The influence of synovial inflammation and hyperplasia on symptomatic outcomes up to 2 years post-operatively in patients undergoing partial meniscectomy.

OBJECTIVE: Synovitis is associated with pain and other symptoms in patients with knee osteoarthritis (OA), and in patients with meniscal tears even in the absence of radiographic OA. Patients undergoing arthroscopic partial meniscectomy were followed for 2 years to determine whether synovitis predicts post-operative symptoms. DESIGN: Thirty-three patients scheduled for arthroscopy were recruited for this pilot study. Symptoms were assessed using a knee pain scale, the Lysholm score, and the short form-12 (SF-12(®)) pre-operatively and at 16 weeks, 1 year and 2 years post-operatively. Synovial inflammation and hyperplasia were graded on surgical biopsies. Linear mixed effects models were tested to determine whether inflammation or hyperplasia is associated with outcome scores over time. RESULTS: Lysholm scores and SF-12(®) physical component sub-scores were worse pre-operatively in patients with inflammation (Lysholm: 52.42 [95% confidence interval (CI) 42.37, 62.47] vs 72.38 [66.03, 78.72], P < 0.001; SF-12: 36.81 [28.26, 45.37] vs 46.23 [40.14, 52.32], P < 0.05). Up to 2-years post-operatively, patients with inflammation achieved mean scores similar to those without inflammation. As a result, the mean improvement in Lysholm scores was 13.01 [1.48-24.53] points higher than patients without inflammation, P = 0.03. 33% (4/12) of patients with inflammation still had fair to poor Lysholm scores 2 years after surgery compared to 7% (1/15, P=0.14) without inflammation. No association between hyperplasia and symptoms was noted. CONCLUSIONS: In this pilot study of patients undergoing partial meniscectomy, synovial inflammation was associated with worse pre-operative symptoms, but not with poorer outcomes in the first 2 years post-arthroscopy. Larger cohorts and longer follow-up should be pursued to confirm this relationship, and determine if the initial response is sustained.

Contractile actin expression in torn human menisci.

The human meniscus is subject to injury that necessitates repair or removal. Many aspects of the cellular response to injury have not been well characterized. The purpose of this study was to describe the cellular distributions within the torn human meniscus. In addition to evaluating the cell density in selected regions, we investigated the cellular expression of a contractile actin isoform that has recently been found in the intact human meniscus. Included as a contemporaneous comparative group were torn human meniscal allografts. We hypothesized that a hypercellular surface zone would be found in the torn menisci, with a higher percentage of cells in this peripheral region expressing alpha-smooth muscle actin compared with other locations in the interior of the remnant. The rationale for this hypothesis was based on prior immunohistochemical investigations of the distribution of alpha-smooth muscle actin-containing cells in the torn human anterior cruciate ligament. Eighteen torn meniscal specimens were obtained from 17 patients, 0.5 to 84 months after injury, and four torn allograft meniscal samples were retrieved from three patients, 11 to 49 months after implantation. Microtomed sections of paraffin-embedded tissue were stained with hematoxylin and eosin and a monoclonal antibody to alpha-smooth muscle actin. The cell density and percentage of cells containing alpha-smooth muscle actin were determined in the following zones: synovial, vascular, hypercellular with loose collagen, hypocellular with dense collagen, and organized collagen. A cellular layer that resembled synovium was present on the surface of all but two of the specimens. Vascular regions were often continuous with the synovium abutting the more interior loose collagen zones. The total cell density was greatest in each of the zones closest to the periphery (synovium, vascular, and loose collagen; p < 0.001), when compared to the interior of the tissue. The synovium-like layer was found to have the highest percentage of alpha-smooth muscle actin-expressing cells and the highest alpha-smooth muscle actin-containing cell density (p < 0.05). Similar results were found for the torn allograft menisci. These findings confirm the working hypothesis and suggest that the torn human meniscus is capable of mounting a reparative response, including the proliferation of cells capable of contributing to wound closure. This underscores the importance of providing a bridging scaffold into which such cells can migrate.

Arthroscopic vs. open Bankart reconstruction: a comparison using expected value decision analysis.

The reporting of midterm failure rates following arthroscopic shoulder stabilization for recurrent anterior instability of the glenohumeral joint has shown that the risk of failure may be higher with arthroscopic techniques than with traditional open methods. The use of expected value decision analysis offers an explicit, consistent, and structured means to assist the clinician in determining which stabilization technique to utilize. Decision analysis reveals that the surgical technique that is favored for a given patient depends on the value that the patient assigns to various potential outcomes following surgery, the perioperative morbidity of each of the two procedures, and the surgeon's probability of success with either technique

Development and validation of the international knee documentation committee subjective knee form.

A committee of international knee experts created the International Knee Documentation Committee Subjective Knee Form, which is a knee-specific, rather than a disease-specific, measure of symptoms, function, and sports activity. The purpose of this study was to evaluate the reliability and validity of the new International Knee Documentation Committee Subjective Knee Form. To provide evidence for reliability and validity, we administered the final version of the form, along with the Short Form-36, to 533 patients with a variety of knee problems. Analyses were performed to determine reliability, validity, and differential item function related to age, sex, and diagnosis. Factor analysis revealed a single dominant component, making it reasonable to combine all questions into a single score. Internal consistency and test-retest reliability were 0.92 and 0.95, respectively. Based on test-retest reliability, the value for a true change in the score was 9.0 points. The International Knee Documentation Committee Subjective Knee Form score was related to concurrent measures of physical function (r = 0.47 to 0.66) but not to emotional function (r = 0.16 to 0.26). Analysis of differential item function indicated that the questions functioned similarly for men versus women, young versus old, and for those with different diagnoses. In conclusion, the International Knee Documentation Committee Subjective Knee Form is a reliable and valid knee-specific measure of symptoms, function, and sports activity that is appropriate for patients with a wide variety of knee problems. Use of this instrument will permit comparisons of outcome across groups with different knee problems.

Meniscal allograft transplantation. Two- to eight-year results.

We evaluated 18 of 23 patients who had undergone cryopreserved meniscal allograft transplantation for compartmental pain after total meniscectomy 2 to 8 years (mean, 5.4) after the operation. The Short Form-36 scores revealed a decrease in pain with a significant improvement in function, although function remained limited. There was no significant decrease in joint space on 45 degrees posteroanterior weightbearing radiographs through the duration of the study. Eight of 22 allograft menisci (36%) tore during the study period, necessitating 6 partial and 2 total meniscectomies. Two patients subsequently underwent reimplantation. Histologic examination of the removed tissue revealed reduced cellularity as compared with normal or torn native menisci. Four specimens also underwent detailed cytokine evaluation and demonstrated reduced cytokine expression compared with controls. While successful in alleviating compartmental pain that may be a late consequence of major meniscectomy, allograft menisci are repopulated with fewer cells than are present in normal or torn native menisci. These cells also demonstrate potentially reduced function, as measured by decreased growth factor production. This decreased biologic activity may be a factor that contributes to the high frequency of retears noted in this and prior studies.

A comparison of ultrasonic suture welding and traditional knot tying.

The slippage of knots and the technical challenge of tying them securely are potential impediments to certain arthroscopic procedures. Ultrasonic energy delivered at 70 kHz can be used to weld No. 2 polypropylene suture. This method was compared with a traditional knot (surgeon's knot with four alternating half hitches) tied with an open technique to determine whether welding of sutures is comparable, in mechanical properties, to hand-tied knots. Both loops were fashioned around a 0.25-inch mandrel and then tested. The load to reach 3-mm elongation (point of likely biologic failure of a repair) was significantly greater for welded sutures than for knots. The elongation at ultimate failure was significantly less for welded sutures than for knots. The number of cycles to failure and the creep after initial displacement were similar for both welded and knotted suture loops. The ultimate load to failure was significantly greater for the knotted than for the welded suture. The welding of suture for the repair of musculoskeletal soft tissue presents an attractive alternative to traditional knot tying, particularly for arthroscopic applications.

The menisci: basic science and advances in treatment.

Once described as a muscle remnant, and therefore treated with disrespect, the meniscus is now known to be a vital structure within the knee. Minimal partial meniscectomy performed arthroscopically, or meniscal repair when practical, have become the standard treatments. In spite of the advancements in understanding meniscal function and its preservation, much remains to be studied. In the future, availability of better repair techniques and the option of meniscal replacement with allograft or prosthetic menisci are expected to improve outcomes.

Meniscal repair in the young athlete.

Twenty-nine meniscal repairs in 26 patients 17 years of age or younger were performed using arthroscopic techniques. Clinical follow-up examinations were performed and the SF-36 Health Status Survey and International Knee Documentation Committee evaluation form were administered. A Lysholm score was determined for each patient. All 26 patients were seen for follow-up at an average of 5.0 years (range, 2.0 to 13.5). All patients had a full range of motion with no effusion, joint line tenderness, or McMurray sign present at the time of examination. No patient experienced symptoms of locking. No patient underwent repeat surgery for a nonhealed meniscal repair. The clinical healing rate in this group was 100%. The SF-36 data demonstrated an average physical functioning score of 91 and an average role physical score of 91. The average Lysholm score was 90. Twenty-two patients (85%) were performing level I activities based on the International Knee Documentation Committee rating. Excellent rates of healing, even higher than those obtained in the adult population, can be obtained with meniscal repairs performed in this young age group.

Transient laxity of an anterior cruciate ligament-reconstructed knee related to pregnancy.

Transient laxity was documented around the end of pregnancy in a woman who had undergone anterior cruciate ligament (ACL) reconstruction 2 months before conception. This temporary laxity in the 3rd trimester and a few months postpartum corresponded to a time when substantial remodeling from large diameter to small diameter collagen fibers has been noted in the ACL graft ligamentization process. This is also a time of high levels of the hormone relaxin (member of the family of insulin-like growth factors), whose action in animals leads to dissociation of large collagen fibrils to smaller disorganized fibrils. The temporary laxity resolved. Careful observation of women who become pregnant in the first few months after ACL reconstruction is recommended.

Two- to five-year followup of arthroscopic Bankart reconstruction using a suture anchor technique.

This is a retrospective review of 27 patients (27 shoulders) with recurrent anterior instability who underwent arthroscopic Bankart reconstruction with a suture anchor technique between 1990 and 1993. Average length of followup was 40 months (range, 26 to 64). The average Bankart rating score was 88 (range, 45 to 100) with 70% good-to-excellent results and 30% fair-to-poor results. The average University of California (Los Angeles) shoulder function score was 32 (range, 27 to 35). The average loss of external rotation in abduction was 1 degree. Eight patients (30%) failed the procedure and had recurrent anterior shoulder instability; seven of these had repeat traumatic events. A Pearson chi-square analysis of multiple variables was performed to determine which variables correlated with a successful result. A higher success rate was obtained if the patient had five or fewer dislocations before surgical reconstruction. This technique should be limited to patients not returning to contact sports, or in whom the improved cosmetic results or increased postoperative external rotation of the arthroscopic procedure are valued.

The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries.

The MOS 36-item short-form health survey is a generic, patient-based health assessment tool. It has been used to assess functional outcome for many medical conditions, both acute and chronic. The use of this survey in evaluating the effects of treatment of any specific disease or injury allows comparison of treatments across a broad spectrum of disease categories. The purpose of this study was to see if this assessment tool could 1) be used to identify those patients requiring anterior cruciate ligament reconstruction, 2) detect changes in the patients with treatment over time, and 3) correlate with the commonly used knee assessment scales. The short-form health survey could not identify those patients requiring anterior cruciate ligament reconstructive surgery. However, it did show important and significant changes with treatment (surgical and nonsurgical) over time. There was a significant correlation between the short-form health survey and the Lysholm and International Knee Documentation Committee scores during this study. The addition of the MOS 36-item short-form health survey to our traditional knee ligament evaluation tools is encouraged. Its use will permit the orthopaedic community to demonstrate the value of our treatment of anterior cruciate ligament injuries to health care planners and generalist physicians.

Long-term followup of Bankart reconstruction. Incidence of late degenerative glenohumeral arthrosis.

We identified 52 patients (56 shoulders) who underwent Bankart reconstructions for recurrent anterior instability between 1970 and 1983. We wanted to determine the prevalence of late degenerative arthrosis of the glenohumeral joint. Thirty-one patients (33 shoulders) returned for evaluation consisting of a questionnaire, physical examination, and radiographs, at an average 15-year followup. A true anteroposterior view and an axillary lateral view of both shoulders were obtained to identify signs of glenohumeral degenerative disease. The Bankart rating score devised by Rowe et al. was used to determine the subjective and objective outcome. The average Bankart score was 84. Average restriction of external rotation was 18 degrees with the arm at the side and 15 degrees with the arm abducted 90 degrees. Radiographic evaluation showed that 13 operated shoulders had normal radiographs, 14 had minimal degenerative changes, 3 had moderate changes, and 1 had severe changes. The patient with severe degenerative changes had marked restriction of external rotation of his operated shoulder. Statistical analysis using Spearman correlation coefficients revealed that there was a relationship between degenerative radiographic changes and restriction of external rotation with the arm abducted 90 degrees and length of followup, although correlations were limited because of the small number of patients with degenerative changes.

Anterior cruciate ligament graft tensioning in full extension.

The purpose of this study was to determine anterior laxity and graft forces in cadaveric knees after anterior cruciate ligament reconstruction in which the graft is tensioned with the knee in full extension. We also analyzed the clinical results from a series of patients who had ligament reconstructions using this technique. We performed anterior cruciate ligament reconstructions on seven fresh cadaveric knees and then measured the anterior laxity, graft set force, and graft tension. We also did a prospective minimum 2-year followup on 57 patients who underwent anterior cruciate ligament reconstruction. The in vitro data showed average anterior laxity of 1.1 mm greater than the intact knee with an 89-N anterior force at 30 degrees of knee flexion. Average graft set force was 68 N, and graft tension in extension was 18 N. In the clinical portion of the study, knee laxity improved from 7.5 to 0.8 mm (side-to-side difference at 89 N). The patients' Lysholm and Tegner scores improved from 65 to 90 and 3.9 to 5.6, respectively. Only one patient had a postoperative contracture. The results of this study suggest that graft tensioning in full extension provides a low incidence of flexion deformity, maintaining excellent functional results and satisfactory biomechanics.

Use of the suture anchor in open Bankart reconstruction. A follow-up report.

We previously reported early results of a new technique using a suture anchor to perform a modified Bankart reconstruction. That study included patients from two medical centers and had an average followup of only 1 year. This report includes patients from a single center with followup extended to a mean of 42 months (range, 33 to 61). Between April 1988 and August 1991, 53 patients with recurrent anterior glenohumeral instability underwent modified Bankart reconstruction with the use of a suture anchor. Thirty-two patients met inclusion criteria (identifiable Bankart lesion, open repair with suture anchors, and minimum followup of 2 years); 4 patients were lost to followup. There have been no complications as a result of this technique. Ninety-three percent of the patients in the study had objectively excellent or good results. There were 2 failures with recurrent anterior dislocation. The use of a suture anchor can simplify the Bankart reconstruction. At average followup of 3 years, 26 patients have returned to presurgery activity levels without recurrent dislocation or subluxation. However, careful attention to anchor placement at the junction of articular cartilage and the glenoid neck is necessary to avoid technical failure.

Dacron ligament reconstruction for chronic anterior cruciate ligament insufficiency.

We report the 5-year follow-up results of a prospective, multicenter study evaluating the use of a Dacron prosthetic ligament in reconstruction of anterior cruciate-deficient knees. The study group consisted of 84 patients, followed for at least 5 years. The patients were divided into 2 groups: 50 patients with isolated anterior cruciate ligament laxity (Group 1) and 34 patients with a failed previous anterior cruciate ligament surgery or combined laxities (Group 2). Two surgical techniques were employed: reconstruction through drill holes in the tibia and femur (30 patients) and reconstruction using the over-the-top position with the Dacron ligament wrapped in a strip of iliotibial band (54 patients). The overall failure rate was 35.7% at 5 years. The failure rate at 2 years was 20%, illustrating a significant deterioration of results between the two follow-up intervals. Evaluation of subjective criteria using the Lysholm score showed an improvement from preoperative status at the 2-year followup; however, there was a slight decline when 5-year results were evaluated. Tegner activity levels increased from a mean of 2.9 +/- 2.1 at the preoperative visit, to a mean of 4.9 +/- 2.0 at the 2-year followup and a mean of 5.0 +/- 2.0 at the 5-year visit. These results show that the Dacron ligament prosthesis achieves the short-term goal of restoring stability and improving function and may be sufficient to provide long-term stability for the anterior cruciate-deficient knee.

The effect of meniscal status on knee stability and function after anterior cruciate ligament reconstruction.

The purpose of this study was to examine the relationship of meniscal status at the time of anterior cruciate ligament (ACL) reconstruction with the ultimate function and stability of the knee joint. Seventy-one patients were studied prospectively following bone-patellar tendon-bone ACL reconstruction. Subjects were divided into six subgroups relative to the integrity (intact, partial meniscectomy, complete meniscectomy) of the two menisci. After a minimum of 2 years of follow-up (range 2-4.1 years), 56 subjects were available for subjective, objective, and radiographic assessment. Meniscal status at the time of ACL reconstruction proved to have no significant bearing on the ultimate stability of the knee. However, individuals who had undergone meniscal excision reported subjective complaints and activity limitations more commonly than those with intact menisci (p < 0.05). Radiographic changes also were more common in the meniscectomized subset.

Anterior cruciate reconstruction using a Dacron ligament prosthesis. A long-term study.

A single-center prospective study is presented on 35 patients who underwent anterior cruciate ligament reconstruction using a Dacron ligament prosthesis. All of the reconstructions were performed by the same surgeon, using the same technique. All of the patients had a history of symptomatic chronic ACL insufficiency. The mean follow-up interval for all patients was 50 months. There was an overall failure rate of 37.1% (13 patients), based on the presence of at least one of the following criteria: the presence of a pivot shift; a 2+ or greater anterior drawer or Lachman; instrumented laxity of greater than 3 mm side-to-side translation in 20 degrees of flexion at 89 N; or by arthroscopic documentation. Six of these 13 patients were documented by arthroscopy and 7 were clinical failures. There were 26 patients with only anterior cruciate ligament laxity, and 9 patients with multiple instabilities or failed previous ACL reconstruction ("salvage"). In the group with isolated anterior cruciate ligament insufficiency, the failure rate was 23% (6 patients). In the salvage group, the failure rate was 78% (7 patients). There was a significant improvement in patient performance with respect to clinical laxity, Lysholm scores, and Tegner activity levels at 2 years postoperatively. There has been a subsequent deterioration in the performance of these patients through time.

Modification of the Bankart reconstruction with a suture anchor. Report of a new technique.

We assessed the effectiveness of a new suture anchor that has been designed to anchor sutures into a blind, straight hole drilled in bone. The strength of fixation in glenoid bone is 67 N for the No. 0 anchor and suture, and 82 N for the No. 2 device with suture. During 1988 and 1989, 32 patients underwent a modified Bankart reconstruction for recurrent anterior glenohumeral instability at two centers as part of a prospective study of this modified technique. There were no complications as a result of the technique. The four surgeons involved agreed that the suture anchor simplified the procedure. Seventeen patients have been reviewed, with more than 1 year followup. Ninety-four percent had good to excellent results according to the Bankart rating scale. There was one recurrent dislocation in a football player.