Autologous chondrocyte implantation of the knee: multicenter experience and minimum 3-year follow-up.

OBJECTIVE: To determine clinical outcome and graft survivorship in patients undergoing autologous chondrocyte implantation (ACI) for the repair of chondral defects of the knee. DESIGN: Prospective cohort study. SETTING: 19 centers in the United States. PATIENTS: 50 patients (37 males, 13 females). Mean age was 36 years (range: 19-53). Defects were grade III or IV with a mean size of 4.2 cm 2. All patients had a minimum of 36 months postoperative follow-up. MAIN OUTCOME MEASUREMENTS: Clinician and patient evaluation based on the modified Cincinnati Knee Rating System. Graft failure was defined as replacement or removal of the graft due to mechanical symptoms or pain. RESULTS: Clinician and patient evaluation indicated median improvements of 4 and 5 points, respectively, at 36 months following ACI (p < 0.001). Previous treatment with marrow stimulation techniques and size of defect did not impact the results with ACI. The most common adverse events reported were adhesions and arthrofibrosis and hypertrophic changes. Three patients had graft failure and required reimplantation or treatment with alternative cartilage repair techniques. Kaplan-Meier estimated freedom from graft failure was 94% at 36 months postoperatively (95% CI = 88-100%). CONCLUSIONS: These results of this study indicate excellent graft survivorship using ACI as well as substantial improvement in functional outcome.

An analysis of anterior cruciate ligament reconstruction in middle-aged patients.

The purpose of this study was to evaluate the results and complications of anterior cruciate ligament surgery in middle-aged patients. Forty-five consecutive patients over 40 years old (average age, 44.6 years) who had arthroscopically assisted anterior cruciate ligament reconstructions with midthird patellar tendon autografts were evaluated. The patients returned for interviews, physical examinations, radiographs, Biodex dynamometer strength testing, and KT-1000 arthrometer testing at an average of 37 months after their surgeries (range, 24 to 96 months). The mean Lysholm and Gillquist score was 91, which corresponds to symptoms only with vigorous activity. The overall scores from the International Knee Documentation Committee form were 29 (64%) normal or nearly normal and 2 (4%) severely abnormal. Side-to-side differences as determined by the KT-1000 arthrometer were < or = 3 mm in 31 of 40 patients (78%), between 3 and 5 mm in 4 patients (10%), and > 5 mm in 5 patients at 30 pounds of anterior displacement. Seventy-six percent of the patients (N = 34) returned to their preoperative activity levels. Three patients required repeat arthroscopic surgery for persistent knee pain and two patients had graft ruptures. This study shows that when middle-aged patients undergo surgery, their results can be successful and satisfying to a degree similar to those of younger patients.

Shoulder symptoms in healthy athletes: a comparison of outcome scoring systems.

We used the Rowe, ASES, UCLA, Constant-Murley, and the Simple Shoulder Test scoring systems to determine the presence and severity of shoulder symptoms in "healthy" collegiate athletes at mid-season. Intercollegiate athletes were surveyed with a single, specific, comprehensive questionnaire regarding both of their shoulders at the mid-season of their respective sport. The questionnaire compiled the previously mentioned scoring systems and additional inquiries. Shoulders were divided into three groups for analysis: dominant-never injured, nondominant-never injured, and history of injury. Significant shoulder symptoms exist in athletes during full participation in their respective sport. Pain was the most frequent symptom, with 47% of all shoulder having some degree of pain. The frequency and degree of symptoms was significantly greater in shoulders with a history of injury. The UCLA scoring system is the most sensitive for evaluating "healthy" athletes at mid-season. However, the ideal shoulder scoring system for athletes has yet to be developed. To expect a "normal" or "symptom-free" shoulder after injury or surgery may be inappropriate. This information can serve as a reference for clinicians when evaluating the results of surgery and other treatment programs.

Increased tibial translation after partial sectioning of the anterior cruciate ligament. The posterolateral bundle.

We measured changes in anterior translation of the tibia with sequential sectioning of the bundles of the anterior cruciate ligament and correlated these changes with the clinical examination. Six fresh cadaveric lower extremities were examined by three experienced knee surgeons in a masked fashion with the anterior cruciate ligament intact and after sectioning of the posterolateral bundle, the posterolateral bundle and 50% of the anteromedial bundle, and the entire ligament. Lachman, anterior drawer, and lateral pivot shift tests were performed. Both KT-1000 arthrometer testing (30 pounds) and biplanar radiography demonstrated progressive increases in anterior translation with incremental sectioning of the anterior cruciate ligament. However, significant (P < 0.05) increases in translation were found only after sectioning both the posterolateral bundle and half of the anteromedial bundle and after complete sectioning of the anterior cruciate ligament. The examiners were accurate in their interpretation of the status of the anterior cruciate ligament in 89% of the intact specimens and 80% of completely sectioned ligaments. Only 11% of the examinations correctly diagnosed the anterior cruciate ligament as partially cut when the posterolateral bundle was sectioned. A soft end point to the Lachman examination was noted only after cutting at least 75% of the ligament, but was not always present. Clinical evaluation is accurate in defining intact and completely sectioned anterior cruciate ligaments. However, it is unable to differentiate a sectioned posterolateral bundle from an intact anterior cruciate ligament, or a 75% sectioned ligament from a completely sectioned ligament. The clinical diagnosis of a partial tear of the anterior cruciate ligament is more likely to represent a complete or "functionally complete" tear.

Fixation strength of rotator cuff repairs with suture anchors and the transosseous suture technique.

The strength of classic transosseous suture repair of rotator cuff tendons was compared with similar repairs with four "third-generation" suture anchors. Results demonstrate the repair construct selected had a significant influence on failure at ultimate load (p = 0.005). Among the anchors tested the Statak design was significantly stronger than the other three. Furthermore Statak, Harpoon, and Superanchor designs were all significantly stronger than the Revo screw. No significant difference was seen between the strength of repairs performed with the Statak, the Harpoon, or the Superanchor compared with the transosseous suture technique. The transosseous suture technique was significantly stronger than repairs performed with the Revo. We conclude suture anchor design has evolved to a point where initial fixation of torn rotator cuff tendons is equivalent to more traditional techniques using only sutures.

Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study.

The reasons why many patients seemingly benefit from arthroscopic treatment of osteoarthritis of the knee remain obscure. The purpose of this pilot study was to determine if a placebo effect might play a role in arthroscopic treatment of this condition. After giving full informed consent, including full knowledge of the possibility and nature of a placebo surgery, five subjects were randomized to a placebo arthroscopy group, three subjects were randomized to an arthroscopic lavage group, and two subjects were randomized to a standard arthroscopic debridement group. The physicians performing the postoperative assessment and the patients remained blinded as to treatment. Patients who received the placebo surgery reported decreased frequency, intensity, and duration of knee pain. They also thought that the procedure was worthwhile and would recommend it to family and friends. Thus, there may be a significant placebo effect for arthroscopic treatment of osteoarthritis of the knee. The small numbers in this preliminary study preclude a valid statistical analysis, and no conclusions can be drawn regarding the superiority of one treatment over another. A larger study is needed to evaluate fully the efficacy of an arthroscopic procedure for this condition and to decide if it is reasonable to expend health care resources for this treatment; the larger study should include a placebo control group.

Radiographic evaluation of native anterior cruciate ligament attachments and graft placement for reconstruction. A cadaveric study.

We examined seven cadaveric knees to determine the radiographic location of the native anterior cruciate ligament insertion sites as well as the location of tunnels used in anterior cruciate ligament reconstruction. Posteroanterior and lateral views at several flexion angles were taken with radiopaque markers around the insertions of the native anterior cruciate ligament and subsequent reconstruction tunnels. The femoral insertion was best seen on the 60 degrees notch view. On the lateral view, the femoral tunnel was easily seen as it crossed the roof of the intercondylar notch; however, because of the angle of the tunnel, the actual entrance into the knee may be well distal and anterior to this location. The tibial insertion and tunnel were easily seen at any flexion angle. The center of the insertion was 40% of the tibial diameter from the anterior margin. The lateral view in extension allowed determination of the tibial tunnel's location in relation to the intercondylar notch roof, but by itself did not allow accurate determination of the femoral tunnel's position. Notch and extension lateral radiographs together provided sufficient information for evaluation of anterior cruciate ligament graft position in a convenient, cost-effective format. Neither view by itself provides enough information to evaluate the position of the graft.

Partial tears of the anterior cruciate ligament. Are they clinically detectable?

Eight cadaveric lower extremities were examined by three experienced knee surgeons in blinded fashion. The knees were examined with intact anterior cruciate ligaments, sectioned anteromedial bundles, and completely sectioned anterior cruciate ligaments to evaluate detectable laxity changes. Lachman, anterior drawer, lateral pivot shift, and KT-1000 arthrometer testing were performed. Optimized biplanar radiography using a defined spatial coordinate reference system was performed with a 30-pound anterior force at 30 degrees of flexion to confirm clinical findings. Physical examination and arthrometer testing detected no difference between intact and partially sectioned anterior cruciate ligaments; these ligaments were significantly different than completely sectioned ligaments, with the Lachman test being the most sensitive. Despite consistent clinical detection of complete sectioning of the anterior cruciate ligament by both physical examination and arthrometer testing, neither method proved accurate in the diagnosis of isolated tears of the anteromedial bundle, but both did show that partially sectioned anterior cruciate ligament closely resembled intact ligament and differed significantly from completely sectioned ligament, as confirmed by radiologic data. Clinically diagnosed "partial tear" is likely to be complete rupture of the anterior cruciate ligament. Historically, clinically diagnosed partial tears of the anterior cruciate ligament have tended to "progress" to symptomatic instability. Our data imply these patients may have had functionally incompetent ligaments from time of injury and, in fact, were demonstrating the expected natural history of an anterior cruciate ligament-deficient knee.

Radial head fracture. A potentially complex injury.

A prospective study was undertaken on 50 acute, consecutive fractures of the radial head. Clinical examination and stress testing were performed on each patient. A valgus stress radiograph, in conjunction with clinical stress testing, was used to assess competence of the medial elbow ligaments. Axial stability of the radius was determined by the axial stress test. Eleven patients (22%) sustained a comminuted radial head fracture; all had instability either to valgus or axial stress. Seventeen patients (34%) had a displaced vertical shear type fracture or an impacted fracture of the radial neck. All sustained some injury to the medial collateral ligament, with variable degrees of valgus elbow instability. Twenty-two (44%) of the fractures were minimally or nondisplaced. All 22 were stable. Radial head fracture morphology can be used to assess the likelihood of associated soft-tissue injury.

EMG analysis of the scapular muscles during a shoulder rehabilitation program.

The purpose of this study was to determine which exercises most effectively use the scapular muscles. Eight muscles in 9 healthy subjects were studied with indwelling electromyographic electrodes and cinematography while performing 16 exercises. The 8 muscles studied were the upper, middle, and lower trapezius; levator scapula; rhomboids; pectoralis minor; and the middle and lower serratus anterior. Each exercise was divided into arcs of motion and the electromyographic activity was quantified as a percentage of the maximal manual muscle test. The optimal exercises for each muscle were identified based on intensity (greater than 50% maximal manual muscle test) and duration (over at least 3 consecutive arcs of motion) of the muscle activity. Twelve of the exercises qualified as top exercises for all of the muscles. On further analysis, a group of 4 exercises was shown to make up the core of a scapular muscle strengthening program. Those 4 exercises include scaption (scapular plane elevation), rowing, push-up with a plus, and press-up.

Child and adolescent day treatment: a descriptive analysis of a model program.

Since the inception of the University of Tennessee Child and Adolescent Day Treatment Program in 1982, a total of 53 patients has received services. This paper provides a broad overview of the patient population as well as descriptive data accumulated during the first 18 months of operation of the program. Several factors which determined patient eligibility and availability are briefly described. Special attention is given to the following variables: (1) age, (2) sex, (3) referral source to the program, (4) diagnosis, (5) length of stay in the program, and (6) discharge disposition. Interrelationships among these variables are also discussed.