asian or Caucasian, and those with either underlying osteoarthritis or avascular necrosis, or both, had lower postoperative pain during periods of activity.

"Before patients come in to the hospital, surgeons should have a thorough discussion with them regarding postoperative pain, particularly in the groups that we found tended to have more pain," Dr. Sculco says. "More aggressive pain management techniques may be necessary for these patients."

For the second study, the researchers used the same medical records to gather information about surgical variables including the length of the incision, type of anesthesia, tourniquet time and pressure, how long the procedure took, estimated blood loss, and radiographic assessment including the amount of knee deformity and implant positioning and alignment.

Risk factors for severe postoperative pain at rest included having general anesthesia as opposed to an epidural or spinal block, longer tourniquet time , more blood loss, and having a large kneecap. Predictors for postoperative pain during activity included having a large kneecap, and techniques such as overstuffing of the patellofemoral joint (where the kneecap meets the thigh bone).

Surgical technique can play a role in reducing pain, Dr. Sculco says. "The surgeon must be aware not to use an implant that is too large for the knee, or a kneecap component that is excessive in size. In addition, the location of the joint line must be accurately positioned after the knee replacement, for if it is too high it may lead to increased pain." Patients with epidural anesthesia also tended to have less pain than those who had general anesthesia, he says.

"Technical accuracy is important, particularly the alignment, patella sizing and joint line level," Dr. Sculco says. "Patients with more complex preoperative deformities often required increased operating time and surgical dissection, which in turn led to increased pain, especially in the younger female patients."

Glucosamine fails to prevent deterioration of knee cartilage, decrease pain

A short-term study found that oral glucosamine supplementation is not associated with a lessening of knee cartilage deterioration among individuals with chronic knee pain. Findings published in Arthritis & Rheumatology, a journal of the American College of Rheumatology (ACR) journal, indicate that glucosamine does not decrease pain or improve knee bone marrow lesions—more commonly known as bone bruises and thought to be a source of pain in those with osteoarthritis (OA).

According to the ACR 27 million Americans over 25 years of age are diagnosed with OA—the most common form or arthritis and primary cause of disability in the elderly. Patients may seek alternative therapies to treat joint pain and arthritis, with prior research showing glucosamine as the second most commonly-used natural product. In fact, a 2007 Gallup poll reports that 10% of individuals in the U.S. over the age of 18 use glucosamine, with more than $2 billion in global sales of the supplement.

For this double-blind, placebo-controlled trial, Dr. C. Kent Kwoh from the University of Arizona in Tucson and colleagues, enrolled 201 participants with mild to moderate pain in one or both knees. Participants were randomized and treated daily with 1500 mg of a glucosamine hydrochloride in a 16-ounce bottle of diet lemonade or placebo for 24 weeks. Magnetic resonance imaging (MRI) was used to assess cartilage damage.

Trial results show no decrease in cartilage damage in participants in the glucosamine group compared to the placebo group. Researchers report no change in bone marrow lesions in 70% of knees, 18% of knees worsened and 10% improved. The control group had greater improvement in bone marrow lesions compared to treated participants, with neither group displaying a worsening of bone marrow lesions. Glucosamine was not found to decrease urinary excretion of C-telopeptides of type II collagen (CTX-II)—a predictor of cartilage destruction.

The joints on glucosamine (JOG) study is the first to investigate whether the supplement prevents the worsening of cartilage damage or bone marrow lesions. Dr. Kwoh concludes, "Our study found no evidence that drinking a glucosamine supplement reduced knee cartilage damage, relieved pain, or improved function in individuals with chronic knee pain."

Lower index to ring finger ration associated with higher risk of osteoarthritis in knee

A new study published online today in the journal Rheumatology has found that the lower the ratio between a person's index finger (2D) and their ring finger (4D), the higher their risk of developing severe osteoarthritis in their knees, requiring a total knee replacement.

Osteoarthritis (OA) is a major public health problem linked with significant disability in knees and hips. Hormonal factors are thought to play a role, which is thought to account for the well documented difference in prevalence of OA between men and women. Anthropological studies have suggested that there are consistent sex differences in the ratio of the lengths of the index and ring fingers (expressed as 2D:4D), with men showing a lower average 2D:4D than women. The aim of this new study was to determine whether 2D:4D was associated with the risk of severe knee or hip OA requiring total joint replacement in a large cohort study.

Dr Yuanyuan Wang and colleagues assessed the hands of 14,511 middle-aged and older participants in the Melbourne Collaborative Cohort Study from hand photocopies and noted the 2D:4D. The incidence of total knee replacement and total hip replacement between 2001 and 2011 was determined by linking the cohort records to the Australian Orthopaedic Association National Joint Replacement Registry.

Over an average 10.5 year follow up, 580 participants had total knee replacements and 499 had total hip replacements for OA. Lower 2D:4D was associated with a higher incidence of total knee replacement, while there was no significant evidence of a link between 2D:4D and total hip replacement. This was the case when the ratio was examined on either the right or left hand, or the average, although the risk was stronger with the right hand.

There were 830 participants whose fingers had features that might have affected the validity of the measurements, and so they were excluded in the additional sensitivity analysis. Among the remaining 13,681 participants, there were 524 total knee replacements and 454 total hip replacements. Again, a lower 2D:4D was associated with a higher incidence of total knee replacement. There was again no significant evidence of a link between 2D:4D and total hip replacement.

Dr Wang says, "Although there is some evidence from previous studies that sporting ability and achievement in sports and athletics are negatively related to 2D:4D, this might not reflect levels of regular physical activity in the general population. In our study, the measure of physical activity did not directly assess sporting activity, nor did the measure report past physical activity that may also be important in this regard."

"Although our study's results may in part be explained by joint injuries associated with high-level physical activity in those with a lower 2D:4D and the greater susceptibility of knee OA in response to injury than hip OA, they may also reflect hormonal influences on the growth of bone, cartilage, and soft tissue, which warrants further investigation."

Hyaluronic acid injection safety, efficacy profile in reducing knee OA pain

Study upholds hyaluronic acid injection safety, efficacy profile in reducing knee OA pain New meta-analysis findings challenge conclusions of recent reviews, confirms evidence that FDA-approved hyaluronic acid injections can help improve function and pain in mild to moderate knee osteoarthritis Raleigh-Durham, NC. -- A new meta-analysis of 29 randomized studies involving more than 4,500 patients with knee osteoarthritis (OA) found that intra-articular hyaluronic acid (HA) injections provided significant improvement in pain and function compared to saline injections. The study, "US-Approved Intra-Articular Hyaluronic Acid Injections are Safe and Effective in Patients with Knee Osteoarthritis: Systematic Review and Meta-Analysis of Randomized, Saline-Controlled Trials," was published online this month in Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders and included results from randomized peer-reviewed studies of six HA injection brands, with identical treatment follow up between the treatment and control groups. The results are in contrast to the Rutjes et al (2012) paper that included data from many HA products which are not FDA approved and not available in the U.S. "The findings of the meta-analysis are important but not unexpected. The safety data in the meta-analysis comes from studies that only used FDA-approved HAs. The data set is consistent with what I and many other physicians have clinically observed for many years – HAs have been found to be safe, can help relieve knee pain from osteoarthritis, and are appropriate treatment for people with mild to moderate forms of the disease," said Mark A. Snyder, MD, an orthopedic surgeon from the TriHealth Orthopedic and Spine Institute in Cincinnati, Ohio. While neither HA or saline injections resulted in serious adverse events, researchers found very large treatment effects between four and 26 weeks for knee pain and function compared to pre-injection values, with standardized mean difference (SMD) values ranging from 1.07 to 1.37 (p<0.001). These changes represent approximately 50 percent improvement in pain and function from baseline with viscosupplementation. Additionally, improvements in knee pain and function with viscosupplementation were statistically superior compared to saline injections (p<0.001) for both. These findings differ with the analysis conducted this year by a U.S.-based orthopaedic physician society which also included products that were not FDA approved. "Studies such as this are critical in helping physicians and patients make informed decisions," said Dr. Snyder. "Currently, there are limited treatment options available to healthy people with mild to moderate OA. Access to HA treatments is a great option for those who are seeking help in staying active. " The review and meta-analysis were conducted by Larry Miller, PhD (Miller Scientific Consulting) and Jon Block, PhD (The Jon Block Group). The authors acknowledge that the study's findings have limitations. Their analysis did not include many subjects with end-stage knee OA or specify efficacy among the different types of HAs. The authors also noted that efficacy outcomes were inconsistent across studies and that there was evidence of publication bias in OA knee pain outcomes. There were no statistically significant differences between HA and saline controls for any safety outcome. Osteoarthritis is a progressive disease that affects 27 million Americans. The most common joint to be affected by OA is the knee. Advancing age, previous joint trauma and misalignment, and genetic predisposition are all risk factors for having the disease, while obesity contributes to its progression. There is no cure, and treatment options are focused on the management of pain and maintaining function. Commonly prescribed non-surgical treatments for patients with symptomatic knee OA include weight loss, exercise, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and HAs. Chronic use of NSAIDs and corticosteroids carries safety risks, especially for elderly patients and any patient with conditions such as heart disease or diabetes. Total knee replacement surgery is also considered an option when other treatment pathways are not successful. ### About the HAVC The meta-analysis was supported by the Hyaluronic Acid Viscosupplementation Coalition (HAVC). The HAVC is a collaborative of hyaluronic acid injection marketers (Bioventus LLC, Durham, N.C.; DePuy Synthes Mitek Sports Medicine, Raynham, Mass.; Ferring Pharmaceuticals Inc., Parsippany, N.J.; Fidia Pharma USA, Inc., Parsippany, N.J.; Zimmer, Inc., Warsaw, Ind.). The group is committed to working with the scientific community, consumer groups and payers to provide accurate information on intra-articular HA to help physicians and their patients make better health care decisions.

Bone Medication May Save Knees

According to research presented this week at the American College of Rheumatology Annual Meeting in Washington, D.C., a daily dose of strontium ranelate -- a medication prescribed for osteoporosis -- may delaBone Medication May Save Kneesy knee osteoarthritis progression. The study also revealed that taking strontium ranelate may improve knee pain, reduce joint damage and the need for surgery. Knee osteoarthritis is caused by cartilage breakdown in the knee joint. Factors that increase the risk of knee osteoarthritis include obesity, age, prior injury to the knee, extreme stress to the joints, and family history. In 2005, 27 million Americans suffered from osteoarthritis, and one in two people will have symptomatic knee arthritis by age 85. Strontium ranelate is an osteoporosis treatment proven to prevent vertebral and hip fractures. In non-clinical studies, strontium ranelate was shown to stimulate bone mass by slowing the breakdown of bone and stimulating new bone growth, having a positive effect on cartilage. Current OA treatments focus on improving disease symptoms through a combination of medication and non-pharmaceutical therapy, but there is currently no treatment approved to delay the progression of the disease. An international group of researchers recently evaluated if strontium ranelate was effective in reducing joint damage and symptoms caused by knee OA. "Osteoarthritis is the most common disease in the elderly and there are currently major unmet medical needs in OA disease management," says Jean-Yves Reginster, MD, PhD, lead investigator in the study and president and chair, department of public health sciences at the University of Liège in Belgium. "There is currently no medication, approved by regulatory authorities to prevent the structural progression of the disease." The Strontium Ranelate Knee Osteoarthritis Trial (also called SEKOIA) studied 1,683 participants with symptomatic primary knee OA over a three-year period. Participants were divided into three groups and randomly selected to receive strontium ranelate or placebo. Participants given strontium ranelate received one or two gram(s) daily dosage. Joint damage was evaluated yearly using digital X-rays. Also, using a computer assisted method, researchers measured knee joint space width, which correlates with cartilage loss. Researchers also evaluated symptoms such as pain, stiffness and changes in physical function using validated tools such as the WOMAC questionnaire. Of the 1,683 participants, 82 percent (or 1,371) completed the study. Sixty-nine percent of the participants were female with average age 63 years-old, average body mass index (also called BMI) of 30±5 kg/m2, and average joint space width measuring 3.5 millimeters. Based on a test that measured disease progression, 60 percent of the patients had mild (stage two) and 40 percent moderate (stage three) knee OA. Researchers noted that strontium ranelate was associated with a decrease in joint damage. After one year, cartilage loss in both groups assessed by the joint space width was -0.23±0.56 mm with 1g/day;-0.27±0.63 mm with 2g/day and -0.37±0.59 mm with placebo. The differences between treatment and placebo groups were 0.14 mm for 1g/day and 0.10 mm for 2g/day. Researchers also noted that strontium ranelate was effective in reducing pain and improving physical function. Overall, treatment with strontium ranelate was well tolerated, with no significant difference in adverse events between both treatment groups and placebo. Additionally, the safety of strontium ranelate was consistent with what was previously observed in osteoporosis. "Strontium ranelate is a drug approved in 102 countries for the management of post-menopausal osteoporosis, which has been proven to be safe when used for ten years in this particular indication. Results of the present trial show also its ability to reduce the progression of osteoarthritis. This could be a major step in the global management of musculo-skeletal disorders in the elderly subjects," says Dr. Reginster. Patients should talk to their rheumatologists to determine their best course of treatment.

Knee Replacement Lowers Risk for Mortality and Heart Failure

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New research presented at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) highlights the benefits of total knee replacement (TKR) in elderly patients with osteoarthritis, including a lower probability of heart failure and mortality.

Investigators reviewed Medicare records to identify osteoarthritis patients, separating them into two groups – those who underwent TKR to relieve symptoms, and those who did not. Outcomes of interest included average annual Medicare payments for related care, mortality, and new diagnoses of congestive heart failure, diabetes and depression. Differences in costs and risk ratios were adjusted for multiple variables including age, sex, race and region. The results (adjusted for underlying health conditions) were compared at fixed periods of one year, three years, five years and seven years after surgery.

The seven-year cumulative average Medicare payments for all treatments were $63,940 for the non-TKR group, and $83,783 for the TKR group, for an incremental increased seven-year cost of $19,843. The cost does not include prescription drugs, which are reportedly much higher in the non-TKR group.

There were significant positives in the osteoarthritis TKR group: the risk of mortality was half that of the non-TKR group and the congestive heart failure rate also was lower, at three, five and seven years after surgery. There was no difference in diabetes rates among both groups. Depression rates were slightly higher in the TKR group during the first three years after surgery, though there was no difference at five and seven years.

“These patients had improved survivorship and reduced risk for cardiovascular conditions,” said Scott Lovald, PhD, MBA, lead investigator and senior associate at Exponent, Inc. “More specifically, total knee replacement in osteoarthritis patients may reduce patient mortality by half. There are few health care investments that are so cost effective.”