Urinary CTX-II concentrations are elevated and associated with knee pain and function in subjects with ACL reconstruction.

OBJECTIVE: Post-traumatic knee osteoarthritis (OA) is prevalent after anterior cruciate ligament reconstruction (ACLR). Biomarkers that identify individuals likely to develop OA, especially symptomatic OA, can help target preventative and therapeutic strategies. This study examined the magnitude and change over time in urinary CTX-II (uCTX-II) concentrations shortly after ACL reconstruction, and, secondarily, the associations with knee pain and function. DESIGN: Subjects were 28 patients with ACLR and 28 age- and sex-matched controls (CNTRL). Testing was conducted at four time points spaced 4 weeks apart (4, 8, 12 and 16 weeks post-operative in ACLR). Measures included demographics, urine samples, Numeric Pain Rating Scale (NPRS) and International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). uCTX-II concentrations were determined with competitive enzyme-linked immunosorbent assay (ELISA). uCTX-II concentrations at each time point in ACLR were compared to the mean concentration over time in CNTRL, with and without adjustment for body mass index (BMI). Changes over time in each measure and correlations between the slopes of change were examined. RESULTS: uCTX-II concentrations were significantly higher in ACLR than CNTRL through 16 weeks post-operative when adjusted for BMI. In ACLR, uCTX-II concentrations significantly decreased over time, and the slope was associated with NPRS (r = 0.406, P = 0.039) and IKDC-SKF (r = -0.402, P = 0.034) slopes. CONCLUSION: uCTX-II concentrations shortly after ACLR were elevated compared to CNTRL and declined over time. Decreasing uCTX-II concentrations were associated with decreasing knee pain and improving function. uCTX-II may have a role as a prognostic marker following ACLR and warrants further investigation.

Biomechanical analysis of the effect of varying suture pitch in tendon graft fixation.

The purpose of this study was to biomechanically assess the effect of varying suture pitch on the holding power of the Krackow suture technique for tendon graft fixation. Seven pairs of rabbit Achilles tendons were sutured with single No. 5 Ti-Cron suture using the Krackow technique. One tendon from each pair was sutured using a 0.5-cm suture pitch (half-pitch group) while the contralateral tendon from each pair was sutured with a 1.0-cm suture pitch (one-pitch group). The tendons were loaded to failure using a servohydraulic materials test system at a loading rate of 0.5 mm/sec. There were no statistically significant differences noted in suture slippage at failure (1.58 cm for half pitch versus 1.45 cm for one pitch) or maximal force to failure (158.5 N for half pitch versus 168.2 N one pitch) between the two treatment groups. However, the construct with the 1-cm suture pitch was significantly stiffer than the construct with the 0.5-cm suture pitch, with stiffness values of 106.2 N/cm and 91.4 N/cm, respectively. The most common mechanism of failure was slippage of the suture at the first suture throw and tearing of the first knot through the most distal portion of the tendon. Four constructs failed by suture rupture, two from each experimental group.

Caudal slope of the tibia and its relationship to noncontact injuries to the ACL.

To determine the role that an increased caudal slope of the tibia might have on the incidence of anterior cruciate ligament (ACL) injury, tibial slope was measured in 49 patients (50 knees), with noncontact ACL injury mechanisms (group 1) and an age-matched group of 39 patients (50 knees) with a diagnosis of patellofemoral pain syndrome (group 2). No significant difference was noted in mean posterior slope between the two groups (group 1: 9.7+/-1.8 degrees and group II: 9.9+/-2.1 degrees) or after controlling for bilateral patients in two separate trials. These results indicate that increased caudal tibial slope does not appear to be a risk factor in the creation of noncontact injuries to the ACL.

Comparison of an optical catheter office arthroscope with a standard rigid rod-lens arthroscope in the evaluation of the knee.

In a prospective, randomized study, 47 patients underwent arthroscopic evaluation of the knee in an operating room setting with both a standard rod-lens arthroscope and a newer flexible optical catheter fiberoptic system. The goal of the study was to assess the diagnostic accuracy of the newer catheter system, which is recommended for use in the office setting. Forty-four patients were included in the data analysis, three were eliminated because we were unable to perform an adequate examination with the catheter scope secondary to intraarticular adhesions or excessive bleeding. A comparison of the two systems revealed an overall underestimation and underrecognition of intraarticular knee pathologic changes. Anterior cruciate ligament tears were missed in 3 of 21 knees; no posterior cruciate ligament tears were detected by the rod-lens arthroscope in 44 knees, but one false-positive result was "seen" using the optical catheter device. Similar trends in diagnosis (sensitivity, 25% to 67%; specificity, 96% to 99%) were seen for tears of the medial and lateral menisci, chondral lesions, and the identification of loose bodies. We conclude from the results of this study that the use of the optical catheter system for arthroscopic evaluation and treatment of the knee in the office setting may result in a significant compromise in visual acuity, resulting in missed and incorrect diagnoses.

Bone tunnel enlargement after anterior cruciate ligament replacement.

Radiographic increase in the size of tibial and femoral tunnels has been observed. This retrospective study compared tibial tunnel diameter in 56 autograft and 87 allograft patellar tendon bone-tendon-bone anterior cruciate ligament replacements whose observed tunnel changes were correlated with clinical results at 1 year postoperatively. Tibial tunnel sclerotic margins were measured approximately 1 cm below the joint line. Exact tunnel dimension was calculated by using a magnification factor determined by the interference screw of known diameter within the same tunnel. Average allograft tunnel enlargement was 1.2 mm (-2.5 to 6.0) compared with the autograft tunnel enlargement of 0.26 mm (-2.5 to 2.7); the difference was significant (P > 0.0002). No significant difference was seen in KT-1000 arthrometer measurements between autograft or allograft groups, and no correlation was seen between increased tunnel size and clinical outcome as determined by the modified Hughston knee evaluation system. Tunnel measurement reproducibility was confirmed by independent repeated measurements. The significance of this tunnel enlargement is unknown and does not appear to adversely affect clinical outcome of allograft utilization. Possible explanations include an immune response with resorption, stress shielding proximal to the interference screw resulting in resorption, or an inflammatory response by synovium in the tunnel.

The results of fresh-frozen patellar tendon allografts for chronic anterior cruciate ligament deficiency of the knee.

This prospective study was done to evaluate the clinical outcome of fresh-frozen patellar bone-tendon-bone allograft tissue used as a substitute for chronic insufficiency of the anterior cruciate ligament. Forty-one patients were followed at a mean of 27 months after surgery. The mean time from injury to reconstruction was 34 months. The same operative procedure and postoperative rehabilitation was performed on each patient. The evaluation method consisted of subjective, objective, and instrumented laxity testing. Thirty-seven patients (90%) thought their knee was normal or improved after surgery and had no further episodes of giving way. The combined modified Hughston Knee Score revealed 30 patients (73%) with an excellent or good result and 9 patients (22%) with a fair or poor result. The mean postoperative Lysholm Knee Score was 91 (range, 56 to 100). Thirty-two had a negative pivot shift (78%). The postoperative KT-1000 arthrometer revealed 37 patients had an injured-to-uninjured difference of 5 mm or less (mean, 1.32 mm; range, 0 to 5). There were three traumatic failures at 24 months postoperatively in this group. There was no rejection phenomenon noted postoperatively. In addition, clinical observation showed less postoperative morbidity when compared to a matched autogenous patellar tendon control group.

The Gore-Tex anterior cruciate ligament prosthesis. Two versus three year results.

A prospective clinical study of the results of prosthetic ligament replacement of the ACL with the Gore-Tex polytetrafluoroethylene prosthesis was undertaken. Thirty-three (80%) of 41 patients were available at a minimum 36 month followup (mean, 48 months; range, 36 to 62). Kaplan-Meier survival analysis revealed an 82% probability of survival of the polytetrafluoroethylene ligament at the 48 month followup. When compared to the same data at a minimum 24 month followup, the results appeared to have deteriorated somewhat over time. Three possible "predictors" of failure at later followup were identified: preoperative subjective symptoms of swelling, subjective symptoms of giving way at 2 years, and an increased anterior drawer sign at 2 years.

Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players.

During five consecutive football seasons at a major university, 28 varsity football players sustained complete isolated tears of the medial collateral ligament of the knee. All were managed nonoperatively with early protected motion and physical therapy. Twenty-one patients returned for follow-up examination. The mean follow-up time was 46 months. Eighteen patients were followed for over two years after the original injury. Twenty patients had results ranging from good to excellent. The average time from injury to return to full-contact drills was 9.2 weeks. The key to success in the nonoperative management of complete tears of the knee is to exclude cases with damage to the anterior cruciate ligament.

Clinical comparison of freeze-dried and fresh frozen patellar tendon allografts for anterior cruciate ligament reconstruction of the knee.

The aim of this study was to evaluate the clinical outcome of freeze-dried compared to fresh frozen allograft tissue used as a substitute for a ruptured ACL of the knee. In addition, the incidence of any graft rejection phenomena was recorded. Forty-one patients with ACL deficient knees underwent reconstructive surgery using a patellar bone-tendon-bone allograft that had been freeze-dried (Group 1, N = 14) or fresh frozen (Group 2, N = 27). All patients underwent the same implant technique and rehabilitation program. Followup ranged from 24 to 36 months. The evaluation consisted of subjective, objective, and instrumented laxity testing (KT-1000, MEDmetric, San Diego, CA; and Genucom, FARO Medical Technologies, Inc., Montreal, Canada). There were 31 males and 10 females. Eleven (79%) patients in Group 1 thought their knee was "normal" or "improved," and 25 (93%) in Group 2 thought the same. In addition, 10 (71%) patients in Group 1 denied any "giving way," compared to 26 (96%) in Group 2. The mean Lysholm knee score in Group 1 was 86/100 (range, 22 to 100) compared to 92/100 (range, 59 to 100). Clinical examination included the Lachman test and tests for anterior drawer sign and pivot shift. Postoperatively, Group 1 patients had the following results: Lachman test--seven Grade 0, six Grade 1, one Grade 2; anterior drawer sign--eight Grade 0, five Grade 1, one Grade 2; and pivot shift--seven Grade 0, five "trace," and two "present."(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative management of complete tears of the medial collateral ligament.

Ten years of experience in treating complete tears of the medial collateral ligament (MCL) nonoperatively are reported, with an emphasis on the role of arthroscopy in the diagnosis of patients with suspected complete MCL tears. Physical examination and assessment of findings are followed by a three-phase treatment protocol. The first phase consists of an orthosis and 30 degrees of flexion, partial weight-bearing with crutches, and strengthening exercises; the second phase allows knee motion from 30 degrees to 90 degrees, followed by the addition of isotonic and isokinetic exercises, and full weight-bearing without crutches, if tolerable; the third phase includes removal of the orthosis, continuation of the exercise regimen, and institution of a running program. Successful treatment depends on clinical or arthroscopic confirmation of a normal anterior cruciate ligament.

Early experience with the GORE-TEX polytetrafluoroethylene anterior cruciate ligament prosthesis.

A prospective study of 41 patients with acute and chronic ACL deficiency underwent reconstruction with the GORE-TEX polytetrafluoroethylene (PTFE) ACL prosthesis beginning in November 1983. Thirty-nine patients who were at least 2 years from their surgical procedure were available for follow-up evaluation, which included subjective questionnaire, clinical examination, and instrumented ligamentous laxity tests. Eight patients had an acute injury to the ACL and 31 patients had chronic ACL insufficiency for which reconstruction was performed. Thirty-four patients had satisfactory results, allowing full return to activity with no appreciable symptomatology. Of the remaining five patients, four had a complete rupture of the prosthesis. The average knee arthrometric measurement improved from a 5.4 mm left/right difference preoperatively to a 2.0 mm left/right difference at 2 year followup. Nine patients had postoperative complications of one or more atraumatic episodes of a sterile effusion. Six patients had recurrent effusions; in five, arthroscopy revealed partial tears of less than one-third of the prosthesis. Three patients who had recurrent effusions had PTFE particles in their synovial biopsies. One patient had an immediate postoperative infection and to data has had salvage of the prosthesis and currently has a stable knee with full return to activities. Based on the early results of this study, the GORE-TEX PTFE ACL prosthesis provided a satisfactory method of reconstruction for ACL deficient knees. Based on the evaluation used, 87% of the patients had satisfactory results. Problems associated with use of this prosthesis include partial or complete tears of the prosthesis and sterile effusions, possibly due to synovial irritation from the PTFE particles.(ABSTRACT TRUNCATED AT 250 WORDS)

Synthetic and allograft anterior cruciate ligament reconstruction.

Although still in the early stages of development, the use of synthetics and allografts in ACL surgery appears promising. Two prosthetic ligaments, the Kennedy LAD and Gore-Tex, are FDA approved for limited indications. The Kennedy LAD has been shown to be effective in augmenting an autograft with inherent structural weakness in its central portion. The proposed benefits of using this device with grafts of greater strength are unproved. The Gore-Tex ACL reconstruction allows a rapid initiation of vigorous rehabilitation and return to full activities. However, the complication rate with this procedure appears to be higher than that with autograft reconstruction. The use of allograft for ACL reconstruction also has many potential advantages and short-term clinical trials have shown good results. However, the benefits must be weighed against the possibility of long-term failure and potential spread of infectious disease.

Trends in rehabilitation following anterior cruciate ligament reconstruction.

In summary, the use of an autogenous intra-articular reconstruction has been identified as an effective treatment modality to stabilize the ACL-deficient knee. However, despite the fact that rehabilitation programs are becoming more aggressive and less time consuming, the patient who elects to have his knee stabilized surgically continues to face a long recovery period. Continued research in surgical and rehabilitative management is necessary to reduce this time and expense if ACL reconstruction is to be practical for all.

Observations on the treatment of lumbar disk disease in college football players.

Over a 4 year period, 12 college players were treated for diskogenic injury. The most common position affected was down-lineman. Symptoms consisted of low back and/or radicular pain. No players could recall the onset of symptoms relative to football activity; weightlifting was associated with symptoms in three cases. Tentative clinical diagnosis was herniated disk disease. Method of diagnosis in the athletic population is presented along with results of surgical treatment. Percutaneous diskectomy appears to be successful for disk herniations occurring at the L4-5 space or higher.

Efficacy of diflunisal versus acetaminophen with codeine in controlling mild to moderate pain after arthroscopy.

An open, randomized clinical study was performed to evaluate the efficacy of diflunisal versus acetaminophen with codeine in patients who underwent outpatient arthroscopy of the knee. Twenty patients were randomly assigned to each treatment group. Nineteen patients in each group successfully completed the study, which consisted of both objective and subjective evaluations. The results showed equal efficacy between the two drugs. However, a larger percentage of patients viewed diflunisal as providing good to excellent results overall compared with acetaminophen with codeine.

The physician to a swimming team.

The physician to a swimming team should organize a health support system that prevents problems through education and encourages prompt and appropriate treatment to reduce complications. The overall goal should be the optimal level of care necessary to enable the swimmers to reach their potential.

Comparison of diflunisal and acetaminophen with codeine in the treatment of mild to moderate pain due to strains and sprains.

Fifty college athletes with acute sprains and strains from football-related activities were randomly assigned to treatment with either diflunisal or acetaminophen with codeine for seven days. Additional treatment in both groups included rest, elevation, local application of cold or heat, splinting, and physical therapy, as indicated. Both treatment groups exhibited clinically significant improvements in pain, tenderness, and swelling. The results of this study show that diflunisal, a peripherally acting nonnarcotic nonsteroidal anti-inflammatory agent with analgesic properties, was as effective as acetaminophen with codeine in relieving mild to moderate pain due to musculo-skeletal sprains and strains. The long duration of action of diflunisal permits less frequent dosing, an important consideration when prescribing medication for active young adults.

A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases.

A retrospective study was conducted to survey the extent of intracapsular damage associated with ACL insufficient knees in both the acute and chronic situation. Previously unoperated knees were studied to assess the effect that reinjury had on the knee joint. One hundred patients with confirmed anterior cruciate ligament damage, both clinically and under general anesthesia, were examined arthroscopically and the findings recorded on video tape. Both anterolateral and posteromedial approaches were used to well visualize the entire intra-articular structures of the knee joint. The incidence of meniscal tears increased from 77% in the acute injury to 91% in the chronically reinjured knee (p less than .06). Furthermore, articular surface disease increased from 23% in the acute injury to 54% in the chronically ACL lax knee (p less than .002). The majority of meniscal tears were medial and amenable to peripheral suture repair (63%). Irrespective of how one approaches ACL insufficiency of the knee acutely, one cannot ignore the likelihood of finding these significant associated lesions. Reinjury to the knee will likely enhance the incidence of meniscal tears and articular changes.