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Online Advanced Release
Articles appearing in this "Online Advanced Release" section have been peer-reviewed and accepted for publication in The Journal of Knee Surgery and posted online before print publication. Articles appear on this site after copyediting and author corrections, but before final proofing. The content of the article will usually remain unchanged, and possible further corrections are fairly minor. The final published article will specify the issue and page numbers. Once the final version is available in print, the version posted here will be removed from this site.
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Table of Contents
Current Trends in Anterior Cruciate Ligament Reconstruction
Thomas R. Duquin, MD; William M. Wind, MD; Marc S. Fineberg, MD; Robert J. Smolinski, MD; Cathy M. Buyea, MS
Submitted: 8/20/07; Accepted: 1/15/08; Posted: 8/29/08In 2006, a survey regarding anterior cruciate ligament (ACL) reconstruction was mailed to physician members of the American Orthopaedic Society for Sports Medicine. A total of 993 responses were received from 1747 possible respondents (57%). The number of ACL reconstructions per year ranged from 1 to 275 (mean = 55). The most important factors in the timing of surgery were knee range of motion and effusion. Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively). A single-incision arthroscopic technique was used by 90%. Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision. There was limited experience (4%) with double-bundle and computer-assisted ACL reconstruction.
Arthroscopic-assisted, single-incision reconstruction using a BPTB autograft fixed with metal interference screws remains the most common technique used for primary ACL reconstruction. In the past 5 years, the use of alternative graft sources and methods of fixation has increased. Consensus regarding the best graft type, fixation method, and postoperative protocol is still lacking.
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The Humeral Head as a Potential Donor Source for Osteochondral Allograft Transfer to the Knees
Michael V. Birman, MD; Dan T. Le, BS; Sabir K. Ismaily, BS; Bruce S. Miller, MD
Submitted: 10/1/07; Accepted: 2/8/08; Posted: 8/29/08This study aimed to determine whether osteochondral allograft plugs from the humeral head are a good topographic match to recipient sites on the femoral condyle. If so, the donor pool for allograft osteochondral transplantation to the knee may increase.
Simulated osteochondral grafts of 1-cm, 1.5-cm, and 2-cm diameters were taken from the surface map of the humeral heads and superimposed and optimized on recipient sites of identical size on the femoral condyles. Primary measurement criteria included contour mismatch and circumferential step-off. These measurements increased with donor plug size. For the 1-cm and 1.5-cm plugs, the lowest mean mismatch (0.068 mm and 0.110 mm, respectively) and step-off (0.057 mm and 0.154 mm, respectively) occurred at the 30º medial position. For the 2-cm plugs, the lowest mean mismatch (0.183 mm) and step-off (0.227 mm) occurred at the 60º lateral position.
Although 1-cm osteochondral plugs were a good topographic match to the recipient sites, the 2-cm plugs had a mismatch approaching 0.5 mm, an offset with a demonstrated peak contact pressure >40% higher than normal. The topographic match of the humeral head suggests it is a potential donor source for osteochondral allograft transfer to the distal femur.
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Andreas H. Gomoll, MD; Richard W. Kang, MD, MS; Andrea L. Chen, BS; Brian J. Cole, MD, MBA
Submitted: 7/21/07; Accepted: 2/8/08; Posted: 8/29/08Arthritis treatment in young patients remains a challenge. Joint replacement surgery offers excellent pain relief but is controversial with this age group because of long-term wear and loosening. Recently, biological reconstructive techniques have become available to improve traditional treatment methods such as osteotomies. We present our experience with a technique for combined meniscal transplantation, chondral repair, and osteotomy in 7 patients presenting with a constellation of meniscal deficiency, focal arthritis, and malalignment.
Patients underwent concurrent or staged meniscal transplantation, cartilage repair, and osteotomy. Evaluation included the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Short Form-12 and Lysholm scales. At average follow-up of 24 months, patients experienced significant improvements in the IKDC, Lysholm, and KOOS functional scores. Six of 7 patients were able to return to unrestricted activities; 1 patient experienced mild pain with high-impact activities. Combined treatment with meniscal transplantation, cartilage repair, and osteotomy demonstrated promising clinical results of unicompartmental arthritis treatment in young patients.
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Potential Market for New Meniscus Repair Strategies: Evaluation of the MOON Cohort
Gary B. Fetzer, MD; Kurt P. Spindler, MD; Annunziato Amendola, MD; Jack T. Andrish, MD; John A. Bergfeld, MD; Warren R. Dunn, MD, MPH; David C. Flanigan, MD; Morgan Jones, MD; Christopher C. Kaeding, MD; Robert G. Marx, MD, MS; Matthew J. Matava, MD; Eric C. McCarty, MD; Richard D. Parker, MD; Michelle Wolcott, MD; Armando Vidal, MD; Brian R. Wolf, MD, MS; Rick W. Wright, MD
Submitted: 8/3/07; Accepted: 1/15/08; Posted: 8/29/08This study aimed to determine the incidence of meniscal tears and describe the tear morphology and selected treatment in patients undergoing anterior cruciate ligament (ACL) reconstruction. We also will discuss the potential market for future tissue engineering aimed at preserving meniscal function. A multicenter cohort of 1014 patients undergoing ACL reconstruction between January 2002 and December 2003 was evaluated. Data on patient demographics, presence of a meniscus tear at time of ACL reconstruction, tear morphology, and meniscal treatment were collected prospectively. Meniscal tears were categorized into 3 potential tissue engineering treatment strategies: all-biologic repair, advanced repair, and scaffold replacement. Of the knees, 36% had medial meniscal tears and 44% had lateral meniscal tears. Longitudinal tears were the most common tear morphology. The most frequent treatment method was partial meniscectomy. Thirty percent of medial meniscal tears and 10% of lateral meniscal tears are eligible for all-biologic repair; 35% of medial meniscal tears and 35% of lateral meniscal tears are eligible for an advanced repair technique; and 35% of medial meniscal tears and 55% of lateral meniscal tears are eligible for scaffold replacement. Although meniscal preservation is generally accepted in the treatment of meniscal tears, most tears in this cohort were not repairable, despite contemporary methods. The results of this cohort will hopefully stimulate and focus future research and development of new tissue engineering strategies for meniscus repair.
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Anthony W. Anderson, BA; Joel J. Smith, MD
Submitted: 9/13/07; Accepted: 1/15/08; Posted: 8/29/08Tibial plateau fracture after patellar tendon autograft is a documented complication of anterior cruciate ligament reconstruction. This case report describes a 24-year-old man who sustained this injury 7 years after anterior cruciate ligament (ACL) reconstruction. The patient tolerated open reduction and internal fixation of the tibial plateau. Tibial plateau fractures can occur relatively late in the recovery process after ACL reconstruction. Measures suggested to potentially reduce this complication include smaller osteotomies, use of allograft for patients with osteoporosis, and procuring the graft from the contralateral knee.
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Localized Pigmented Villonodular Synovitis of the Posterior Capsule of the Knee: Case Report
Dong Ju Chae, MD; Gautam M. Shetty, MS; Ki Hoon Kang, MD; Ji Hoon Kim, MD; Kyung Wook Nha, MD
Submitted: 10/30/07; Accepted: 3/5/08; Posted: 8/29/08Localized pigmented villonodular synovitis involving the posterior intra-articular structures of the knee joint is rare. We report a case of localized pigmented villonodular synovitis arising from the posterior capsule of the knee joint in a patient who presented with a history of repeated joint effusions and loss of terminal knee flexion. After successful, complete removal of the mass through the posteromedial portal, the patient was asymptomatic, with no evidence of recurrence during the 26-month follow-up period.
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William I. Sterett, MD; Bruce S. Miller, MD; Thomas A. Joseph, MD; Valerie J. Rich, PhD; Elizabeth M. Bain, MPH
Submitted: 9/12/06; Accepted: 1/15/08; Posted: 7/31/08This study examined whether medial opening wedge osteotomy inadvertently changes posterior tibial slope and whether this change affects range of motion and functional outcomes. Lateral radiographs of 82 knees with varus arthrosis were reviewed to measure posterior tibial slope before and after medial opening wedge high tibial osteotomy. Anterior or posterior cruciate ligament-deficient knees were excluded. Twenty-one osteotomies were performed using distraction osteogenesis/medial external fixator, 26 using acute distraction/Arthrex plate fixation, and 35 using acute distraction/EBI plate fixation. Preoperative and postoperative Lysholm scores and range of motion were recorded. Posterior slope increased from a mean of 12.5° preoperatively to 16.5° postoperatively (P < .01). Fixation types revealed no difference in posterior slope change. Large slope changes had less preoperative knee flexion than did small changes (123 versus 131; P = .012). No significant correlation existed between posterior slope change and postoperative Lysholm scores (r = 0.047, P > .05). We found that medial opening wedge osteotomy may alter sagittal alignment by increasing posterior tibial slope.
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Stephen Lyman, PhD; Warren R. Dunn, MD, MPH; Chris Spock, BA; Peter B. Bach, MD, MAPP; Lisa A. Mandl, MD, MPH; Robert G. Marx, MD, MSc, FRCSC
Submitted: 8/21/07; Accepted: 1/15/08; Posted: 7/31/08Many arthroplasty outcome studies use administrative data to evaluate complications and mortality. Most databases use International Classification of Diseases, Ninth Revision or Current Procedural Terminology codes, which lack laterality information. This study determined the frequency with which a second operation occurs on the same side after total hip replacement (THR) and total knee replacement (TKR) and identified variables associated with ipsilateral reoperation. In a hospital-based sample of patients undergoing multiple THR or TKR, the side of the index operation was compared with the side of the subsequent operation. Concordance was defined as the percentage of same-side reoperations. Overall concordance was 23% for THR and 22% for TKR, suggesting most reoperations were on the contralateral hip or knee. This study provides estimates of misclassification of reoperation after lower extremity arthroplasty when conducting orthopedic research with administrative data. Studies using these data should be aware of this limitation, and efforts should be made to limit reoperation to revision THR and TKR.
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Thomas Moyad, MD, MPH; Daniel Estok, MD
Submitted: 8/8/07; Accepted: 10/5/07; Posted: 7/31/08Total knee arthroplasty (TKA) performed in knees with mild or moderate intra-articular deformity often can be resolved with careful ligament balancing and bone resection. However, extra-articular deformity may require an osteotomy to safely create rectangular flexion and extension gap balance. In these challenging situations, restoring the mechanical axis through intra-articular bone resection and soft tissue releases alone can lead to excessive bone loss and ligament instability. We report a case of TKA with combined femoral and tibial osteotomies in a post-polio patient with extra-articular deformities. Although a few small case studies have been previously published in the literature, specific details regarding this procedure are lacking. Our objective is to provide a detailed surgical technique and to review the indications for extra-articular osteotomies performed during TKA.
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Common Peroneal Nerve Neuropraxia After Arthroscopic Inside-Out Lateral Meniscus Repair: Case Report
Anthony W. Anderson, BA; Robert F. LaPrade, MD, PhD
Submitted: 7/25/07; Accepted: 11/1/07; Posted: 7/31/08Common peroneal nerve injury caused by suture entrapment is a complication of arthroscopic inside-out lateral meniscus repair. In the literature, the treatment of this complication has been described as immediate reexploration. We present a case of recovery after late neurolysis performed 7 months postoperatively for a common peroneal nerve neuropraxia. In addition to describing return of function after late exploration, we discuss the management and prevention of this complication.
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Extraskeletal Para-Articular Osteochondroma of the Posterior Knee: Case Report
Aditya V. Maheshwari, MD; Carlos A. Muro-Cacho, MD; J. David Pitcher, Jr, MD
Submitted: 6/4/07; Accepted: 8/15/07; Posted: 6/30/08Extraskeletal para-articular osteochondromas are unusual osteocartilaginous lesions that arise in the soft tissues adjacent to the joint with no bone or joint continuity. This diagnosis should be considered in patients with a well-circumscribed, extraskeletal, mineralized mass without any direct continuity with adjacent bone or joint. Although the knee is a common location for extraskeletal para-articular osteochondroma, it has not been described arising in the posterior aspect of the knee. This article presents a case of extraskeletal para-articular osteochondroma posterior to the knee joint. Differentiation from other extraskeletal mineralized lesions, particularly extraskeletal sarcomas and synovial osteochondromatosis, is essential to avoid unnecessary aggressive surgical procedures as marginal excision is adequate for these lesions. Correlation of clinical and radiographic features with pathology is essential for diagnosis. The lesion in our patient was marginally excised, and the postoperative course was uneventful with no recurrence at 2-year follow-up.
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Patient-Based Outcomes in Patellofemoral Arthroplasty
M.M. Utukuri, MS (Orth), FRCS Ed, FRCS (Tr & Orth); V. Khanduja, MRCS (G), MSc, FRCS (Tr & Orth); H.S. Somayaji, MS, MRCS; G.S.E. Dowd, MD, MCh (Orth), FRCS
Submitted: 4/23/07; Accepted: 8/15/07; Posted: 6/30/08This retrospective study evaluated the short-term functional outcome of patellofemoral arthroplasty using patient-based outcome measures. The study cohort included 17 patients who underwent patellofemoral arthroplasty (14 unilateral and 3 bilateral) between 1996 and 2005. Mean patient age was 56 years (range, 43-65 years), and mean follow-up was 52.5 months (range, 24-84 months). Clinical and radiographic assessment was performed using the Hospital for Special Surgery (HSS) knee score. Functional assessment was performed using the Short Form-36 (SF-36) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Mean HSS knee score was 64 (range, 51-79) preoperatively and 90 (range, 71-100) postoperatively. Mean postoperative SF-36 scores were compared with normative data compiled by the British Omnibus Survey in 1992. Scores for physical and social functioning, role limitation due to physical and emotional problems, and pain were poorer compared with mental health and energy/vitality. Mean postoperative scores for the 5 KOOS subscales ranged from 51% to 72%. These findings indicate patient-based outcome measures should be used routinely for functional assessment of patients undergoing patellofemoral arthroplasty.
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Long-Term Functional Results and Complications in Patients With Knee Dislocations
Kevin D. Plancher, MD; John Siliski, MD
Submitted: 1/14/07; Accepted: 9/4/07; Posted: 6/30/08This retrospective study evaluated outcome and associated complications in 48 patients with 50 knee dislocations treated between 1968 and 1993. Average follow-up was 8.3 years. Thirty-one knees underwent operative treatment, and 19 knees underwent nonoperative treatment. Open dislocations occurred in 26% of knees, and associated injuries occurred in 58%. Peroneal nerve injuries occurred most frequently (36%), followed by popliteal artery injuries (24%). Six knees treated nonoperatively required either above-knee amputation (4) or knee arthrodesis (2). Mean Lysholm at follow-up was 80.2 and Hospital for Special Surgery (HSS) score was 76.8. Differences in HSS score (P = .001), Lysholm score (P = .007), pain with rest, knee flexion, and return to athletics were statistically significant between patients treated operatively and nonoperatively, with operative patients scoring better. Patients treated surgically were less likely to develop severe radiographic degenerative changes. These findings demonstrate patients treated operatively for knee dislocations have better functional results.
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Xavier C. Simcock, BS; Richard S. Yoon, BS; Peter Chalmers, BS; Jeffrey A. Geller, MD; Howard A. Kiernan, MD; William Macaulay, MD
Submitted: 10/1/07; Accepted: 1/4/08; Posted: 6/30/08Patients undergoing total knee arthroplasty (TKA) often experience a difficult recovery due to severe postoperative pain. Using a multimodal pain management protocol, a blinded, randomized, placebo-controlled study was designed to evaluate the efficacy of patient-selected music on reducing perceived pain. Thirty patients undergoing primary unilateral TKA were enrolled and randomized into the music group (15 patients) or the control group (15 patients). Postoperative pain scores, assessed with the visual analog scale, indicated the music group experienced less pain at 3 and 24 hours postoperatively than did the nonmusic group (at 3 hours: 1.47±1.39 versus 3.87±3.44, P = .01; at 24 hours: 2.41±1.67 versus 4.03±2.89, P = .04). Intraoperative music provides an inexpensive nonpharmacological option to further reduce postoperative pain.
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William Macaulay, MD; Richard S. Yoon, BS
Submitted: 10/13/07; Accepted: 1/4/08; Posted: 6/30/08Fixed bearing, medial unicondylar knee arthroplasties were performed in 33 knees (32 patients). We report a minimum 2-year follow-up, with a mean follow-up of 3 years. Kaplan-Meier survivorship analysis reported 97% survivorship at a mean follow-up of 38 months. Average preoperative WOMAC pain scores improved significantly from 40±22 to 92±15 (P < .0001). Average preoperative Knee Society knee and function scores improved significantly from 52±7 to 90±9 (P < .0001) and from 48±16 to 84±17 (P < .0001), respectively. In addition, average Short Form-12 Physical Component scores significantly increased. Overall stiffness and physical function assessed via the WOMAC index also exhibited significant improvement. Of note, all categories of the WOMAC Index and the Knee Society scores experienced statistically significant improvements at 3-month follow-up, indicating a rapid return to improved function and diminished pain.
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Gabriel D. Brown, MD; Christopher S. Ahmad, MD
Submitted: 6/29/07; Accepted: 9/12/07; Posted: 6/30/08Patellar instability is a common knee disorder encountered in young athletes. Patients with normal osseous anatomy and mechanical alignment of the lower extremity are candidates for soft tissue reconstructive procedures. In skeletally immature patients, surgical techniques that address patellar instability must avoid disruption of open physes and therefore must rely on soft tissue techniques. Biomechanical research demonstrates that the medial patellofemoral ligament is the primary soft tissue restraint to lateral subluxation of the patella, and the medial patellotibial ligament is an important secondary stabilizer. We present a novel physeal-sparing surgical technique that anatomically reconstructs both the medial patellofemoral and medial patellotibial ligaments using semitendinosus autograft.
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Transient Osteoporosis of the Knee: Case Report
Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho); Mathew Varghese, MS (Ortho); Balu Sankaran, FRCS(C), FAMS
Submitted: 12/20/06; Accepted: 3/26/07; Posted: 5/30/08Idiopathic transient osteoporosis is a self-limiting, reversible, and uncommon condition. There is usually an overlap between various clinical syndromes, which includes reflex sympathetic dystrophy and avascular necrosis. This article reports a case of idiopathic transient osteoporosis involving the femur and tibia in the knee following trauma in a 45-year-old man. The diagnosis was confirmed by magnetic resonance imaging. The patient was treated conservatively with bed rest, nonsteroidal anti-inflammatory drugs, protected weight bearing, and physiotherapy. He had a full clinical and radiographic recovery.
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