Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons.

PURPOSE: Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction. LEVEL OF EVIDENCE: Cross sectional study, Level IV. METHODS: Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport. RESULTS: A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1 years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9 months in 67% and overall 94% from 6 to 12 months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery. CONCLUSION: Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6 months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.

Synovial chemokine expression and relationship with knee symptoms in patients with meniscal tears.

OBJECTIVE: In patients with knee OA, synovitis is associated with knee pain and symptoms. We previously identified synovial mRNA expression of a set of chemokines (CCL19, IL-8, CCL5, XCL-1, CCR7) associated with synovitis in patients with meniscal tears but without radiographic OA. CCL19 and CCR7 were also associated with knee symptoms. This study sought to validate expression of these chemokines and association with knee symptoms in more typical patients presenting for meniscal arthroscopy, many who have pre-existing OA. DESIGN: Synovial fluid (SF) and biopsies were collected from patients undergoing meniscal arthroscopy. Synovial mRNA expression was measured using quantitative RT-PCR. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was administered preoperatively. Regression analyses determined if associations between chemokine mRNA levels and KOOS scores were independent of other factors including radiographic OA. CCL19 in SF was measured by ELISA, and compared to patients with advanced knee OA and asymptomatic organ donors. RESULTS: 90% of patients had intra-operative evidence of early cartilage degeneration. CCL19, IL-8, CCL5, XCL1, CCR7 transcripts were detected in all patients. Synovial CCL19 mRNA levels independently correlated with KOOS Activities of Daily Living (ADL) scores (95% CI [-8.071, -0.331], P = 0.036), indicating higher expression was associated with more knee-related dysfunction. SF CCL19 was detected in 7 of 10 patients, compared to 4 of 10 asymptomatic donors. CONCLUSION: In typical patients presenting for meniscal arthroscopy, synovial CCL19 mRNA expression was associated with knee-related difficulty with ADL, independent of other factors including presence of radiographic knee OA.

Dissociative energy flow, vibrational energy redistribution, and conformeric structural dynamics in bifunctional amine model systems.

Time-resolved multiphoton ionization mass spectrometry coupled with Rydberg Fingerprint Spectroscopy (RFS) has been used to analyze the structural and electronic dynamics of N,N-dimethylphenethylamine (PENNA) and N,N-dimethylcyclohexethylamine (CENNA). In PENNA, the molecule converts from 3p to 3s on a time scale of 149 fs, a process that is reflected in the mass spectrum as the onset of fragmentation. Once in 3s, the overall signal intensity of the PENNA 3s signal shows biexponential decay kinetics, which is attributed to the electronic curve crossing from the Rydberg state to a dissociative antibonding orbital of the ethylenic bridge. This curve crossing exemplifies a possible fragmentation pathway observed in electron capture dissociation of proteins. The initially fast reaction (1.3 ps) is greatly slowed down as a result of an apparent relaxation process with a 5.6 ps time constant. The electron binding energy of the 3s Rydberg state of PENNA is observed to shift with a time constant of 4.8 ps, which is correlated to a cation-π interaction driven conformeric rearrangement.

Outpatient anterior cruciate ligament reconstruction: an analysis of charges and perioperative complications.

All outpatient anterior cruciate ligament (ACL) reconstructions using patellar tendon autograft performed at an accredited outpatient surgical center between 1994 and 1998 were prospectively studied. Hospital charges pertaining to the procedures were examined, and perioperative morbidities that might be attributed to an outpatient procedure were evaluated. The study group comprised 284 patients; average patient age at surgery was 28.7 years. Patients were subgrouped into group 1 (isolated ACL reconstructions; n=163), group 2 (ACL reconstructions and meniscal repair; n=48), and group 3 (ACL reconstructions and partial meniscectomy; n=73). Surgicenter facility charges, reoperation rate, complication rate, motion, pain management, hospital emergency room visits, hospital admission, and outpatient surgical facility visits were analyzed. Historical controls from our hospital and our initial outpatient pilot study (May 1994 through November 1995) were used as financial controls. The average surgical center charge for all patients was $3,443. On average, there was a $600 increase for all subgroups from May 1994 through November 1995 compared to December 1995 through August 1998. In the latter time interval, the fixed facility charges were $3,150, $4,075, and $4,275 for groups 1, 2, and 3, respectively. Overall, 19 (7%) patients required a reoperation including 7 (2.5%) patients who required arthroscopic debridement for symptomatic motion deficits. This study expands on our initial published report regarding hospital charges pertaining to an outpatient ACL reconstruction. Extended over another 4 years, we noted slight increases reflective of regional inflationary increases. Compared to our initial inpatient study (1988-1993), significant charge reductions were maintained. This study demonstrated a low complication rate and high patient subjective satisfaction level.

Anterior cruciate ligament reconstruction in men and women: An outcome analysis comparing gender.

PURPOSE: Recent studies have shown that female athletes suffer a higher incidence of anterior cruciate ligament (ACL) tears than comparable male athletes. The purpose of this study was to evaluate the effect gender has on outcome in ACL reconstruction using bone-patellar tendon-bone autograft. TYPE OF STUDY: Retrospective case review and outcome study. METHODS: A retrospective review of a single surgeon's practice revealed 279 ACL reconstructions that met our criteria for inclusion. Two-hundred forty-nine of these patients (91%) were contacted. Two-hundred (72%) were evaluated with physical examination, KT-1000 testing, functional testing, and radiographic evaluation. Outcome was assessed with Tegner, Lysholm, modified HSS, and Cincinnati Knee rating scales, as well as the SF-36 health survey and a self-administered questionnaire. There were 137 men and 63 women. Data were evaluated with Wilcoxon rank sum testing, analysis of variance testing, chi-square analysis, and the Student t test. The level of significance was set at P <.05. RESULTS: Postoperatively, no differences were noted on Lachman, anterior drawer, pivot shift, or functional testing in either groups. Male patients had a significantly greater mean prone heel height difference (1.80 v 1.10 cm, P =.0018) and mean KT-1000 maximum manual side-to-side difference (0.76 v 1.73 mm, P =.014). However, no differences were noted in the percentage of patients with greater than 5-mm side-to-side difference, with 5 men (4%) and 2 women (3%) classified as arthrometric failures. No differences were noted in mean Tegner, Lysholm, Noyes Cincinnati, and modified HSS scores. Men had significantly lower HSS radiographic scores (24.98 v 26.22, P =.0016). Men and women were compared with gender-matched controls for SF-36 testing, and women scored higher compared with controls than did men in the Role Physical, Body Pain, and General Health categories. No differences were noted in either group regarding donor-site pain, patellofemoral crepitance, or problems with stair climbing. Ninety-six percent of men and 98% of women would have had the surgery over again given similar circumstances. CONCLUSIONS: Objective criteria failed to detect clinically significant differences in physical examination and arthrometric results between men and women. Knee rating scale scores were similar. Comparable outcome with high satisfaction and equal success can be expected in both men and women undergoing ACL reconstruction using bone-patellar tendon-bone autograft. No basis exists for the inclusion of gender as a determining factor regarding the decision to perform ACL reconstructive surgery with bone-patellar tendon-bone autograft.

Dynamic function after anterior cruciate ligament reconstruction with autologous patellar tendon.

The purpose of this study was to dynamically assess the functional outcome of patients who had undergone successful anterior cruciate ligament reconstruction using an autologous patellar tendon technique and to determine whether their dynamic knee function was related to quadriceps and hamstring muscle strength. The knee kinematics and kinetics of 22 subjects who had undergone anterior cruciate ligament reconstruction (mean age, 27 +/- 11 years) and of 22 age- and sex-matched healthy control subjects were determined during various dynamic activities using a computerized motion analysis and force plate system. The differences in the sagittal plane angles and external moments between the two groups during light (walking), moderate (climbing and descending stairs), and higher-demand (jogging, jog and cut, jog and stop) activities were related to isokinetic strength measurements. Although patients who are asymptomatic and functioning well after anterior cruciate ligament reconstruction can perform normally in light activities, higher-demand activities reveal persistent functional adaptations that require further study.

Outcomes of anterior cruciate ligament reconstruction in patients with Workers' Compensation claims.

SUMMARY: A general perception exists that outcomes of orthopaedic procedures in patient's with Workers' Compensation claims fare worse than those of patients without such claims. We retrospectively reviewed the outcomes of anterior cruciate ligament (ACL) reconstruction in patients who have Workers' Compensation claims. This minimum 2-year follow-up study analyzed the occupational, functional, and objective results of patients who underwent arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction. Twenty-two patients with Workers' Compensation claims representing 5% of patients who underwent ACL reconstruction at our institution between 1987 and 1995 were included in the current study. All reconstructions were performed by the senior author (B.R.B.) using arthroscopic-assisted techniques (single and double-incision) with bone-patellar tendon-bone autografts followed by an accelerated rehabilitation protocol. Postoperative follow-up physical examinations revealed a negative anterior drawer in 19 patients (91%), a negative Lachman in 15 patients (68%), and a negative pivot shift in 21 patients (96%). The KT-1000 arthrometric evaluation at follow-up showed a mean maximum manual difference of 1. 9 mm with 15 patients (68%) having a maximum manual difference of

Results of arthroscopic treatment of symptomatic loss of extension following anterior cruciate ligament reconstruction.

Symptomatic loss of knee extension is an important cause of postoperative morbidity following anterior cruciate ligament reconstruction. In a series of 342 consecutive reconstructions performed by the senior author, 17 knees in 16 patients had symptomatic extension deficits (>5 degrees) refractory to a minimum of 4 months of intensive physical therapy that required arthroscopic debridement. Thirteen knees in 12 patients were available for evaluation at a mean follow-up of 3.9+/-1.7 years and form the treatment group. Twenty-six knees in 26 patients who underwent reconstruction but did not develop arthrofibrosis were matched to the treatment group and served as controls. At a mean of 12+/-8 months following reconstruction, patients in the treatment group underwent examination under anesthesia, arthroscopic debridement, revision notchplasty as necessary, and controlled manipulation. Postoperatively, patients were assigned to a closely supervised rehabilitation protocol emphasizing restoration of knee extension. At final evaluation, knee extension deficits had improved from a preoperative mean of 10 degrees (SD 5 degrees) to 3 degrees (SD 4 degrees) (P<.001). Multiple functional rating scales also were used to evaluate the treatment and control groups. With the numbers available, there was no statistically significant difference in function at final evaluation between the treatment and control groups. The best treatment for loss of knee extension is preventive. Complications are avoided by careful patient selection, appropriate timing of surgery, attention to operative detail, and aggressive rehabilitation. However, patients reaching a plateau in rehabilitation with significant residual extension deficits, patellofemoral symptoms, or both predictably benefit from arthroscopic debridement.

Osteochondritis dissecans of the knee.

Osteochondritis dissecans is a separation of an articular cartilage subchondral bone segment from the remaining articular surface. This is a different entity from osteonecrosis, with which osteochondritis dissecans is commonly confused. In osteochondritis dissecans, the fragment separates from a vascular normal bony bed, while in osteonecrosis, the fragment typically is more peripheral and separates from an avascular bony bed. Osteochondritis dissecans is more common in adolescents and young adults, with the knee, elbow, and ankle being the most common sites. Injury to an area of fairly tenuous blood supply is the most likely cause. Treatment is typically nonoperative for stable lesions and operative for unstable lesions. Most patients do well with no long-term sequelae, but this depends on a variety of factors including the location and size of the lesion, patient age, and treatment.

A prospective study of pain and analgesic use in outpatient endoscopic anterior cruciate ligament reconstruction.

A prospective study was undertaken to evaluate the postoperative pain and analgesic profiles of a group of 50 patients undergoing outpatient anterior cruciate ligament (ACL) reconstruction and to compare their profiles with those of a group of 50 patients undergoing outpatient non-ACL arthroscopic surgery. All patients received preoperative and postoperative ketorolac, intraincisional/intra-articular bupivacaine, intraoperative ketorolac, and propofol anesthetic. The percentage of patients receiving supplemental analgesia in the recovery room was 49% (average, 2.2 mg intravenous morphine sulfate) for the ACL group and 31% (average, 1.2 mg intravenous morphine sulfate) in the non-ACL group. Narcotic use and pain scores peaked in both groups on postoperative days 1 and 2. The ACL group used significantly more narcotic and had higher pain scores in the first week after surgery than did the non-ACL group. However, there were no subsequent admissions, readmissions, or emergency room visits for pain. All were satisfied with the outpatient nature of this surgery. Patients tolerate outpatient endoscopic ACL reconstruction with moderate pain and narcotic use. Outpatient endoscopic ACL reconstruction can be performed safely, effectively, and with considerable cost savings.

Functional gait adaptations in patients with anterior cruciate ligament deficiency over time.

Functional adaptations in knee kinematics and kinetics during level walking in 30 patients with unilateral anterior cruciate ligament deficiency and 30 healthy control subjects were studied. To examine the impact of time after injury on the functional adaptations, patients were placed into three time interval groups: early, intermediate, and chronic. The patients with anterior cruciate ligament deficiency had significantly decreased external knee flexion moments (balanced by net quadriceps contraction) and significantly increased external knee extension moments (balanced by net knee flexors contraction) as compared with the control subjects. As time after the injury increased, changes in the sagittal plane knee moments were more pronounced. A significant linear relationship (positive correlation) was found between the midstance knee flexion moment and the corresponding knee flexion angle. The patients with anterior cruciate deficiency had a greater knee flexion angle when generating a comparable midstance knee flexion moment as compared to the control subjects. The identification of gait adaptations over time provides additional information on the natural history of anterior cruciate ligament deficiency and may have implications regarding conservative rehabilitation, evaluation of outcomes, progression of meniscal injury, and the development of degenerative arthritis of the knee.

Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Five- to nine-year follow-up evaluation.

We retrospectively reviewed the results of 97 patients with anterior cruciate ligament reconstructions using an arthroscopically assisted two-incision technique without extraarticular augmentation at an intermediate followup of 5 to 9 years postoperatively. Evaluation included detailed history, physical examination, functional testing, KT-1000 arthrometer measurements, multiple scoring systems, and radiographs. The results were compared with those from a previous study that evaluated a smaller patient cohort using the identical surgical technique at a 2- to 4-year followup. The postoperative physical examination and KT-1000 arthrometer results were statistically improved when compared with preoperative findings. A negative pivot shift result was noted in 83% of patients, and a 1+ result in 17% of patients. Seventy percent of patients had < 3 mm difference on manual maximum side-to-side testing. Functional testing averaged less than 2% asymmetry for vertical jump, single-legged hop, or timed 6-meter hop. The Tegner activity level was significantly improved from prereconstruction ratings and similar to preinjury ratings. The mean Lysholm score was 87. The modified Hospital for Special Surgery scores resulted in good or excellent results in 82% of the patients (mean, 87 points). The mean Noyes sports function score was 89, and the reoperation rate for a symptomatic knee flexion contracture was 12%. Ninety-seven percent of patients indicated that they would undergo the procedure again. When compared with this same population at 2 to 4 years, we saw no deterioration in scoring scale results.

Single-incision endoscopic anterior cruciate ligament reconstruction using patellar tendon autograft. Minimum two-year follow-up evaluation.

We conducted a retrospective, minimum 2-year follow-up study to evaluate the effectiveness of a single-incision endoscopic anterior cruciate ligament reconstruction technique using patellar tendon autograft without extraarticular augmentation and followed by accelerated rehabilitation. One hundred three patients were evaluated (mean followup, 36 months; range, 24 to 55). There were significant improvements in physical examination test results (Lachman, anterior drawer, and pivot shift) postoperatively, and 94 patients (91%) had negative pivot shift results. KT-1000 arthrometric testing showed a significant reduction in manual maximum anterior translation and side-to-side differences at followup. Good range of motion was achieved. Patients with asymmetric prone heel heights usually had hyperextension in the contralateral knee. Functional tests showed 4% to 6% differences in side-to-side comparisons for a timed single-legged hop, single-legged hop for distance, and vertical jump. Postoperatively, the results of the Tegner scale were similar to preinjury scores. The mean results of the Hospital for Special Surgery scale (90), Lysholm score (89), and Noyes sport function score (90) were all excellent or good. Only 5 patients (5%) required reoperations for flexion contractures. Ninety-six patients (93%) reported they were "mostly" or "completely" satisfied, and 98 (95%) would recommend the procedure to others. These results demonstrated encouraging outcome using this single-incision technique.

Osteochondritis dissecans of the knee.

Osteochondritis dissecans (OCD) should be considered in young, active patients who have generalized or anterior knee pain. A careful physical exam includes a Wilson test, thigh girth measurements, diagnostic tunnel view radiographs, and other imaging studies as needed for grading and prognosis. Two case reports demonstrate the signs and symptoms of OCD. Treatment by primary care physicians with sports medicine training may be conservative if lesions are medial and in situ and if patients are not skeletally mature; otherwise, referral is advised. Prompt surgical treatment is generally successful.

Patterns of meniscal injury in the anterior cruciate-deficient knee: a review of the literature.

The importance of addressing meniscal pathology associated with anterior cruciate ligament (ACL) insufficiency stems from the increased incidence of meniscal tears with chronic instability. The combined effect of instability and meniscal lesions can lead to the development of knee arthrosis. A predominance of lateral meniscal tears has been demonstrated with acute ACL rupture, whereas the incidence of medial meniscal tears increases significantly with chronic ACL insufficiency. The percentage of repairable meniscal tears is higher on the medial than the lateral side and decreases overall with the chronicity of ACL insufficiency. The likelihood of a successful meniscal repair is enhanced significantly when combined with ACL reconstruction. This review suggests that maximal meniscal preservation is best achieved with ACL reconstruction. This review suggests that maximal meniscal preservation is best achieved with ACL reconstruction shortly after injury and simultaneous repair of coexisting peripheral meniscus tears.