Tibiofemoral Osteoarthritis After Surgical or Nonsurgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review.

OBJECTIVE: To determine if surgical or nonsurgical treatment of anterior cruciate ligament rupture affects the prevalence of posttraumatic tibiofemoral osteoarthritis (OA). DATA SOURCES: Studies published between 1983 and April 2012 were identified via EBSCOhost and OVID. Reference lists were then screened in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. STUDY SELECTION: Studies were included if (a) treatment outcomes focused on a direct comparison of surgical versus nonsurgical treatment of anterior cruciate ligament rupture, (b) the prevalence of tibiofemoral OA was reported, and (c) they were written in English. Studies were excluded if (a) the included patients were treated with cast immobilization after surgery, (b) the mean follow-up was less than 10 years, or (c) the patients underwent anterior cruciate ligament revision surgery. DATA EXTRACTION: Two independent investigators reviewed the included articles using the Newcastle-Ottawa Scale. Frequency of OA, surgical procedure, nonsurgical treatments, and participant characteristics were extracted and summarized. We calculated prevalence (%) and 95% confidence intervals for treatment groups for each individual study and overall. We developed 2 × 2 contingency tables to assess the association between treatment groups (exposed had surgery, referent was nonsurgical treatment) and the prevalence of OA. DATA SYNTHESIS: Four retrospective studies were identified (140 surgical patients, 240 nonsurgical patients). The mean Newcastle-Ottawa Scale score was 5 (range = 4-6 [of 10] points). Average length of follow-up was 11.8 years (range = 10-14 years). The prevalence of OA for surgically treated patients ranged from 32.6% to 51.2% (overall = 41.4%, 95% confidence interval = 35.0%, 48.1%) and for nonsurgical patients ranged from 24.5% to 42.3% (overall = 30.9%, 95% confidence interval = 24.4%, 38.3%). CONCLUSIONS: Although OA prevalence was higher in the surgical treatment group at a mean follow-up of 11.8 years, no definitive evidence supports surgical or nonsurgical treatment after anterior cruciate ligament injury to prevent posttraumatic OA. Current studies have been limited by small sample sizes, low methodologic quality, and a lack of data regarding confounding factors.

Prevalence of Radiographic Knee Osteoarthritis After Anterior Cruciate Ligament Reconstruction, With or Without Meniscectomy: An Evidence-Based Practice Article.

Reference: Claes S, Hermie L, Verdonk R, Bellemans J, Verdonk P. Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):1967-1976. CLINICAL QUESTION: What is the prevalence of radiographic knee osteoarthritis (OA) at a mean follow-up equal to or greater than 10 years after autologous anterior cruciate ligament (ACL) reconstruction, with or without meniscectomy? DATA SOURCES: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were used to conduct this meta-analysis. Studies were identified by searching PubMed, MEDLINE, EMBASE, and Cochrane Library dating from their earliest file until October 2010. Key terms applied for searching were anterior cruciate ligament or ACL, autologous, follow-up, long-term, outcome, reconstruction, results, treatment, and (osteo)arthritis or osteoarthrosis. The reference lists of included studies were also manually checked to ensure that relevant articles were not omitted. STUDY SELECTION: The authors limited their search to English- and French-language journals. Included studies provided radiographic outcomes after autologous ACL reconstruction and had a mean follow-up of ≥10 years. Excluded studies evaluated ACL reconstruction with major concomitant surgical procedures (eg, meniscal allograft transplantation, high tibial osteotomy). In addition, data from 2 studies completed by the same research team with identical patient populations were limited to the article with the longest follow-up. Finally, manuscripts with inaccurate or incomplete data were excluded. DATA EXTRACTION: The following key characteristics of each study were extracted: type of study (prospective or retrospective); ACL surgical procedure (eg, open or arthroscopic bone-patellar tendon-bone graft); time frame of surgery; mean follow-up (in years) post-ACL reconstruction; total number of participants with radiographs; total number of participants with radiographic OA at follow-up; and number of participants with meniscectomy before, during, or after ACL reconstruction. Although the OA diagnosis was based on radiographic criteria, the included studies used 4 OA classifications and grading scales: Ahlbäck, Fairbanks, Kellgren and Lawrence, and International Knee Documentation Committee. Regardless of classification or grading scale, OA was defined as the presence of joint-space narrowing: Ahlbäck grades 1 through 5, modified Fairbanks grades 2 and 3, Kellgren and Lawrence ≥2, and International Knee Documentation Committee grades C and D. Tibiofemoral and patellofemoral OA data were collapsed due to the lack of reporting specificity among the studies. Participants were categorized into a meniscectomy or nonmeniscectomy group if this information was reported. Partial or total meniscectomies before, during, or after ACL reconstruction were collapsed regardless of location (medial or lateral compartment), and those patients who underwent a meniscal repair were grouped into the nonmeniscectomy group. Data were analyzed using odds ratios, the Cochran χ2 test, and a random-effects meta-regression analysis. The DerSimonian and Laird approach was used to assess study heterogeneity. P values below .05 were considered statistically significant. MAIN RESULTS: The initial computerized database search resulted in 211 possible studies. However, after the authors applied the inclusionary and exclusionary criteria, only 16 studies were relevant. A total of 1554 participants were available at the follow-up period. Mean follow-up ranged from 10 to 24.5 years; 11 of the 16 articles had a mean follow-up between 10 and 12 years. Heterogeneity was large (I2 = 96%), which indicated that the included studies generated a wide range of knee OA prevalence (2%-79%). Almost 28% (95% confidence interval [CI] = 16.3%, 43.5%) of participants had radiographic knee OA. A total of 1264 participants were involved in studies that evaluated meniscectomies (n = 11). Among the 614 participants with either partial or total meniscectomies, 50.4% had radiographic knee OA (95% CI = 27.4%, 73.1%). In contrast, only 16.4% (95% CI = 7.0%, 33.9%) of those without a meniscectomy had radiographic knee OA. CONCLUSIONS: The findings of Claes et al reflected a radiographic knee OA prevalence at a minimum average of 10 years' postautologous ACL reconstruction that was lower than commonly perceived (up to 79%). In addition, meniscectomy was an important risk factor (3.54-fold increase) for developing OA after ACL reconstruction.

Effectiveness of Glenohumeral-Joint Stability Braces in Limiting Active and Passive Shoulder Range of Motion in Collegiate Football Players.

OBJECTIVE: To determine the effectiveness of glenohumeral-joint stability braces in limiting active and passive shoulder abduction and external rotation in collegiate football players. DESIGN AND SETTING: A 2-factor, repeated-measures design was used. The independent variables were brace condition (Denison and Duke Wyre harness, Sawa shoulder brace) and force application (active, passive). The dependent variables were shoulder abduction (45 degrees braced limit) and external-rotation angular displacements. SUBJECTS: Fifteen National Collegiate Athletic Association Division I male college football players (age = 19.9 +/- 1.37 years, height = 183.2 +/- 7.85 cm, mass = 89.9 +/- 14.79 kg) participated in the study. MEASUREMENTS: We used the PEAK Motus motion analysis system to measure angular displacements. RESULTS: Neither brace maintained the arm position at the 45 degrees braced limit during active or passive shoulder abduction (motion ranged from 56.8 degrees to 73.0 degrees ). Although we did not use a priori external-rotation limits in this study, motion ranged from 71.6 degrees to 93.9 degrees with the braces. A repeated-measures multivariate analysis of variance indicated no significant interaction effect (P =.41), but main effects were significant for brace condition and force application (P <.001). Reported differences are statistically significant. For abduction, the Denison and Duke Wyre harness resulted in 12.3 degrees (21%) greater angular displacement than the Sawa shoulder brace, and passive abduction resulted in 3.9 degrees (6%) more angular displacement than active abduction. For external rotation, the Denison and Duke Wyre harness resulted in 6.7 degrees (9%) more angular displacement than the Sawa shoulder brace, and passive external rotation resulted in 15.6 degrees (21%) more angular displacement than active external rotation. CONCLUSIONS: Preset, braced abduction motion limits were not realized during active and passive physiologic loading of the glenohumeral joint. However, protection against the vulnerable position of 90 degrees of abduction and external rotation was attained at a preset braced limit of 45 degrees of abduction (the exception was the Denison and Duke Wyre harness during passive external rotation). The Sawa shoulder brace was most effective for this purpose.

Head Position and Football Equipment Influence Cervical Spinal-Cord Space During Immobilization.

OBJECTIVE: To assess the effect of head position and football equipment (ie, helmet and shoulder pads) on cervical spinal cord space in individuals lying supine on a spine board. DESIGN AND SETTING: The independent variables were head position (0-cm, 2-cm, and 4-cm occiput elevation with no helmet and shoulder pads and with helmet and shoulder pads) and cervical spine level (C3, C4, C5, C6, and C7). The 3 dependent variables were sagittal space available for the cord (SAC) (mm), sagittal spinal-cord diameter (mm), and cervical-thoracic angle ( degrees ), determined via magnetic resonance imaging. SUBJECTS: Twelve men (age = 24.3 +/- 2.1 years; height = 181.1 +/- 5.7 cm; weight = 93.9 +/- 3.6 kg). MEASUREMENTS: Sagittal space available for the cord was determined by subtracting the sagittal spinal-cord diameter from the corresponding sagittal spinal-canal diameter. The spinal-canal diameter was measured as the shortest distance from the vertebral body to the spinolaminar line at each of the spinal levels. Each measurement was taken 3 times, and the 3 measurements were averaged. RESULTS: Sagittal space available for the cord was significantly greater (P <.01) for 0-cm (mean = 5.50 mm) than for 2-cm (mean = 4.86 mm) and 4-cm (mean = 5.07 mm) occiput elevation. SAC was also significantly greater (P <.01) for the equipment condition (mean = 5.34 mm) than for the 2-cm and 4-cm elevation levels. No significant difference (P =.093) in SAC existed between 0-cm elevation and the equipment condition. CONCLUSIONS: The helmet and shoulder pads should be left on during spine-board immobilization of the injured football player. Similarly, during spine-board immobilization of an individual without football helmet and shoulder pads, the head should be maintained at 0 cm of occiput elevation. Sagittal spinal-cord space is optimized in both of these conditions.

Cervical Spine Stenosis Measures in Normal Subjects.

OBJECTIVE: To compare 2 methods of determining cervical spinal stenosis (Torg ratio, space available for the cord [SAC]); determine which of the components of the Torg ratio and the SAC account for more of the variability in the measures; and present standardized SAC values for normal subjects using magnetic resonance imaging (MRI). DESIGN AND SETTING: The research design consisted of a posttest-only, comparison-group design. The independent variable was method of measurement (Torg ratio and SAC). The dependent variables were Torg ratio and SAC scores. SUBJECTS: Fourteen men (age = 24.4 +/- 2.5 years, height = 181.0 +/- 5.8 cm, weight = 90 +/- 13.5 kg) participated in this study. The C3 to C7 vertebrae were examined in each subject (n = 70). MEASUREMENTS: The Torg ratio was determined by dividing the sagittal spinal-canal diameter by the corresponding sagittal vertebral-body diameter. The SAC was determined by subtracting the sagittal spinal-cord diameter from the corresponding sagittal spinal-canal diameter. The Torg ratio and SAC were measured in millimeters. RESULTS: The SAC ranged from 2.5 to 10.4 mm and was greatest at C7 in 71% (10 of 14) of the subjects. The SAC was least at C3 or C5 in 71% (10 of 14) of the subjects. A Pearson product moment correlation revealed a significant relationship between the Torg ratio and SAC (r =.53, P <.01). Regression analyses revealed the vertebral body (r (2) =.58) accounted for more variability in the Torg ratio than the spinal canal (r (2) =.48). Also, the spinal canal (r (2) =.66) accounted for more variability in the SAC than the spinal cord (r (2) =.23). CONCLUSIONS: The SAC measure relies more on the spinal canal compared with the Torg ratio and, therefore, may be a more effective indicator of spinal stenosis. This is relevant clinically because neurologic injury related to stenosis is a function of the spinal canal and the spinal cord (not the vertebral body). Further research must be done, however, to validate the SAC measure.