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.”

Patients at risk of knee joint complications when new technology is used

Introducing a new knee replacement model increases the likelihood of early revision surgery


Orthopaedic surgeons face a steep learning curve to get used to new prostheses, and the instruments and methods that go with them, before new total knee replacement procedures are as safe and effective as conventional methods. Patients who undergo the first 15 operations using a new device in a hospital are 48 percent more likely to need early revision surgery, than patients undergoing an operation to fit a prosthesis previously used in the hospital. The work by Mikko Peltola from the National Institute for Health and Welfare in Finland, and colleagues, is published online in Springer's journal, Clinical Orthopaedics and Related Research.

Total knee arthroplasty, or replacement, is an established treatment for patients with severe osteoarthritis of the knee. There are numerous brands and models of endoprostheses (a prosthesis used internally) available and new models continue to emerge as a result of a combination of new technology, marketing efforts and the increasing number of patients requiring the surgery.

Hospital staff makes important decisions when choosing the implants and instruments they use, and these decisions carry consequences for patients' health. According to the research team, however, new equipment and techniques are often used in clinical practice, occasionally without evidence of effectiveness and safety.

Peltola and team looked at the risk of early revision surgery following the introduction of a new endoprosthesis model for total knee arthroplasty. They studied data from the Finnish Arthroplasty Register to identify centers that had performed total knee replacement operations for primary osteoarthritis between 1998 and 2004. Of the 23,707 total number of patients who underwent the surgical procedure, 22,551 were followed up for five years.

The researchers found that the introduction of an endoprosthesis model in a hospital put the first patients at greater risk of revision surgery. The effect was substantial for the first 15 patients operated on with the new model, who were at 48 percent greater risk than patients having undergone an operation to implant a conventional endoprosthesis. Overall, the likelihood of needing revision surgery was greatest during the first two years after the surgery. The learning curve smoothed quickly, however, with no increased risk after the first 15 operations with the new model.
The authors conclude: "Patients should be informed if there is a plan to introduce a new model and offered the option to choose a conventional endoprosthesis instead. Although introducing potentially better endoprosthesis models is important, there is a need for managed uptake of new technology."

Reference

Peltola M et al (2011). Introducing a knee endoprosthesis model increases risk of early revision surgery. Clinical Orthopaedics and Related Research.DOI 10.1007/s11999-011-2171-9

Patients who use narcotics prior to knee replacement experience worse results

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Patients who are dependent on opioids (narcotic pain relievers) for pain management before knee replacement surgery have much more difficulty recovering, a study recently published in the Journal of Bone and Joint Surgery (JBJS) has found. These patients tend to have longer hospital stays, more post-surgical pain, a higher rate of complications, and are more likely to need additional procedures, than patients who are not opioid-dependent.

"We expected to find that the opioid-dependent patients have worse outcomes," says orthopaedic surgeon Michael A. Mont, M.D., the principal investigator and Director of the Center for Joint Preservation and Reconstruction at the Rubin Institute for Advanced Orthopaedics at Sinai Hospital of Baltimore. "But the differences between the two groups of patients were even greater than we thought they would be. The chronic narcotics users did significantly worse in every category."

Study Findings:

Patients included in the study were matched according to age, sex, body-mass index, insurance type, as well as a variety of medical factors. When those factors were accounted for, the study still found that chronic opioid users:

• had to remain in the hospital longer after surgery
• were more likely to need referrals for pain management
• were more likely to suffer unexplained pain or stiffness
• had lower function and less motion in the replaced knee

"This doesn't mean that opioid users shouldn't have the surgery," Mont says. "But those patients and their physicians should know that their results may not be as optimal. It might be possible that we can work with these patients to improve their surgical outcomes."

Dr. Mont and his co-authors outline several strategies to help improve patient outcomes; including:

• weaning patients off strong opioid medications prior to surgery
• prescribing alternate, non-opioid pain medications
• considering non-pharmaceutical pain management strategies

The study's authors acknowledge that some patients who become dependent on opioids before surgery may have lower pain thresholds than those who do not. In addition, those patients may be less compliant with rehabilitation plans and other post-surgical treatments. However, the results of this study are important enough to warrant attention to this issue.

"Previous studies have found that patients who use opioids are more dissatisfied after surgery," Mont says. "But these are more powerful findings since patients require additional surgeries. This is a topic our orthopaedic community and other care providers need to address together."

Glucocorticoid Treatment May Prevent Long Term Damage to Joints,

Joint injury can result in irreversible damage of cartilage which, despite treatment and surgery, often eventually leads to osteoarthritis (OA) in later life. New research published in BioMed Central's open access journal Arthritis Research & Therapy demonstrates that short term treatment of damaged cartilage with glucocorticoids can reduce long term degenerative changes and may provide hope for prevention of OA after injury.

A normal joint is covered by a layer of cartilage containing proteoglycans such as aggrecan and lubricating fluid containing glycosaminoglycans (GAG) such as hyaluronic acid. In a double whammy, after injury proteoglycans and other molecules in cartilage begin to break down and the synthesis of these proteoglycans within cartilage is reduced. Additionally proinflammatory cytokines such as TNFα, IL-1β, and IL-6 are released into the synovial fluid after injury and further increase GAG loss from cartilage.

Using a 'worst-case scenario' system in which cartilage was subjected to mechanical injury and bombarded with immune system-stimulating bio-molecules (TNFα and IL-6) the glucocorticoid dexamethasone (DEX) was able to reduce GAG loss and restore proteoglycan synthesis levels to normal.

Prof Alan Grodzinsky from the MIT Center for Biomedical Engineering said, "Glucocorticoid injections are sometimes used to relieve the pain of established osteoarthritis, but there are concerns about long-term use. Our results suggest that short-term glucocorticoid treatment after joint injury may help restore components of cartilage to preinjury levels and consequently may prevent the long term changes which lead to osteoarthritis."

Infected prosthetic knees cause problems

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The number of people that undergo an operation to have a prosthetic knee joint is increasing. One reason is that the population is getting older, another is that people are also getting heavier, which is a factor in the development of osteoarthritis. The number of knee replacement operations has increased by 9 per cent a year in recent years.

"So if 1-2 per cent of the operations lead to bacterial infection, then the need for revision – re-operation – will also increase", says Anna Stefánsdóttir.

This often involves two operations. First, the old prosthesis is removed and temporarily replaced with bone cement, while the patient is treated with antibiotics to eradicate the infection. This takes 6𔃆 weeks and during this time the patient can usually remain at home. Then a further operation follows to insert a new prosthesis.

In some cases it is not possible to put in a new prosthesis. These patients can be treated with an arthrodesis, or removal of the prosthesis (which leaves the leg without a real knee joint, often confining the patient to a wheelchair). In exceptional cases the infection leads to amputation.

Anna Stefánsdóttir has reviewed almost 480 cases of revision knee replacement between 1986 and 2000.

"Over time more patients have received a new knee prosthesis and fewer are treated with an arthrodesis, but still there are many people who do not get rid of the infection. Other studies show that those who have to have a second operation because of an infection are less satisfied than those who have to have their knee joint changed because the prosthesis has come loose or become worn", she says.

Therefore it is important that the healthcare service does its utmost to avoid infection in the wound. This means having good ventilation in the operating theatre, ensuring the doors are tightly closed, and ensuring that preventive antibiotics are given at exactly the right time before the operation.

"It is also important to be observant of wound complications. If an infection is discovered in time, it is possible to open the wound and clean out the bacteria before they have had chance to spread. Newly operated patients should have a 'VIP lane' so that they can go straight to the hospital orthopaedics department and not have to go via primary care", says Anna Stefánsdóttir.

In Ms Stefánsdóttir's view, re-operations due to infection should be centralised to specialist units, because they require such close cooperation between orthopaedists and infectious disease specialists.

Nowadays, there are orthopaedics clinics that only carry out one such operation a year, which makes it more difficult to establish the right routines.

Lubricating the knee cartilage after ACL injury may prevent osteoarthritis

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PROVIDENCE, RI – An injury to the anterior cruciate ligament (ACL) is fairly common, especially among young athletes. While it can often be corrected through surgery, the injury can lead to increased risk of developing degenerative joint diseases, including osteoarthritis (OA). The problem is that fluid in the knee joint, which lubricates the cartilage, is impacted by the trauma of the injury and begins to deteriorate. A new study from Rhode Island Hospital researchers identifies options for restoring that lubrication to potentially prevent development of OA. The study is published in the August 2010 edition of the journal Arthritis & Rheumatism and is now available online ahead of print.

The study was led by Gregory Jay, MD, PhD, an emergency medicine physician and researcher at Rhode Island Hospital. Jay says, "We know that acute ACL injury is a significant risk factor for the development of post-traumatic osteoarthritis. We also know why that occurs, due to the degeneration of the fluids in the joint and cartilage and joint instability, among other things. Our goal for this study was to determine an effective way to counter that process to prevent the development of OA."

The most movable joints in the body, known as synovial joints, contain synovial fluid (SF). This fluid acts as a lubricant to reduce friction between cartilage in the joint during movement. Following a traumatic injury to the ACL, SF concentration of the natural lubricant, lubricin, in the injured joints is significantly lower in those joints than in the healthy, uninjured joint.

The goal was to identify biologic methods to address the loss of lubricin. In their study, they used animal models with torn ACLs to test three types of fluids that could be injected into the joints and could serve as a substitute for the lost SF. The first was human synoviocyte lubricin that was created in a culture and then purified to be injected into the injured knees. The second is recombinant protein, with a change in the genetic make-up of the cell so that it makes a molecule of interest. The reasoning behind using a recombinant protein is that if it is commercialized, that is likely how it will be manufactured. The third was lubricin from human SF that would otherwise be discarded. The human SF is then purified before injection, and because it is more closely aligned with the natural lubricin, it represents a positive control in the study.

Through their study, the researchers report three key findings. Jay, who is also a professor of emergency medicine and engineering at The Warren Alpert Medical School of Brown University says, "First and foremost, we found that you can limit cartilage deterioration. This is evident by using a well-accepted OA biomarker which shows that the breakdown of cartilage collagen type 2 and recovered in the urine has been muted by treating the knee joint with lubricin." The human synoviocyte lubricin was the most effective form in this experiment, however, the recombinant form also had a good degree of success.

Second, the study results indicate that when lubricin is placed back into the traumatized joint, it encourages the joint to make its own lubricin. Jay explains, "We found that you are limiting deterioration of the joint endogenously by the greater secretion of the lubricin molecule. Basically, by placing the lubricin there, it encouraged the joint's normal activity to produce this molecule."

Jay, who is also a physician with University Emergency Medicine Foundation in Providence, stresses that this study is important for another reason. "This is a huge advance over the existing technology of viscosupplementation injections. The concept was good, but the chemistry isn't there to support it." Jay continues, "When viscosupplements were approved as devices in the 90s, it was thought then that hyaluronic acid used in this treatment was tied to joint lubrication because it was viscous. We now know that joint lubrication has little to do with viscosity. We are inventing a new type of joint lubrication strategy: Tribosupplementation, taken from the Greek, meaning to wear or to rub" "

Jay notes, "Viscosupplementation is a $500 million per year device market that just doesn't work particularly well. Past studies by us and others indicate this. We now need a paradigm shift in how we are thinking about preventing and treating arthritic diseases."

Jay and his colleagues believe the study findings represent that paradigm shift. Jay says, "We found that lubricin may prevent the fundamental process that can lead to OA following an ACL injury. It is a promising biologic candidate since it is a replacement for a normally occurring glycoprotein. This is very germane to the health care bill, which supports the creation of new therapeutic biologics." Biologics are important and their development is encouraged because they are very specific and have low toxicity profiles, meaning they are better for patients in terms of better results with fewer complications.

Jay concludes that this and related papers are key to future treatment of joint trauma. "In the peri-injury period following joint trauma, joint surfaces are vulnerable to enhanced wear. This study is pointing us in the right direction, and has shown that this can potentially be mitigated by simply reintroducing the joint's natural lubricant." He continues, "We are confident that further studies will perfect the technology and this will be the way that joints will be treated in the future to prevent OA."

Many knee and hip replacement patients experience weight decrease after surgery

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Total knee and hip arthroplasties can lead to healthier living

A Mount Sinai School of Medicine study has found that patients often exhibit a significant decrease in weight and body mass index (BMI) after undergoing knee or hip replacement surgery (arthroplasty). The study is the first of its type to correct for the annual increase in BMI typically found in North Americans between the ages of 29 to 73 years. The study was recently published in Orthopedics.

A total of 196 Mount Sinai patients who had knee or hip replacement from 2005 – 2007 to treat osteoarthritis were randomly selected for the study. Mean patient age at surgery was 67.56 years, with about 65 percent female and 35 percent male. Of this group, 19.9 percent demonstrated a clinically significant decrease in weight (defined as the loss of five percent or more of body weight) and BMI following knee or hip replacement. In addition, the mean weight of the group dropped from 79.59 kg (175.47 lbs) to 78.13 kg (172.24 lbs) after surgery.

Significant BMI decrease was found to be greater in knee replacement patients (21.5 percent) than hip replacement patients (16.9 percent). Patients who were obese prior to surgery, with BMI greater than 30, were the most likely to experience significant post-surgery weight reductions.

"Total joint arthroplasties are performed with the intent of relieving a patient's pain and disability," said the study's lead author Michael Bronson, MD, Chief of Joint Replacement Surgery at Mount Sinai School of Medicine. "Both total knee patients and total hip patients experienced a statistically significant and clinically significant corrected weight loss following surgery, which indicates a healthier overall lifestyle."

The incidence of overweight and obese adults has been steadily increasing over the past five decades in the U.S. Lifestyle modification, consisting of changes in patterns of dietary intake, exercise, and other behaviors, is considered the cornerstone of overweight and obesity management. Overweight patients often argue that their osteoarthritis limits their mobility and ability to exercise. Thus, patients may feel frustrated that they are unable to lose weight, and are often hopeful that losing weight would be easier postoperatively.

These results suggest that patients have improved weight parameters when compared to North American adults. Dr. Bronson and his joint replacement team at Mount Sinai believe that additional studies of total knee and total hip arthroplasty postoperative patients, which also incorporate nutritional guidance and long-term fitness goals, may show even more encouraging results.

More Than Half of All ACL Reconstructions Could Be Avoided

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Anterior cruciate ligament (ACL) injuries are common injuries to the knee, primarily affecting young people who practise sport and often treated with surgical reconstruction. A research group from Lund University has now shown that 60 per cent of these operations could be avoided, without negatively affecting treatment outcomes.


The research group's study is known as the KANON study and started in 2001. The group is publishing its results in the New England Journal of Medicine.

"In our study, patients with acute ACL injuries were randomly divided into two groups for treatment with rehabilitation plus early ACL reconstruction or rehabilitation alone with the possibility of a later operation if this was deemed necessary. After two years only 40 per cent of the latter group needed to have an ACL reconstruction.

"Despite the fact that many of the patients were active sportsmen and women, we found no difference between the treatment groups in terms of knee function, activity level or well-being two years after the injury. Neither did we find any difference in these respects when we compared those who were treated with rehabilitation alone with those who had an early operation," says Richard Frobell, researcher at Lund University, Skåne University Hospital and Helsingborg Hospital.

A total of 121 patients took part in the study, which was carried out in collaboration with Helsingborg Hospital and Skåne University Hospital in Lund. The patients were aged between 18 and 35 and had an acute ACL injury in a previously healthy knee. Professional athletes and those who did not regularly practise sport were excluded from the study. All patients underwent extensive rehabilitation, led by experienced physiotherapists.

Sixty-two patients were selected at random to also undergo surgical reconstruction of the injured ligament within four to six weeks of the injury, and 59 patients were selected at random to initially undergo treatment with rehabilitation alone. All the operations were carried out in accordance with well established methods and by experienced surgeons. The patients were examined on several occasions over two years and gave their own opinions of the status of the injured knee.

"There are almost 10 000 scientific publications addressing the ACL and 50 per cent of these are about surgical treatment. However, none of these studies have shown that surgical reconstruction produces better results than rehabilitation alone. Despite this, we perform 3 000 cruciate ligament reconstructions a year in Sweden," says Stefan Lohmander, professor and consultant at Lund University and Skåne University Hospital. "In the USA there are 200 000 operations of this type, at a cost of USD 3 billion!"

The research group's results have strengthened their conviction that there is no evidence to support the recommendation of ACL reconstruction as a first method of treatment.

Rehabilitation with experienced physiotherapists produces the same results as operation for more than half of the individuals in this patient group and only four out of ten need to be exposed to the risks involved in an operation.

The patients in the study will continue to be examined in order to find out whether the results are the same in the longer term and to see if there is any difference between treatments in terms of the risk of developing osteoarthritis in the knee.

Knee arthritis? Flexible options can help keep you active

Tailoring treatment programs to individual goals and activities is the key to success

Middle-aged men and women with osteoarthritis of the knee now have more options than ever before for treatments that may allow them to remain active in the sports they love, according to a review published in the July 2010 issue of of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

"The number of patients between the ages of 40 and 60 who are experiencing knee arthritis is growing, and unlike most older patients, this patient population presents a unique set of treatment challenges," noted lead author Brian Feeley, M.D., assistant professor of orthopaedic surgery, University of California, San Francisco. "Understanding available options and tailoring treatments to each patient's needs and desires is the key to successful outcomes."

The review examined both surgical and non-surgical treatments available for younger patients with knee arthritis, to determine the best course of action for patients who want to continue to participate in demanding sports. Unlike elderly patients, where pain reduction and basic mobility are the two primary goals, Dr. Feeley noted younger, more active patients require more flexible treatment programs to allow them to remain as active as they would like.

"There is an increasing trend in the United States of people who want to stay active in sports and recreational activities after the age of 40. These patients are not content with being told to stop what they love doing," added Dr. Feeley. "As a result, orthopaedic surgeons and other physicians need to come up with different treatment strategies including non-operative treatments or even cartilage restoration procedures, to address pain and functionality, and to help keep patients as active as possible."

While some patients may eventually require surgery, Dr. Feeley said in most cases, non-operative management such as bracing, viscosupplementation (injection of hyaluronic acid), activity modification or anti-inflammatory medication might be used initially, to see if the symptoms resolve or if there is enough improvement to make surgery unnecessary.

"In a vast majority of cases, the onset of arthritis is a slow, degenerative process and therefore there is rarely a need to rush to surgery," he added. "Depending on the symptoms and activity level, many patients can be managed well with non-operative treatment strategies, whereas others truly benefit from surgical procedures. For each patient, it is important to tailor treatment to their symptoms and activity level, and to look for a healthcare provider who is willing to work with them over time to keep their knee as healthy as possible."

Although alternative treatments like acupuncture, glucosamine and chondroitin may be incorporated into an overall treatment plan, Dr. Feeley noted that currently there is no strong clinical evidence supporting the efficacy of these alternative-types of treatment.

For patients suffering with arthritis of the knee, Dr. Feeley recommends the following approach to help patients remain active:

• Take control of your situation—understand the disease process and learn about different treatment options.
• Work with your physician to come up with both short-term and long-term courses of treatment to help manage your symptoms early while maintaining the health of your knee and body for as long as possible.
• Be flexible with your activities and do not put the exact same stresses on the knee everyday. In some cases, mild activity modification such as switching to more biking or swimming and less running may make a huge difference in the number and severity of symptoms. Trying new activities also can help keep morale high.
• Don't be afraid to ask questions of your physician. Look for a doctor who can help you understand the advantages and disadvantages of each treatment option, and who is willing to work with you to tailor a treatment strategy to your individual needs.

"Even when surgery is necessary, proper follow-up treatment and physical therapy tailored to the patient's needs can go along way toward keeping that patient active and satisfied in the long-term," stated Dr. Feeley.

Glucosamine appears to provide little benefit for chronic low-back pain

Even though it is widely used as a therapy for low back pain, a randomized controlled trial finds that patients with chronic low back pain (LBP) and degenerative lumbar osteoarthritis (OA) who took glucosamine for six months showed little difference on measures of pain-related disability, low back and leg pain and health-related quality of life, compared to patients who received placebo, according to a study in the July 7 issue of JAMA.

"Osteoarthritis is a common condition that currently affects more than 20 million individuals in the United States, and this number is expected to increase," the authors write. "Low back pain is widespread and is the second most common concern expressed by patients in primary care. It poses a diagnostic and therapeutic challenge to clinicians due to the unclear etiology [cause] and the range of interventions with limited effect." Glucosamine is widely used as a treatment for OA, despite its controversial and conflicting evidence for effect, and is also increasingly taken by LBP patients, even though the evidence of its effectiveness remains inconclusive.

Philip Wilkens, M.Chiro., of Oslo University Hospital and University of Oslo, Norway, and colleagues investigated the effect of a 6-month intake of glucosamine in reducing pain-related disability by conducting a randomized, placebo-controlled trial with 250 patients older than 25 years of age with chronic LBP (for longer than 6 months) and degenerative lumbar OA. Patients took either 1,500 mg. of oral glucosamine (n = 125) or placebo (n = 125) daily for 6 months, with effects assessed after the 6-month intervention period and at 1 year. The primary outcome was pain-related disability as measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity and a quality-of-life measure. Data collection occurred at the beginning of the trial and at 6 weeks, 3 and 6 months, and at 1 year.

At the beginning of the trial, the average RMDQ score was 9.2 for the glucosamine group and was 9.7 for the placebo group. The 6-month average RMDQ score was 5.0 for both the glucosamine and placebo group, and 1-year score was 4.8 for the glucosamine group, and 5.5 for the placebo group. No statistically significant difference in change between groups was found when assessed after the 6-month intervention period and at 1 year for RMDQ, and for measures of LBP at rest, LBP during activity and quality-of-life. Mild adverse events were reported in 40 patients in the glucosamine group and 46 patients in the placebo group.

"Based on our results, it seems unwise to recommend glucosamine to all patients with chronic LBP and degenerative lumbar OA. Further research is needed to clarify whether glucosamine is advantageous in an alternative LBP population," the authors conclude.

Failed ACL Repairs: More Common than You May Think

Nick Van Erp, active in soccer since elementary school and lacrosse since junior high, tore the anterior cruciate ligament in his knee during a spring lacrosse game his freshman year of high school. His injury, caused by stepping into a pothole and hyper-extending his knee, required surgical repair, ending his season prematurely and the remainder of his high school sports career.

Three years and two failed surgeries later, he made his way to the University of Michigan Health System in July 2009 to get what he hopes will be his final knee surgeries.

“I haven’t played soccer since freshman year and I’ve tried to play lacrosse, but every time, [my ACL] tears,” says Van Erp, a Grand Rapids resident.

Failed ACL repairs common

This eighteen-year-old’s story is not unique—an estimated 400,000 people suffer an ACL injury each year, requiring primary reconstruction surgery to repair the injury. Unfortunately, 18,000 to 35,000 of those repairs will fail and require revisions, which are additional surgeries for reconstruction. Revisions are more complicated, less successful and require a longer rehabilitation period than the first surgery.

Orthopaedic surgeons at U-M perform 200-300 ACL primary reconstructions each year. In addition to primary reconstructions, U-M surgeons perform about 30 revisions each year to correct failed ACL primary reconstructions performed elsewhere.

“Why those ligaments fail is subject to a lot of debate but probably has something to do with the techniques used the first time, and then the fact that so many [patients] go back to the sports that originally caused the problem,” says Ed Wojtys, M.D., director of the MedSport sports medicine clinic at U-M.

Primary ACL reconstruction surgeries, performed by orthopaedic surgeons, replace the injured ligament with an autograft from the patient’s body, such as a tendon of the kneecap or hamstring.

Most reconstruction surgeries are done by making small incisions in the knee and inserting instruments to perform the repair. After surgery, typically four to six months of rehabilitation therapy is needed for the repair to fully heal. If surgery and rehabilitation is done correctly, the patient typically will have reduced pain, good knee function and stability, and return to normal levels of activity.

“The most common reason for an ACL [repair] to fail is technical error, where the actual graft is placed in a non-anatomic position and the most common wrong position is too vertical—too up and down—which doesn’t allow the graft to restore rotation,” Jon Sekiya, M.D., associate professor of orthopaedics at U-M.

Common reasons for ACL repair failure include:_• inadequate time for rehabilitation, _• physiological factors such as the alignment of the patient’s bones or muscle function, _• additional injuries at the same time as an ACL injury—such as to cartilage in the knee or another knee ligament—which may also require repair to restore stability to the knee, _• reoccurring trauma due to intense physical activity, and _• improper surgical techniques.

Finding an experienced surgeon

An American Board of Orthopedic Surgeries survey found that 85 percent of surgeons who are doing ACL [repairs] do 10 or less per year.

“I definitely don’t think that the exact number of surgeries you do is indicative of necessarily the skill level,” Sekiya says. “However, I do think there are subtleties to this surgery that if encountered during an operation, may not be recognized in a less experienced ACL surgeon and can lead to failure. We do see that.”

To reduce the chance of an ACL repair failure, Sekiya says patients should talk to surgeons and other clinical staff who may be involved in their care about their experience before deciding on where to get the surgery.__“When trying to choose a place to take care of their ACL and their injury, [patients] should make sure the surgical staff and therapists are well versed to take care of all the problems they may encounter,” says Sekiya, who is also Nick Van Erp’s orthopaedic surgeon. “Patients can simply ask their surgeon if they are comfortable doing the procedure – they will likely get an honest answer.

Long road to repair

Nick Van Erp, who was en route to a third ACL repair surgery elsewhere when he was referred to U-M for a second opinion, is now on the road to recovery.

“I think we were headed down a course that was similar to the two episodes that had previously failed,” says Jeff Van Erp, who is Nick’s father and also a practicing physician.

Upon examination, Sekiya found that Van Erp’s problem was more complicated than a failed ACL repair. He and the Van Erps opted for diagnostic arthroscopy, to fully evaluate the knee and prepare it for future surgeries. This took place in August 2009.

The procedure revealed that Van Erp’s meniscus had been removed during a previous surgery, which is a secondary stabilizer to the ACL, and that he had bowed knees, which also contributed to his two previous ACL reconstruction failures. During the procedure, Sekiya also removed previously placed hardware and filled in the tunnels left behind with bone grafts.

In October 2009, Sekiya performed a tibial osteotomy, where he had to break and re-fix Van Erp’s shin bone to realign his knee. And finally, in March 2010, Sekiya transplanted a new meniscus and performed a double-bundle ACL reconstruction to provide stronger reinforcement to the knee.

“[I have] no real pain anymore,” Nick Van Erp says. ”And I know the tibial osteotomy worked because [my knee] feels more stable.”

“We’re obviously very happy that we decided to invest the time and energy into getting an opinion from someone who specializes in essentially catastrophic joint situations like Dr. Sekiya,” says Jeff Van Erp.

Nick Van Erp hopes to play intramural lacrosse at Kalamazoo College next year.

“I’m hoping this is the last knee surgery,” he says. “Hopefully everything will work and I can go to college and not have to worry about this.”

• Nick Van Erp has been undergoing physical therapy and expects to be completed in September 2010.
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Surgical repair of knee injuries does not decrease risk of osteoarthritis

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Arthroscopic surgical repair of torn anterior cruciate ligaments (ACL) or meniscal cartilage injuries in the knee does not decrease the chances of developing osteoarthritis, according to a new study published in the online edition and August print issue of the journal Radiology.

A decade after the initial injuries were diagnosed using MRI, localized knee osteoarthritis was evident in patients, regardless of whether or not the injuries had been surgically repaired.

"This study proves that meniscal and cruciate ligament lesions increase the risk of developing specific types of knee osteoarthritis," said Kasper Huétink, M.D., the study's lead author and resident radiologist at Leiden University Medical Center in the Netherlands. "Surgical therapy does not decrease that risk."

According to the American Academy of Orthopaedic Surgeons, the ACL, which is one of four ligaments that connect the bones in the knee, is the most commonly injured ligament. Injury typically occurs when the ACL is overstretched or torn.

Approximately half of ACL injuries will cause damage to other areas of the knee, including the meniscus, a wedge-shaped piece of cartilage that acts as a shock absorber for the knee joints. Surgical treatment is usually advised to repair these injuries.

Knee osteoarthritis is a common public health problem affecting more than nine million Americans. It typically develops gradually over several years. Knee osteoarthritis symptoms can include pain, stiffness, swelling and reduction in knee mobility.

For the study, researchers gathered information from the database of a previous multicenter study of 855 patients. The earlier study was conducted from 1996 to 1997 to evaluate the diagnostic value of knee MRI relative to arthroscopy in patients with knee pain.

In the current study, Dr. Huétink and colleagues followed up with 326 of the original 855 patients. All 326 patients had experienced knee pain for four weeks or more prior to the initial MRI and treatment. Initial findings and differences in treatment were compared with current follow-up x-rays and MRI exams.

The results showed that patients with ACL and meniscus tears are at a greater risk for developing osteoarthritis. Meniscectomy, which is the surgical removal of all or part of a torn meniscus, did not reduce that risk.

According to Dr. Huétink, the long-term and short-term clinical benefits of partial meniscectomy vs. meniscal repair procedures need to be further investigated.

"There is a higher risk of developing knee osteoarthritis at specific sites after tearing a meniscus or cruciate ligament," Dr. Huétink said. "We showed a direct relationship between injury and long-term consequences, and showed that surgery has no impact on long-term outcomes."

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15 Years After ACL Knee Reconstruction, 84% of Male Patients Still Highly Active

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Eighty-four percent of males who had ACL knee (anterior cruciate ligament) reconstruction with a patellar tendon (the tendon that attaches the knee to the front of the tibia or shin bone) graft continue at a high level of activity 15 years later, according to a study presented today at the American Orthopaedic Society for Sports Medicine’s Specialty Day in New Orleans, Louisiana (March 13). Additionally, these patients have not developed severe osteoarthritis and their knees remain stable.

“We have done this procedure for many years and this study looks at patients as far back as 17 years,” said Leo Pinczewski, MD, corresponding author and consultant surgeon at the North Sydney Orthopaedic & Sports Medicine Centre, Wollstonecraft, Australia. “The results of this technique, which was new almost 20 years ago, were excellent at five years, outstanding at 10 years and still very, very good at 15 years. Patients went back to sport quickly, had an easy rehabilitation with no brace and were frequently walking straight away.”

The goal of ACL knee surgery is to stabilize the knee with a short rehabilitation letting patients get back to an active lifestyle. Long-term, the surgery aims to prevent additional damage to the knee and minimize osteoarthritis.

But Dr. Pinczewski’s success with the procedure almost didn’t occur, he noted. In 1989, Dr. Pinczewski had gone to a medical seminar to hear Tom Rosenberg, MD, of Salt Lake City, Utah, who had pioneered a surgery to arthroscopically reconstruct the ACL using the patellar tendon. Previously, this knee surgery had been an “open” (not minimally invasive) procedure with a long rehabilitation and a high incidence of osteoarthritis. All he was able to obtain was the procedure summary from literature left at the lecture.

“So, I worked out how to do it from the abstract,” said Dr. Pinczewski. “Little did I know that I got it wrong, according to Dr. Rosenberg’s method. But, in fact, it proved to be fortuitous. The way I performed the surgery was to drill the hole into the femoral bone before drilling into the tibia. Dr. Rosenberg’s technique drilled into the tibia first. It turned out you can get the graft into a better position and a more stable knee if you drill in that order. I didn’t know I had it ‘wrong’ until after I’d performed hundreds of successful operations.”

In the study, 90 patients (46 men and 44 women between 15-42 years) had endoscopic ACL knee surgery performed by Dr. Pinczewski. After 15 years, 82 patients (88%) were examined and documented. In evaluating knee function (limp, locking, instability, pain, swelling and trouble climbing stairs), the patients had a median score of 95 (in a range of 39-100). Rating the function of their knee on a scale of 0 – 10, with 10 being normal, excellent function and 0 being inability to perform daily activities, patients reported their knee function at an average of 9.5 after 15 years.

As for sports participation, 84 percent of males and 45 percent of females were participating in very strenuous activities such as soccer and basketball or in strenuous activities such as skiing or tennis. 24 percent of patients participated in moderate activities such as running or jogging and14 percent participated in light activities such as walking 15 years after surgery. However, 89 percent of patients had no signs of osteoarthritis at 15 years after the surgery. The study did note a concern for increased kneeling pain in patients due to the donor site for the patellar tendon graft that needed further scrutiny.

A sporting chance for active total knee replacement patients

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Study finds implant durability not affected by high-impact sports participation

Total knee arthroplasty (TKA) patients may be able to participate in high-impact sports without increasing risk of early implant failure, according to a new study presented today at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). In addition, the authors observed better clinical scores in the group of patients who participated in activities discouraged by the Knee Society (KS) than those of the control group.

The Knee Society recommends TKA patients avoid activities that cause high stress loads on the implant and may increase the risk of early failure. Such activities include high-impact aerobics, football, soccer, baseball, basketball, jogging and power lifting, among others.

"Recent studies have shown that as many as one in six total knee replacement patients participate in non-recommended activities," said Sebastian Parratte, M.D., PhD, an orthopaedic surgeon from the Mayo Clinic in Rochester, MN and the Aix-Marseille University, Center for Arthritis Surgery, Hospital Sainte-Marguerite in Marseille, France. "This study offers some reassurance to those patients who choose to return to an active lifestyle after surgery."

Researchers evaluated outcomes of 218 patients between the ages of 18 and 90 who underwent primary knee arthroplasty at the Mayo Clinic and reported performing heavy manual labor or practicing a non-recommended sport following surgery. The "sport group" was matched by age, gender and BMI to a control group of 317 patients who underwent the same procedure using an identical implant and followed recommended activity guidelines.

Clinical and radiologic results were measured using Knee Society (KS) scores and implant survivorship was evaluated using multivariate analysis according to the Cox model.

At an average follow-up of seven-and-a-half years after surgery, the study found:

No significant radiological differences and no significant differences in implant durability could be demonstrated between the sport group and the control group;
The sport group showed slightly higher KS Knee and function scores compared to the control group;
The control group experienced a 20 percent higher revision rate for mechanical failure (loosening, wear or fracture) compared to the sport group;
After accounting for all variables, including co-morbidities, the sport group had a 10 percent higher risk of mechanical failure compared to the control group.
These results were quite surprising to Dr. Parratte and his team.

"We hypothesized that high-impact activities would not increase the risk of implant failure, but we did not foresee that such activities might actually improve clinical results," he said. "It is clear that more research is necessary to evaluate the short and long-term effect of high-impact activities on the durability and function of modern TKA implants."

He added that, although the industry is not ready or able at this point to revise its recommendations, that possibility may exist in the not-too-distant future. In the meantime, he noted that surgeons and patients should continue to follow all industry recommendations relating to recovery following joint replacement surgery.

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Learn more.

About Joint Replacement

Joint replacement, also known as arthroplasty, is considered by many to be one of the most successful medical innovations of the 20th century. Total joint replacement is a surgical procedure in which the patient's natural joint is replaced with an artificial one, made of a combination of plastic, metal, and/or ceramic.

The most common reasons for this surgery are pain and stiffness that limits normal activities such as walking and bending and that cannot be satisfactorily treated with medications or other therapies. Therefore, joint replacement surgery often provides a significantly improved quality of life to patients who would otherwise have to live with severe pain.

In 2007, there were 550,161 total knee replacements performed in the United States, and that number is on the rise—particularly as the Baby Boomer population continues to age. Because of this trend, it is important to optimize patient outcomes.