Effects of intraarticular IL1-Ra for acute anterior cruciate ligament knee injury: a randomized controlled pilot trial (NCT00332254).

OBJECTIVE: To evaluate the clinical effectiveness of intraarticular IL-1 receptor antagonist (IL-1Ra) for anterior cruciate ligament (ACL) tear. METHODS: Eleven patients with acute ACL tear confirmed by magnetic resonance imaging (MRI) were randomized to receive a single intraarticular injection of IL-1Ra (anakinra 150 mg, n = 6) or equal volume of saline placebo (1 ml, n = 5). The double-blinded treatment was administered a mean 2 weeks after injury. Synovial fluid (SF) (n = 9 patients) and sera (all patients) were available at baseline (prior to injection) and immediately prior to surgery (mean 35 days later) and analyzed for SF IL-1α, IL-1ß, IL-1Ra and serum hyaluronan (HA), an indicator of synovial inflammation. The primary outcome, standardized Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, was obtained at 0 (baseline), 4, and 14 days after injection. RESULTS: Compared with placebo, the IL-1Ra group had substantially greater improvement in key outcomes over 14 days (KOOS pain P = 0.001; activities of daily living P = 0.0015; KOOS sports function P = 0.0026; KOOS quality of life (QOL) P = 0.0048; and total KOOS P < 0.0001). There were no adverse reactions in either group. SF IL-1α (P = 0.05) and serum HA (P = 0.03), but not IL-1ß, or IL-1Ra, decreased significantly in the IL-1Ra but not the placebo treated patients. Compared with placebo, IL-1α was borderline significantly different in the IL-1Ra treated group (P = 0.06). CONCLUSIONS: Administered within the first month following severe knee injury, IL-1Ra reduced knee pain and improved function over a 2-week interval. This promising proof of concept study provides a new paradigm for studies of acute joint injury and suggests that a larger follow-up study is warranted.

The effects of femoral graft placement on in vivo knee kinematics after anterior cruciate ligament reconstruction.

Achieving anatomical graft placement remains a concern in Anterior Cruciate Ligament (ACL) reconstruction. The purpose of this study was to quantify the effect of femoral graft placement on the ability of ACL reconstruction to restore normal knee kinematics under in vivo loading conditions. Two different groups of patients were studied: one in which the femoral tunnel was placed near the anterior and proximal border of the ACL (anteroproximal group, n=12) and another where the femoral tunnel was placed near the center of the ACL (anatomic group, n=10) MR imaging and biplanar fluoroscopy were used to measure in vivo kinematics in these patients during a quasi-static lunge. Patients with anteroproximal graft placement had up to 3.4mm more anterior tibial translation, 1.1mm more medial tibial translation and 3.7° more internal tibial rotation compared to the contralateral side. Patients with anatomic graft placement had motion that more closely replicated that of the intact knee, with anterior tibial translation within 0.8mm, medial tibial translation within 0.5mm, and internal tibial rotation within 1°. Grafts placed anteroproximally on the femur likely provide insufficient restraint to these motions due to a more vertical orientation. Anatomical femoral placement of the graft is more likely to reproduce normal ACL orientation, resulting in a more stable knee. Therefore, achieving anatomical graft placement on the femur is crucial to restoring normal knee function and may decrease the rates of joint degeneration after ACL reconstruction.

A comparison of cleat types during two football-specific tasks on FieldTurf.

OBJECTIVE: To examine the effect of different cleat plate configurations on plantar pressure during two tasks. DESIGN: Thirty-six athletes ran an agility course 5 times while wearing 4 different types of Nike Vitoria cleats: (1) bladed, (2) elliptical firm ground, (3) hard ground and (4) turf. Plantar pressure data were recorded during a side cut and a cross cut using Pedar-X insoles. SETTING: Controlled laboratory study PARTICIPANTS: No history of lower extremity injury in the past 6 months, no previous foot or ankle surgery, not currently wearing foot orthotics and play a cleated sport at least twice a week. MAIN OUTCOME MEASUREMENTS: Total foot contact time, contact area, maximum force, peak pressure and the force-time integral (FTI) in the medial, middle and lateral regions of the forefoot were collected. A 1x4 ANOVA (alpha = 0.05) was performed on each dependent variable. A Bonferroni adjustment was conducted (alpha = 0.008). RESULTS: In the cross cut task, statistical differences between cleats were observed in three variables: total foot peak pressure, lateral forefoot FTI, and lateral forefoot normalised maximum force. In the side cut task, statistical differences between cleats were observed in 4 variables: total foot peak pressure, the medial and middle forefoot FTI, and the medial and middle forefoot normalised maximum force. CONCLUSIONS: Significant differences in forefoot loading patterns existed between cleat types. Based on the results of this study, it might be beneficial to increase the forefoot cushioning in cleats in an attempt to decrease loading in these regions of the foot.

Development of a virtual reality arthroscopic knee simulator.

The virtual reality arthroscopic knee simulator (VR-AKS) consists of a computer platform, a video display, and two force-feedback (haptic) interfaces which also monitor the position of the instruments in the user's hands. The forces that the user would normally apply to the lower limb during arthroscopy are directed through an instrumented surrogate leg. Proprietary software furnishes the mathematical representation of the physical world and replicates the visual, mechanical, and behavioral aspects of the knee while task-oriented programs monitor and record specific areas of user performance. A prototype has demonstrated the feasibility of the system and work on the first, fully functional simulator will begin soon.

Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group).

The purpose of this study was to gain insight into the pathophysiologic processes of severe lower-abdominal or inguinal pain in high-performance athletes. We evaluated 276 patients; 175 underwent pelvic floor repairs. Of the 157 athletes who had not undergone previous surgery, 124 (79%) participated at a professional or other highly competitive level, and 138 patients (88%) had adductor pain that accompanied the lower-abdominal or inguinal pain. More patients underwent related adductor releases during the later operative period in the series. Evaluation revealed 38 other abnormalities, including severe hip problems and malignancies. There were 152 athletes (97%) who returned to previous levels of performance. The syndrome was uncommon in women and the results were less predictable in nonathletes. A distinct syndrome of lower-abdominal/adductor pain in male athletes appears correctable by a procedure designed to strengthen the anterior pelvic floor. The location and pattern of pain and the operative success suggest the cause to be a combination of abdominal hyperextension and thigh hyperabduction, with the pivot point being the pubic symphysis. Diagnosis of "athletic pubalgia" and surgery should be limited to a select group of high-performance athletes. The consideration of other causes of groin pain in the patient is critical.

Tibia and fibula fractures in soccer players.

We performed a retrospective review of 31 athletes who sustained a fracture of the lower leg from a direct blow while playing soccer. Fifteen fractures involved both the tibia and fibula 11 only the tibia, and 5 only the fibula. Information was collected using a standardized questionnaire. The mean follow-up from the time of injury was 30 months. Injuries typically occurred in young, competitive athletes during game situations. The mechanisms were broadly classified into several categories: contact during a slide tackle (13, 42%), a collision with the goalkeeper (8, 26%), two opposing players colliding while swinging for a loose ball (7, 23%), or a player being kicked by a standing opponent (3, 10%). The majority of fractures (26, 90%) occurred while the athletes were wearing shin guards. The point of impact was with the shin guard prior to the fracture in 16 cases (62%). Return to competitive soccer averaged 40 weeks for combined tibia and fibula fractures, 35 weeks for isolated tibia fractures, and 18 weeks for isolated fibula fractures. Injuries were associated with a high incidence of major complications (12 out of 31, 39%), especially in concurrent tibia and fibula fractures (8 out of 15, 50%). These findings suggest that lower leg fractures in soccer players are serious injuries, often necessitating a prolonged recovery time. In addition, this study questions the ability of shin guards to protect against fractures.

Snapping popliteal tendon as a source of lateral knee pain.

A 25-year-old female patient underwent surgery for a history of pain and popping on the lateral aspect of her right knee. It was initially thought that the patient had iliotibial (IT) band syndrome which was refractory to conservative treatment. However, upon release of the IT band, the snapping which was audible and palpable pre-operatively was still present. Further exploration of the posterior-lateral aspect of the knee revealed that the popliteal tendon was snapping over the incisura poplitea extensoria on the lateral femoral condyle. Excision of the prominent portion of the articular ridge below the sulcus popliteus eliminated the snapping sensation. The patient has remained asymptomatic since surgery for the past 22 months.

Comparison of synovial fluid cartilage marker concentrations and chondral damage assessed arthroscopically in acute knee injury.

OBJECTIVE: To examine the correlation between synovial fluid cartilage markers and degree of cartilage damage determined by arthroscopic evaluation in subjects with acute knee injury. DESIGN: Chondral damage was quantified using a validated arthroscopic scoring system in 20 subjects with effusive acute knee injuries of less then 4 months duration and no history or radiographic evidence of joint pathology. Levels of synovial fluid 3B3(-) neoepitope, 3B3(+) chondroitinase generated epitope of proteoglycan, keratan sulfate (KS) and hyaluronic acid (HA) were measured by competitive enzyme-linked immunosorbent assays using monoclonal antibodies 3B3 and 5D4. Total sulfated glycosaminoglycan (GAG) was measured by 1,9-dimethylmethylene blue colorimetric dye-binding assay. RESULTS: We found a dramatic decrease in levels of 3B3(-) (rs = -0.62, P = 0.004), and GAG (rs = -0.49, P = 0.03) with increasing chondral damage score; but no correlation of damage score with 3B3(+), KS or HA levels. CONCLUSION: These data reveal a change in cartilage metabolism within the first 4 months of symptomatic knee injury evinced by a significant inverse correlation of 3B3(-) and GAG levels to chondral lesion severity. These results suggest that serial measurement of these synovial fluid markers in the setting of acute knee injury could predict chondral lesion severity and aid in the decision to intervene surgically.

What would you do? Acute extension block caused by anterior cruciate ligament tear: a case report.

Acute knee locking is usually attributed to a displaced meniscus tear. This case involved late diagnosis of mechanical extension block caused by anterior displacement of a torn anterior cruciate ligament (ACL) with impingement in extension. Definitive reconstruction was delayed after debridement of the ACL stump to improve preoperative range of motion. Despite this, the patient still had difficulty regaining extension after surgery. Early treatment of mechanical extension block may facilitate motion recovery after ACL reconstruction.

Acute dislocation of the patella. A correlative pathoanatomic study.

The objective of our study was to elucidate the characteristic pathoanatomy associated with patellar dislocation and report the preliminary results of early surgical repair. Twenty-three patients with documented patellar dislocation had standard radiographs and a magnetic resonance imaging scan. Intraarticular lesions were evaluated and treated arthroscopically followed by an open exploration of the medial aspect of the knee in 16 patients. Twelve patients were observed for a minimum of 2 years after surgical repair (average, 34 months). Eleven patients returned for a follow-up examination. Magnetic resonance imaging revealed effusion (100%), tears of the femoral insertion of the medial patellofemoral ligament (87%), increased signal in the vastus medialis muscle (78%), and lateral femoral condyle (87%) and medial patellar (30%) bone bruises. Arthroscopic examination revealed osteochondral lesions involving the patella and the lateral femoral condyle in 68% of cases. Open surgical exploration revealed tears of the medial patellofemoral ligament off the femur in 15 of 16 patients (94%). After medial patellofemoral ligament repair, none of the patients experienced recurrent dislocation. Overall 58% of the results were considered to be good or excellent and 42% were fair. Fifty-eight percent of the group returned to their previous sport with no or minor limitations.

Incomplete, intrasubstance strain injuries of the rectus femoris muscle.

Rectus femoris muscle strain injuries commonly occur at the distal muscle-tendon junction of the quadriceps tendon. However, we have recently recognized a pattern of strain injury that consists of an incomplete intrasubstance tear at the muscle-tendon junction formed by the deep tendon of the muscle's indirect head and those muscle fibers originating from this tendon. These injuries are found more proximally within the thigh than the "classic" distal rectus femoris muscle strain. We reviewed 10 athletes with these intrasubstance tears, all of whom had diagnostic imaging performed using computed tomography or magnetic resonance imaging or both. Two of these patients required surgical intervention. The mechanism of injury usually involved kicking or sprinting. All patients had chronic thigh pain or an anterior thigh mass or both. Physical examination revealed thigh asymmetry and a nontender to mildly tender intrasubstance muscle mass. Magnetic resonance imaging demonstrated abnormal signal intensity centered about the intramuscular tendon of the indirect head of the muscle. Surgical findings included a mass of fibrous scar and fatty tissue encasing the deep tendon. Surgical removal of this fibrous mass appears curative. We contrast this injury from distal strains of the rectus femoris muscle, as well as from soft tissue neoplasms.

Graft isometricity in unitunnel anterior cruciate ligament reconstruction: analysis of influential factors using a radiographic model.

A radiographic model was developed to investigate the influence of three surgical variables on the change in attachment point distance (CAPD) of a hypothetical graft using the unitunnel technique of anterior cruciate ligament (ACL) reconstruction. Using three different femoral target points, we tested the hypothesis that varying the angle of knee flexion between 70 degrees and 110 degrees and varying the tibial starting point over a 4-cm range do not result in a significant variation in CAPD. We also tested the hypothesis that the CAPD from 0 degrees to 135 degrees is greater than the CAPD from 0 degrees to 90 degrees. There was a statistically significant correlation (r = 0.8465, P < 0.0001) between radiographically estimated and isometer-measured values of CAPD. The tibial starting point and the femoral target point were found to affect the CAPD significantly (P < 0.005). A more proximal tibial starting point was associated with a lower CAPD. Both the center of the anatomic femoral attachment of the ACL, and a point 1 mm medial to the junction of the roof and lateral wall of the femoral intercondylar notch and 6 mm anterior to its posterior margin, were associated with lower CAPD values than a target point 5 mm superior and posterior to the center of the femoral ACL attachment. The angle of knee flexion did not significantly affect the CAPD. The CAPD [0 degrees-135 degrees] was significantly greater than the CAPD [0 degree-90 degrees] for all combinations of variables (P < 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

The medial patellofemoral ligament revisited: an anatomical study.

The purpose of this study was to provide a comprehensive description of the anatomy of the medial patellofemoral ligament (MPFL). The anterior and medial aspects of 4 unpreserved and 16 preserved cadaveric human knees were dissected with particular attention being paid to the relationship of the various layers to one another and to the place of the MPFL within these layers. We confirmed that the MPFL is a distinct structure lying within layer II. Its bulk varies considerably between individuals but not from side to side in a given individual. The visualisation, attachments, and gross morphology of the ligament are described. The attachments of the MPFL and the orientation of its fibres suggest that it may have a role in limiting lateral excursion of the patella. The common attachment of the tendon of the vastus medialis muscle and the ligament to the superomedial patella suggests that there may be a dynamic element to such a stabilising function.

An algorithm for arthroscopy in the over-50 age group.

We conducted a retrospective study to identify the preoperative variables that correlated with a successful outcome for knee arthroscopy in patients over the age of 50. We mailed questionnaires to 94 patients (57 responded) and reviewed their medical records and radiographs. A modified Hospital for Special Surgery knee rating system was devised. The average follow-up was 33 months. The percentage of those who felt they had successful results decreased with time: 82.8% felt their knees had improved immediately after postoperative rehabilitation; this decreased to 78.1% at 6 months, 73.5% at 1 year, 65.5% at 2 years, and 50.0% at 3 years. Therefore, the subjective success rate was 67%. We performed statistical analysis of all variables to determine which had a beneficial or detrimental effect on outcome. In addition, we devised an equation to allow postoperative prediction of score. We found that age was not a factor and that radiographic findings had the greatest impact on postoperative results.

Commentary and historical perspective of anterior cruciate ligament rehabilitation.

This article serves as the introduction and historical perspective of anterior cruciate ligament surgery and rehabilitation. Several physician-therapist teams have been invited to share their "state of the art" techniques and to contrast their programs to that espoused by Shelbourne and Nitz in 1990. Our commentary/review of "Accelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction" (Shelbourne KD, Nitz P, Am J Sports Med 18:292-299, 1990) is provided to contextualize the reader to what most clinicians would recognize as an extremely aggressive rehabilitation approach that is being popularized in the 1990s. A comparison is then presented of the rehabilitation sequence used in the MacIntosh procedures, demonstrating how early motion/functional rehabilitation was the hallmark of this type of extraarticular rehabilitation sequence and how today's pattern has evolved to follow that philosophy. Each of the teamed authors has attempted to present his surgery and rehabilitation/techniques and highlight differences between his program and that of Shelbourne and Nitz. We hope that the readers find this glimpse of the past and present helpful in formulating their rehabilitation sequences and that the future will be predicated on excellent basic science and clinical judgment. J Orthop Sports Phys Ther 1992;15(6):265-269.

Magnetic resonance imaging of traumatic knee articular cartilage injuries.

The purpose of this study was to assess the sensitivity of magnetic resonance imaging in determining the presence of articular cartilage injuries of the knee with arthroscopy as the standard for comparison. Forty-nine articular cartilage lesions were documented in 28 knees (27 patients) by arthroscopy. There were 22 men and 5 women with an average age of 29 years. Multiplanar magnetic resonance imaging was performed with spin echo and gradient-refocused acquisition in a steady state pulse technique. All of the knees had magnetic resonance imaging done within 4 weeks prior to arthroscopy. The magnetic resonance images were interpreted before arthroscopy and interpreted again after the results of arthroscopy were known to better define the potential learning curve for evaluating chondral lesions and to identify the technical limits of the existing imaging protocol/software. For full-thickness articular cartilage lesions, the prearthroscopy sensitivity of magnetic resonance imaging was 41% (12/29) and the postarthroscopy sensitivity was 83% (24/29). For partial-thickness chondral injury, the prearthroscopy sensitivity of magnetic resonance imaging was 15% (3/20) and the postarthroscopy sensitivity was 55% (11/20). The presence of an intraarticular effusion assisted the detection of chondral lesions because of an "arthrogram" effect. As a noninvasive method of evaluating articular cartilage and despite experienced interpretation and the benefit of retrospective analysis, both the prearthroscopy and the postarthroscopy sensitivity of magnetic resonance imaging was low using the imaging parameters described. Injury to articular cartilage is a frequent cause of knee pain and knee surgery; it is important to note at this time that magnetic resonance imaging cannot reliably exclude the presence of an articular cartilage injury.

Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia.

There has been increasing interest within the European sports medicine community regarding the etiology and treatment of groin pain in the athlete. Groin pain is most commonly caused by musculotendinous strains of the adductors and other muscles crossing the hip joint, but may also be related to abdominal wall abnormalities. Cases may be termed "pubalgia" if physical examination does not reveal inguinal hernia and there is an absence of other etiology for groin pain. We present nine cases of patients who underwent herniorrhaphies for groin pain. Two patients had groin pain without evidence of a hernia preoperatively (pubalgia). In the remaining seven patients we determined the presence of a hernia by physical examination. At operation, eight patients were found to have inguinal hernias. One patient had no hernia but had partial avulsion of the internal oblique fibers from their insertion at the public tubercle. The average interval from operation to return to full activity was 11 weeks. All patients returned to full activity within 3 months of surgery. One patient had persistent symptoms of mild incisional tenderness, but otherwise there were no recurrences, complications, or persistence of symptoms. Abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the internal oblique muscle, can be an overlooked source of groin pain in the athlete. Operative treatment of this condition with herniorrhaphy can return the athlete to his sport within 3 months.

Arthroscopic subacromial decompression: results in advanced impingement syndrome.

A study group composed of 25 shoulders in 24 patients underwent arthroscopic subacromial decompression for advanced impingement syndrome. There were no full thickness rotator cuff tears, biceps tendon ruptures, significant acromioclavicular arthrosis, or evidence of glenohumeral instability. Twenty men and four women ranging in age from 18 to 63 years (mean age 37) with dominant arm involvement in 17/24 were evaluated for an average follow-up of 20.3 months (range 14-32) postoperatively. Operative results were based on the UCLA shoulder rating scale. Eighty-eight percent of the cases (22/25) had good or excellent results. Twelve percent had fair results (3/25). There were no poor results. The average UCLA pain score improved from 2.6 preoperative (constant pain) to 7.8 postoperative (occasional pain). Ninety-two percent of the patients were satisfied, said they were better, and that they would have the surgery again. Arthroscopic subacromial decompression is recommended as an alternative to open anterior acromioplasty in advanced impingement syndrome.

Evaluation of acute traumatic hemarthrosis of the knee joint.

Acute hemarthrosis of the knee usually results from a significant injury. Preoperative assessment, examination under anesthesia, and arthroscopic examination were conducted on patients with a total of 132 acutely injured knees associated with hemarthrosis and minimal clinical laxity to determine the presence and extent of injury to ligamentous and/or intra-articular structures. Partial or complete tear of the anterior cruciate ligament was found in 101 (77%) of the knees. Peripheral meniscal tears were responsible for the hemarthrosis in 17 cases (13%), and osteochondral fractures were found in 11 cases (8%). Injury to the anterior cruciate ligament was frequently associated with concomitant injury to other structures: meniscal tears (61%), ligament/capsular injury (40%), and hyaline chondral damage (16%). Patients' responses to preoperative anterior drawer, pivot shift, and Lachman tests were within normal limits in 18%, 29%, and 73% of cases, respectively. Patients under anesthesia responded to the anterior drawer and pivot shift tests normally 50% and 74% of the time. The Lachman test, performed under anesthesia, was 98% accurate in predicting anterior cruciate injury. Experience gained in evaluating posttraumatic hemarthrosis of the knee suggests clinical examination alone may not demonstrate the severity of many of these injuries. Arthroscopy, although not necessary to determine competence of the anterior cruciate ligament, is invaluable in determining the existence of other injuries with or without an associated anterior cruciate ligament tear.