KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study.

OBJECTIVE: The prevalence of radiographic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) approaches 50%, yet the prevalence of significant knee pain is unknown. We applied three different models of Knee injury and Osteoarthritis Outcome Score (KOOS) thresholds for significant knee pain to an ACLR cohort to identify prevalence and risk factors. DESIGN: Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort patients with a unilateral primary ACLR and normal contralateral knee were assessed at 2 and 6 years. Independent variables included patient demographics, validated Patient Reported Outcomes (PRO; Marx activity score, KOOS), and surgical characteristics. Models included: (1) KOOS criteria for a painful knee = quality of life subscale <87.5 and ≥2 of: KOOSpain <86.1, KOOSsymptoms <85.7, KOOSADL <86.8, or KOOSsports/rec <85.0; (2) KOOSpain subscale score ≤72 (≥2 standard deviations below population mean); (3) 10-point KOOSpain drop from 2 to 6 years. Proportional odds models (alpha ≤ 0.05) were used. RESULTS: 1761 patients of median age 23 years, median body mass index (BMI) 24.8 kg/m(2) and 56% male met inclusion, with 87% (1530/1761) and 86% (1506/1761) follow-up at 2 and 6 years, respectively. At 6 years, n = 592 (39%), n = 131 (9%) and n = 169 (12%) met criteria for models #1 through #3, respectively. The most consistent and strongest independent risk factor at both time-points was subsequent ipsilateral knee surgery. Low 2-year Marx activity score increased the odds of a painful knee at 6 years. CONCLUSIONS: Significant knee pain is prevalent after ACLR; with those who undergo subsequent ipsilateral surgery at greatest risk. The relationship between pain and structural OA warrants further study.

Meniscus treatment and age associated with narrower radiographic joint space width 2-3 years after ACL reconstruction: data from the MOON onsite cohort.

OBJECTIVE: To identify risk factors for radiographic signs of post-traumatic osteoarthritis (OA) 2-3 years after anterior cruciate ligament (ACL) reconstruction through multivariable analysis of minimum joint space width (mJSW) differences in a specially designed nested cohort. METHODS: A nested cohort within the Multicenter Orthopaedic Outcomes Network (MOON) cohort included 262 patients (148 females, average age 20) injured in sport who underwent ACL reconstruction in a previously uninjured knee, were 35 or younger, and did not have ACL revision or contralateral knee surgery. mJSW on semi-flexed radiographs was measured in the medial compartment using a validated computerized method. A multivariable generalized linear model was constructed to assess mJSW difference between the ACL reconstructed and contralateral control knees while adjusting for potential confounding factors. RESULTS: Unexpectedly, we found the mean mJSW was 0.35 mm wider in ACL reconstructed than in control knees (5.06 mm (95% CI 4.96-5.15 mm) vs 4.71 mm (95% CI 4.62-4.80 mm), P < 0.001). However, ACL reconstructed knees with meniscectomy had narrower mJSW compared to contralateral normal knees by 0.64 mm (95% C.I. 0.38-0.90 mm) (P < 0.001). Age (P < 0.001) and meniscus repair (P = 0.001) were also significantly associated with mJSW difference. CONCLUSION: Semi-flexed radiographs can detect differences in mJSW between ACL reconstructed and contralateral normal knees 2-3 years following ACL reconstruction, and the unexpected wider mJSW in ACL reconstructed knees may represent the earliest manifestation of post-traumatic osteoarthritis and warrants further study.

Collagen expression and biomechanical response to human recombinant transforming growth factor beta (rhTGF-beta2) in the healing rabbit MCL.

We investigated biomechanical and collagen expression in a healing bilateral rabbit medial collateral ligament (MCL) model to human recombinant transforming growth factor beta (rhTGF-beta2) at three and six weeks. Each rabbit had rhTGF-beta2 in a bioabsorbable pellet administered in one side, with the contralateral side serving as control (no rhTGF-beta2). All MCL healed with rhTGF-beta2 producing a profoundly increased scar mass at three weeks which decreased in size toward control at six weeks. In-situ hybridization demonstrated collagen expression (type I and III) no different than control at three weeks, but by six weeks elevated expression of type I was seen. Biomechanical analysis at three weeks showed no effect of rhTGF-beta2 on structural properties. However, at six weeks rhTGF-beta2 significantly inhibited both the maximum load (p < 0.05) and energy absorbed (p < 0.05) with no change in stiffness. Despite increased type I collagen expression and profound increase in early scar mass, rhTGF-beta2 did not improve the structural properties. Whether the dose or mode of delivery is responsible for decline in structural properties cannot be determined in this design. We hypothesize investigations of healing ligaments to cytokines should have biologic and biomechanical properties correlated in the same study at a minimum of two time points.

Cryotherapy: an effective modality for decreasing intraarticular temperature after knee arthroscopy.

Cryotherapy is a modality commonly used after arthroscopic procedures. We divided 17 patients into two groups after routine knee arthroscopy: 12 patients were immediately treated with ice and 5 control patients were treated without ice for the first hour. In all patients, thermocouple probes were placed intraarticularly into the lateral gutter of the knee. Ice was placed on the operative knees of the treatment group for 2 hours. The control group had no intervention for the 1st hour and then had ice applied for the 2nd hour. Temperatures were continually recorded every minute for 2 hours. The temperature in the treatment group declined significantly, by 2.2 degrees C (95% confidence interval [-3.6 degrees C, -0.72 degrees C]) over the 1st hour and by 0.79 degrees C (95% CI [-1.8 degrees C, 0.18 degrees C]) over the 2nd hour (P = 0.008). The temperature in the control group increased significantly, by 5.0 degrees C (95% CI [2.4 degrees C, 7.5 degrees C]) over the 1st hour (P = 0.006). After ice was applied, the temperature fell significantly, by 4.0 degrees C (95% CI [-8.3 degrees C, 0.26 degrees C]) (P = 0.06). The difference between the temperature decrease in the treatment group and the increase in the control group at 60 minutes was 7.1 degrees C. This is the first rigorously conducted study in human patients that documents a statistically significant decline in intraarticular knee temperature with the application of ice and compression to the skin. The mechanism by which cryotherapy acts must therefore include the cooling effect on the intraarticular environment and synovium.

Analgesia with femoral nerve block for anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction is performed routinely as an outpatient surgical procedure despite few studies of patient acceptance or postoperative patient analgesia. This study reports the first series of postoperative femoral nerve blocks as analgesia for outpatient anterior cruciate ligament reconstruction. The authors retrospectively reviewed 161 patients undergoing two incision arthroscopically assisted autograft middle 1/3 patellar tendon anterior cruciate ligament reconstruction on an out-patient basis at the authors' institution during a period of 30 months. Hospital and anesthesia records were reviewed, and 83% of patients were contacted retrospectively to survey their perceptions of the procedure and its outcome. Ninety-eight percent of the patients were discharged from the ambulatory surgery center, with 51% discharged the same day as the surgery and 47% discharged by 7:00 AM the next day. As the study progressed, the number of patients staying overnight was reduced by 50%. Ninety-eight percent of patients surveyed found femoral nerve block to be beneficial, and the same percentage thought the discharge time was appropriate. However, 69% of patients staying overnight cited reasons other than pain as factors in their stay. No significant complications were reported. Based on these results, the administration of a femoral nerve block is recommended for patients undergoing outpatient anterior cruciate ligament reconstruction because it is a highly effective form of analgesia with an excellent degree of patient satisfaction.

Stress fractures in skeletally immature patients.

Stress fractures are a common injury in an active population. As children become increasingly involved in organized sports, the recognition of stress fractures and differentiation from infections or neoplasms requires a knowledge of their most common sites, presentation, and clinical course. We retrospectively reviewed 34 stress fractures in 32 skeletally immature patients from June 1977 to May 1993. Age, fracture location, treatment, time to union or healing, associated conditions, complications, radiographs, and clinical outcome were recorded. Fifty percent of patients were involved in sports; the most common complaint was pain with activity. The most common site was the tibia (47%) followed by the fibula (21%) and femur (12%). All had resolution of symptoms and returned to normal activity. All but two healed with either activity modification or cast immobilization. The radiographic findings included early periosteal callus formation that rapidly consolidated to new bone on serial studies. A careful history, physical examination, and radiographs can help diagnose most common stress fractures in the skeletally immature individual and can differentiate stress fractures from infection or neoplasm with appropriate conservative treatment.

Femoral nerve block as an alternative to parenteral narcotics for pain control after anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) reconstruction is associated with significant postoperative pain, usually requiring parenteral narcotics. A prospective study of arthroscopically assisted autograft patellar tendon ACLR was initiated using Winnie's "three-in-one" femoral nerve block (FNB) as the primary means of postoperative pain control. Patient satisfaction and absence of parenteral narcotic use indicated clinical success. Of 24 patients studied, 92% had no parenteral narcotics administered following FNB. Ninety-five percent of patients believed FNB was beneficial and would request another. The average duration of pain control was 29 hours and the majority of patients (79%) believed discharge was possible within 23 hours. There were two patients who failed to respond to FNBs (8%) and no major complications. FNB is a safe, reliable, and effective form of analgesia following ACLR, eliminating the need for parenteral narcotics.

Osteomyelitis of the pubic symphysis in athletes: a case report and literature review.

Groin pain is a common problem in athletes. Osteitis pubis, a chronic inflammatory condition involving the pubic symphysis, is a rare cause, and pyogenic osteomyelitis of the pubis is seen even more rarely in healthy athletes. We report one of four cases of pyogenic osteomyelitis of the pubis seen at our institution, review our experience with all four cases, and present a review of the literature (7 cases). The diagnosis is established by the presence of extreme pain, point tenderness at the pubic symphysis, fever, and either a positive culture of blood, needle aspiration, or open biopsy of the pubis. White blood cell count, erythrocyte sedimentation rate, and the results of bone scan and computerized tomography may initially be normal and therefore cannot exclude the diagnosis. Prompt treatment with intravenous (i.v.) antibiotics effective against Staphylococcus aureus (causative organism in all documented cases-9/11) should initially be administered and then guided by culture and sensitivity information. Oral antibiotics should be given if the infection is responsive to i.v. antibiotic treatment. Prompt recognition and treatment with antibiotics may obviate the need for surgical debridement. All athletes who returned to sports activity did so by 6 months after diagnosis.

Prospective study of osseous, articular, and meniscal lesions in recent anterior cruciate ligament tears by magnetic resonance imaging and arthroscopy.

Fifty-four patients with anterior cruciate ligament tears that were arthroscopically reconstructed within 3 months of initial injury were prospectively evaluated. Patients with grade 3 medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament tears were excluded. Eighty percent of our patients had a bone bruise present on the magnetic resonance image, with 68% in the lateral femoral condyle. Two of the latter findings--an abnormal articular cartilage signal (P = 0.02) and a thin and impacted subchondral bone (P = 0.03)--had a significant relationship with injury to the overlying articular cartilage. Meniscal tears were found in 56% of the lateral menisci and 37% of the medial menisci. A significant association was present between bone bruising on the lateral femoral condyle and the lateral tibial plateau (P = 0.02). Results of our study support the concept that the common mechanism of injury to the anterior cruciate ligament involves severe anterior subluxation with impaction of the posterior tibia on the anterior femur. Determination of the significance of bone bruising, articular cartilage injury, or meniscal tears will require a long-term followup that includes evaluation for arthritis, stability, and function. These 54 patients represent the first cohort evaluated in this ongoing prospective clinical study.

Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value.

The sensitivity, specificity, and predictive value of magnetic resonance imaging in the diagnosis of lesions of the rotator cuff, glenohumeral capsule, and glenoid labrum were evaluated in ninety-one patients and fifteen asymptomatic volunteers. Magnetic resonance imaging demonstrated 100 per cent sensitivity and 95 per cent specificity in the diagnosis of complete tears, and it consistently predicted the size of the tear of the rotator cuff. There was a definite correlation between atrophy of the supraspinatus muscle and the size of a complete, chronic tear of the rotator cuff. The sensitivity and specificity of magnetic resonance imaging in the differentiation of tendinitis from degeneration of the cuff were 82 and 85 per cent, and in the differentiation of a normal tendon from one affected by tendinitis with signs of impingement the sensitivity and specificity were 93 and 87 per cent. The formation of spurs around the acromion and acromiocalvicular joint correlated highly with increased age of the patient and with chronic disease of the rotator cuff. The sensitivity and specificity of magnetic resonance imaging in the diagnosis of labral tears associated with glenohumeral instability were 88 and 93 per cent. The study showed that high-resolution magnetic-resonance imaging is an excellent non-invasive tool in the diagnosis of lesions of the rotator cuff and glenohumeral instability.