Isolated Arthroscopic Partial Meniscectomy Is More Effective at Improving Meniscal Symptoms in Comparison With Mechanical Symptoms in Patients With Concomitant Untreated Chondral Lesions.

PURPOSE: To rank Knee Injury and Osteoarthritis Outcome Score (KOOS) questions from most to least improvement after arthroscopic partial meniscectomy (APM) and compare improvement of meniscal versus mechanical symptoms. METHODS: A secondary analysis of the Chondral Lesions and Meniscus Procedures (ChAMP) Trial was performed. Inclusion criteria were age 30 years or older with degenerative meniscal tear failing nonoperative management, with or without associated unstable chondral lesions. No chondral debridement was performed. Responses to the 42 KOOS questions ranged from 0 (extreme problems) to 4 (no problems), and were answered preoperatively and at 1 year after isolated APM. The 1-year mean change, or delta (Δ), was calculated for each KOOS question and the Δ for meniscal and mechanical symptoms were statistically compared. RESULTS: Greatest improvement in 135 eligible patients was observed for questions about (1) awareness of knee problems (Δ = 1.93, standard deviation [SD] = 1.38), (2) frequency of knee pain (Δ = 1.93, SD = 1.29), (3) degree of difficulty while twisting/pivoting on the injured knee (Δ = 1.88, SD = 1.13), (4) degree of difficulty while running (Δ = 1.67, SD = 1.30), and (5) being troubled by lack of confidence in the knee (Δ = 21.67, SD = 1.11). Least improvement was observed for questions about: (1) degree of difficulty while getting on/off the toilet (Δ = 0.94, SD = 0.96), (2) feel grinding or hear clicking when the knee moves (Δ= 0.90, SD = 1.25), 3) degree of difficulty while getting in/out of the bath (Δ= 0.88, SD = 1.00), (4) knee catches/hangs up during movement (Δ= 0.80, SD = 1.09), and (5) the ability to straighten the knee fully (Δ= 0.54, 1.44). There was greater improvement for the KOOS questions pertaining to meniscal versus mechanical symptoms (P < .00001). CONCLUSIONS: KOOS symptoms as reported by subjects' responses to the questions pertaining to the frequency of knee pain, twisting/pivoting, running, squatting, and jumping showed the most improvement 1 year after isolated APM, whereas those relating to mechanical symptoms improved the least. Focusing on meniscal rather than mechanical symptoms may help surgeons better identify patients expected to benefit from APM. LEVEL OF EVIDENCE: IV, retrospective analysis of prospectively collected data.

Better Outcomes but No Difference in Joint Space Narrowing at Five Years Among Patients Without Unstable Chondral Lesions Versus Those With Unstable Chondral Lesions (Left In Situ) at the Time of Arthroscopic Partial Meniscectomy.

PURPOSE: To compare 5-year outcomes among patients with and without unstable chondral lesions undergoing arthroscopic partial meniscectomy (APM). METHODS: Using data from the Chondral Lesions And Meniscal Procedures (ChAMP) Trial, we compared outcomes for patients with unstable chondral lesions found at the time of APM and left in situ (CL-noDeb, N = 71) versus patients without unstable chondral lesions (NoCL, N = 47) at 5 years after APM. Outcomes included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analog pain scale, Short-form Health Survey (SF-36), physical knee measurements, progressive joint space narrowing on radiographs, and the rate of additional knee surgery. Multivariate linear regression was used to obtain mean differences (MDs) with corresponding 95% confidence intervals (CIs) adjusted for age, body mass index, and preoperative score (for postoperative scores). RESULTS: Compared with CL-noDeb, NoCL subjects had significantly greater improvement at 5 years in the KOOS score for function in sport and recreation (MD = 9.9 [95% CI, 0.7-19.1]), SF-36 pain (MD = 13.9 [95% CI, 5.5-22.3]), knee extension (MD = 0.8 [95% CI, 0.1-1.5]), and decreased quadriceps circumference at the mid-portion of the patella (MD = -1.5 [95% CI, -2.7 to -0.3). A greater proportion of patients in the NoCL group achieved the MCID for all outcome scores except for the WOMAC pain score (89% CL-NoDeb vs 87% NoCL) and SF-36 general (29% CL-NoDeb vs 23% NoCL). There were no significant group differences in measures of progressive radiographic joint space narrowing in any compartments of the operative knee and no significant difference in the rate of additional knee surgery within 5 years of the initial APM. CONCLUSIONS: Patients undergoing APM without unstable chondral lesions had statistically significantly better outcomes than patients with unstable chondral lesions at 5 years after surgery; however, there were no group differences in progressive radiographic joint space narrowing. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Observation Versus Debridement of Unstable Chondral Lesions During Partial Meniscectomy: Analysis of Patient Outcomes and Degenerative Joint Disease at 5 Years in the Chondral Lesions And Meniscus Procedures (ChAMP) Randomized Controlled Trial.

BACKGROUND: The purpose of this study was to examine the effect of debridement (CL-Deb) versus observation (CL-noDeb) of unstable chondral lesions on knee pain 5 years after arthroscopic partial meniscectomy (APM) in patients enrolled in the Chondral Lesions And Meniscus Procedures (ChAMP) Trial. Secondarily, other knee symptoms, function, general health, and the rate of additional surgery on the affected knee were examined. METHODS: Patients aged ≥30 years who had an unstable Outerbridge grade-II, III, or IV chondral lesion when undergoing APM were randomly allocated to the CL-Deb (n = 98) or CL-noDeb (n = 92) group; ∼80% in each group completed a 5-year follow-up. Outcomes were measured preoperatively and at 5 years postoperatively, and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, Short Form-36 (SF-36), physical knee measurements, knee radiographs, and rate of additional knee surgery at 5 years. The primary outcome was the 5-year WOMAC pain score. Group comparisons were made using the t test for continuous outcomes and the Fisher exact test for categorical outcomes. RESULTS: There were no significant differences between the groups with respect to the primary outcome, the WOMAC pain score (CL-Deb: 86.0 [95% confidence interval (CI): 82.9 to 89.1]) versus CL-noDeb: 88.3 [95% CI: 85.5 to 91.1]; p = 0.27), or secondary outcomes at 5 years. There were also no differences in radiographic measurements of joint-space narrowing in any compartment (medial or lateral tibiofemoral or medial, central, or lateral patellofemoral) as well as no difference in the rate of additional knee surgery within 5 years after APM between the CL-Deb and CL-noDeb groups. CONCLUSIONS: Outcomes for the CL-Deb and CL-noDeb groups did not differ at 5 years postoperatively, suggesting that there is no long-term benefit of arthroscopic debridement of chondral lesions encountered during APM. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Association Between Bone Marrow Lesions, Chondral Lesions, and Pain in Patients Without Radiographic Evidence of Degenerative Joint Disease Who Underwent Arthroscopic Partial Meniscectomy.

Background: Bone marrow lesions (BMLs) have been found on magnetic resonance imaging in patients with meniscal tears. Purpose: We sought to determine the prevalence and location of BMLs, the association between BMLs and chondral lesions, and the association between BMLs and pain in patients without radiographic evidence of degenerative joint disease who underwent arthroscopic partial meniscectomy (APM). Study Design: Cohort study; Level of evidence, 2. Methods: We performed a secondary analysis of the Chondral Lesions And Meniscus Procedures (ChAMP) randomized controlled trial. BMLs were assessed on preoperative magnetic resonance imaging, and chondral lesions were documented at the time of surgery. Pain was assessed preoperatively and at 1 year after APM using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Knee injury and Osteoarthritis Outcome Score (KOOS). The chi-square test was used to examine the association between BMLs and chondral lesions, and the F test was used to examine the association between BMLs and pain. Results: Of 241 patients, 58.9% had ≥1 BMLs, and most were located on the medial tibial plateau (MTP; 74.6%) and/or medial femoral condyle (MFC; 28.9%). Most MTP BMLs were submeniscal (56%), and most MFC BMLs extended beyond the meniscus (73%). There were more MFC chondral lesions for patients with any MFC BMLs (P = .01) and submeniscal MFC BMLs (P = .02) versus those without BMLs, and there was no association between BMLs and chondral lesions on the MTP. There was also no association between BMLs and preoperative or postoperative pain scores. Conclusion: In patients without radiographic evidence of degenerative joint disease who underwent APM, BMLs were found in 58.9% of knees and were primarily located in the medial compartment. There was a borderline statistically significant association between BMLs and chondral lesions for the MFC; however, BMLs were not associated with pain scores preoperatively or at 1 year after surgery.

How Does the Presence of Unstable Chondral Lesions Affect Patient Outcomes After Partial Meniscectomy? The ChAMP Randomized Controlled Trial.

BACKGROUND: Chondral lesions are commonly encountered during arthroscopic partial meniscectomy (APM); however, it is unknown how these lesions affect postoperative outcomes. PURPOSE: The authors compared postoperative outcomes among patients with and without unstable chondral lesions 1 year after APM. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors conducted a secondary analysis of data from the ChAMP (Chondral Lesions and Meniscus Procedures) randomized controlled trial. They compared the following outcomes for patients with unstable chondral lesions that were left in situ and observed (CL-noDeb) versus patients without unstable chondral lesions (NoCL) at 1 year after APM: Western Ontario and McMaster Universities Osteoarthritis Index, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain, the Short Form Health Survey, range of motion, quadriceps circumference, and effusion. Multivariate linear regression was used to obtain mean differences (MDs) with corresponding 95% CIs adjusted for age, body mass index, and preoperative score (for postoperative scores). RESULTS: Compared with the CL-noDeb group, the NoCL group had greater improvement in Western Ontario and McMaster Universities Osteoarthritis Index for pain (MD, 7.9, 95% CI: 2.7-13.1), stiffness (MD, 9.1, 95% CI: 1.9-16.3), and physical function (MD, 4.6, 95% CI: 0.1-9.0) and Knee injury and Osteoarthritis Outcome Score for pain (MD, 8.4, 95% CI: 2.7-14.0), function in sport and recreation (MD, 11, 95% CI: 3.0-19.1), and quality of life (MD, 10.4, 95% CI: 2.3-18.5). The NoCL group was less likely than the CL-noDeb group to have an effusion ( P = .02) 1 year after surgery. CONCLUSION: Patients undergoing APM without unstable chondral lesions had better outcomes than patients with unstable chondral lesions.

The Effect of Body Mass Index on Clinical Outcomes in Patients Without Radiographic Evidence of Degenerative Joint Disease After Arthroscopic Partial Meniscectomy.

PURPOSE: To examine the effect of obesity on clinical outcomes at 1 year after arthroscopic partial meniscectomy. METHODS: We conducted a secondary analysis of the ChAMP (Chondral Lesions and Meniscus Procedures) randomized controlled trial (N = 256). The visual analog scale for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), range of motion, and presence of effusion were assessed preoperatively and at 1 year after arthroscopic partial meniscectomy. Body mass index was categorized as normal weight, 24.99 or less; overweight, 25 to 29.99; or obese, 30 or greater. Analysis of variance or the Cochran-Mantel-Haenszel test was used to examine differences in clinical outcomes between body mass index categories, and mean ± standard deviation or number (percentage) is reported. RESULTS: Preoperatively, obese patients had worse WOMAC pain (56.2 ± 17.2 vs 61.3 ± 17.2, P = .02), WOMAC physical function (55.8 ± 17.1 vs 62.8 ± 17.1, P = .004), pain visual analog scale (4.9 ± 2.1 vs 4.2 ± 1.9, P = .01), KOOS pain (49.5 ± 14.9 vs 54.0 ± 15.1, P = .02), and KOOS quality-of-life (27.9 ± 18.3 vs 36.9 ± 17.0, P = .001) scores, as well as decreased flexion (121.8° ± 22.6° vs 132.3° ± 16.5°, P = .003), compared with normal-weight patients. Overweight patients (n = 51 [51.5%], P = .03) and obese patients (n = 56 [52.8%], P = .002) were more likely to have knee effusion before surgery than normal-weight patients (n = 17 [34%]). At 1 year after surgery, overweight (130.2° ± 7.7°, P = .03) and obese (128.1° ± 7.1°, P = .003) patients had decreased flexion compared with normal-weight patients (134.5° ± 8.3°). CONCLUSIONS: Obese patients had worse pain, physical functioning, and quality-of-life scores, as well as decreased flexion, compared with normal-weight patients before arthroscopic partial meniscectomy. At 1 year after arthroscopic partial meniscectomy, there were no statistically significant differences in clinical outcomes but obesity was associated with decreased knee flexion. LEVEL OF EVIDENCE: Level II, prospective comparative trial.

Patient Outcomes After Observation Versus Debridement of Unstable Chondral Lesions During Partial Meniscectomy: The Chondral Lesions And Meniscus Procedures (ChAMP) Randomized Controlled Trial.

BACKGROUND: It is unknown whether unstable chondral lesions observed during arthroscopic partial meniscectomy (APM) require treatment. We examined differences at 1 year with respect to knee pain and other outcomes between patients who had debridement (CL-Deb) and those who had observation (CL-noDeb) of unstable chondral lesions encountered during APM. METHODS: Patients who were ≥30 years old and undergoing APM were randomized to receive debridement (CL-Deb group; n = 98) or observation (CL-noDeb; n = 92) of unstable Outerbridge grade-II, III, or IV chondral lesions. Outcomes were evaluated preoperatively and at 8 to 12 days, 6 weeks, 3 months, 6 months, and 1 year postoperatively. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) pain score, Short Form-36 (SF-36) health survey, range of motion, quadriceps circumference, and effusion. The primary outcome was the WOMAC pain score at 1 year. T tests were used to examine group differences in outcomes, and the means and standard deviations are reported. RESULTS: There were no significant differences between the groups with respect to any of the 1-year outcome scores. Compared with the CL-Deb group, the CL-noDeb group had improvement in the KOOS quality-of-life (p = 0.04) and SF-36 physical functioning scores (p = 0.01) as well as increased quadriceps circumference at 8 to 12 days (p = 0.02); had improvement in the pain score on the WOMAC (p = 0.02) and KOOS (p = 0.04) at 6 weeks; had improvement in SF-36 physical functioning scores at 3 months (p = 0.01); and had increased quadriceps circumference at 6 months (p = 0.02). CONCLUSIONS: Outcomes for the CL-Deb and CL-noDeb groups did not differ at 1 year postoperatively. This suggests that there is no benefit to arthroscopic debridement of unstable chondral lesions encountered during APM, and it is recommended that these lesions be left in situ. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

How Accurate Are Patients at Diagnosing the Cause of Their Knee Pain With the Help of a Web-based Symptom Checker?

BACKGROUND: Researching medical information is the third most popular activity online, and there are a variety of web-based symptom checker programs available. PURPOSE: This study evaluated a patient's ability to self-diagnose their knee pain from a list of possible diagnoses supplied by an accurate symptom checker. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: All patients older than 18 years who presented to the office of 7 different fellowship-trained sports medicine surgeons over an 8-month period with a complaint of knee pain were asked to participate. A web-based symptom checker for knee pain was used; the program has a reported accuracy of 89%. The symptom checker generates a list of potential diagnoses after patients enter symptoms and links each diagnosis to informative content. After exploring the informative content, patients selected all diagnoses they felt could explain their symptoms. Each patient was later examined by a physician who was blinded to the differential generated by the program as well as the patient-selected diagnoses. A blinded third party compared the diagnoses generated by the program with those selected by the patient as well as the diagnoses determined by the physician. The level of matching between the patient-selected diagnoses and the physician's diagnoses determined the patient's ability to correctly diagnose their knee pain. RESULTS: There were 163 male and 165 female patients, with a mean age of 48 years (range, 18-76 years). The program generated a mean 6.6 diagnoses (range, 2-15) per patient. Each patient had a mean 1.7 physician diagnoses (range, 1-4). Patients selected a mean 2 diagnoses (range, 1-9). The patient-selected diagnosis matched the physician's diagnosis 58% of the time. CONCLUSION: With the aid of an accurate symptom checker, patients were able to correctly identify the cause of their knee pain 58% of the time.

Design of a randomized controlled trial to compare debridement to observation of chondral lesions encountered during partial meniscectomy: The ChAMP (Chondral Lesions And Meniscus Procedures) Trial.

BACKGROUND: Few studies have examined whether chondral lesions encountered in patients undergoing meniscectomy should be surgically treated. The primary aim of the ChAMP (Chondral Lesions And Meniscus Procedures) Trial is to determine whether there is a difference in knee pain between patients undergoing debridement versus observation of chondral lesions encountered during arthroscopic meniscectomy. This paper describes the rationale and study design for the ChAMP Trial. METHODS/DESIGN: The ChAMP Trial is a randomized controlled trial of patients aged 30 and older undergoing partial meniscectomy and randomly allocated to debridement (CL-Deb, N=98) or observation (CL-Obs, N=92) of chondral lesions identified during surgery and deemed to be significant (Outerbridge Grade II-IV). Patients and data collectors were unaware of treatment allocation until completion of the study. Patients with surgically insignificant (Outerbridge Grade I) chondral lesions or no chondral lesions were included as a third non-randomized comparison group (NoCL, N=76). The primary outcome is the difference in knee pain assessed by WOMAC (Western Ontario and McMaster Universities Arthritis Index) between the CL-Deb and CL-Obs groups at 1-year after surgery. Secondary outcomes include 1-year differences in additional measures of knee pain, function, symptoms, activity, and quality of life assessed by the WOMAC, KOOS (Knee Injury and Osteoarthritis Outcome Score), visual analog pain scale, and physical exam; as well as general health assessed with the SF-36 (Short-form Health Survey). Increased intraoperative costs associated with the addition of chondral debridement will also be assessed. DISCUSSION: This study will add to the scant literature regarding management of chondral lesions in patients undergoing meniscectomy and might provide treatment guidance for clinicians and their patients.

Accuracy of a computer-based diagnostic program for ambulatory patients with knee pain.

BACKGROUND: Looking up information regarding a medical condition is the third most popular activity online, and there are a variety of web-based symptom-checking programs available to the patient. However, the authors are not aware of any that have been scientifically evaluated as an accurate measure for the cause of one's knee pain. PURPOSE/HYPOTHESIS: The purpose of this study was to design and evaluate an Internet-based program that generates a differential diagnosis based on a history of knee pain entered by the patient. The hypothesis was that the program would accurately generate a differential diagnosis for patients presenting with knee pain. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A web-based program was created to collect knee pain history and generate a differential diagnosis for ambulatory patients with knee pain. The program selected from 26 common knee diagnoses. A total of 527 consecutive patients aged ≥18 years, who presented with a knee complaint to 7 different board-certified orthopaedic surgeons during a 3-month period, were asked to complete the questionnaire in the program. Upon completion, patients were examined by a board-certified orthopaedic surgeon. Both the patient and physician were blinded to the differential diagnosis generated by the program. A third party was responsible for comparing the diagnosis(es) generated by the program with that determined by the physician. The level of matching between diagnoses determined the accuracy of the program. RESULTS: A total of 272 male and 255 female patients, with an average age of 47 years (range, 18-84 years), participated in the study. The median number of diagnoses generated by the program was 4.8 (range, 1-10), with this list containing the physician's diagnosis(es) 89% of the time. The specificity was 27%. CONCLUSION: Despite a low specificity, the results of this study show the program to be an accurate method for generating a differential diagnosis for knee pain.

Current trends in anterior cruciate ligament reconstruction.

In 2006, a survey regarding anterior cruciate ligament (ACL) reconstruction was mailed to physician members of the American Orthopaedic Society for Sports Medicine. A total of 993 responses were received from 1747 possible respondents (57%). The number of ACL reconstructions per year ranged from 1 to 275 (mean=55). The most important factors in the timing of surgery were knee range of motion and effusion. Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively). A single-incision arthroscopic technique was used by 90%. Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision. There was limited experience (4%) with double-bundle and computer-assisted ACL reconstruction. Arthroscopic-assisted, single-incision reconstruction using a BPTB autograft fixed with metal interference screws remains the most common technique used for primary ACL reconstruction. In the past 5 years, the use of alternative graft sources and methods of fixation has increased. Consensus regarding the best graft type, fixation method, and postoperative protocol is still lacking.

Evaluation and treatment of posterior cruciate ligament injuries: revisited.

Current knowledge and treatment of posterior cruciate ligament injuries continue to lag behind that of anterior cruciate ligament injuries. This is the result of the relative infrequency of posterior cruciate ligament injuries and the lack of consensus with respect to its natural history, surgical indications, technique, and postoperative rehabilitation. Recent anatomical and biomechanical studies have improved our understanding of the posterior cruciate ligament in an attempt to reproduce its anatomy and function during reconstruction. The following is a comprehensive review on the evaluation and treatment of posterior cruciate ligament injuries with special focus on the current surgical techniques.

Reliability of common knee injection sites with low-volume injections.

This study's purpose was to evaluate the reliability of knee injection sites with low-volume (2-3 cc) injection typical of viscosupplementation. This was a prospective study of 131 knees randomly assigned to 3 injection groups before to knee arthroscopy: SM-superomedial, superolateral, and lateral joint line (LJL). Needles were inserted to the hub, and aspiration was attempted before injection with 3 cc diluted methylene blue (MB). Injections then were graded at the time of arthroscopy as good, fair, or poor, depending on the intra-articular staining of MB. We conclude that a lateral joint line injection site may not be reliable for routine injections of low volumes into knees, because it results in good intra- articular delivery less than half of the time, with a high incidence of soft-tissue infiltration.

Sports for the physically challenged child.

Participation in sports is important for the physical and emotional health of the physically challenged child. Sports can improve strength, endurance, and cardiopulmonary fitness while providing companionship, a sense of achievement, and heightened self-esteem. With interest in such participation increasing, it is necessary for the physicians, therapists, and families of children with special needs to understand the preparticipation evaluation, athletic options, specialized equipment, and sport-specific risks. Recommendations that provide guidelines for safe, effective participation in sports are currently available for common congenital and developmental disabilities such as Down syndrome, cerebral palsy, myelodysplasia, hemophilia, congenital amputations, and arthritic disorders.

Predicting ulnar nerve location in pinning of supracondylar humerus fractures.

Thirty-four consecutive patients with displaced supracondylar humerus fractures were treated with reduction and percutaneous pinning. The precise location of the ulnar nerve to the medial pin was determined by intraoperative nerve stimulation. In 22 of the 34 patients, the authors attempted to predict the location of the ulnar nerve by palpation and placing a mark on the skin. They also recorded the ability to feel the anatomic landmarks for pin fixation, including the medial epicondyle and ulnar nerve. The average distance from the medial pin to the predicted location was 9.3 mm, whereas the actual distance measured 7.6 mm, for a significant difference of 1.7 mm. Statistically, the authors could not accurately predict the location of the ulnar nerve prior to blind percutaneous crossed K-wire fixation of supracondylar humerus fractures. However, clinically they were fairly close in their prediction and documented safe insertion and distance from the nerve. Intraoperative nerve stimulation may assist in localizing the nerve prior to placement of the medial pin. Stimulation of the pin itself following insertion is another technique to ensure safe pin placement and decrease the risk of injury.