Functional bracing was no better than nonbracing after anterior cruciate ligament repair.
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Comment↗
Biomedical subjects
Robert G Marx
Publications and source records attributed to Robert G Marx.
Measuring improvement following total hip and knee arthroplasty using patient-based measures of outcome.
BACKGROUND: Patient-derived outcome scales have become increasingly important to physicians and clinical researchers for measuring improvement in function after surgery. The goal of the present study was to evaluate the ability of health-status instruments to measure early functional recovery after total hip and total knee arthroplasty. METHODS: Four hundred and six patients undergoing total hip arthroplasty and 266 patients undergoing total knee arthroplasty completed health-status questionnaires preoperatively and six months postoperatively to determine the standardized response mean. In the second phase of the study, a group of patients undergoing knee and hip arthroplasty were evaluated with several instruments before and after surgery to test for postoperative ceiling effects. RESULTS: The standardized response mean at six months was 1.7 for the MODEMS Hip Core, 1.2 for the MODEMS Knee Core, and 1.5 and 1.1 for the Physical Component Summary of the SF-36 for patients managed with hip and knee replacement, respectively. A standardized response mean of 1.0 is generally satisfactory for measuring improvement in orthopaedic surgery. In Phase 2 of the study, the vast majority of patients who had a score of 95 to 100 (that is, a maximum or near-maximum score) on the joint-specific scales generally believed that the hip or knee was normal and could not be better. CONCLUSIONS: The MODEMS, Oxford, and WOMAC scales all demonstrated a ceiling effect following total knee and total hip arthroplasty. These scores likely reflected the patients' perception of the status of the knee or hip rather than an inability to measure their improvement beyond the highest possible score. The Physical Component Summary score of the SF-36 had similar standardized response means when compared with hip and knee-specific instruments, and, therefore, consideration should be given to using this scale without a joint-specific scale for the measurement of improvement following total knee and total hip replacement, as a way to decrease responder burden (that is, the time required to complete the questionnaires).
Adult↗
The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study.
BACKGROUND: Microfracture is a frequently used technique for the repair of articular cartilage lesions of the knee. Despite the popularity of the technique, prospective information about the clinical results after microfracture is still limited. The purpose of our study was to identify the factors that affect the clinical outcome from this cartilage repair technique. METHODS: Forty-eight symptomatic patients with isolated full-thickness articular cartilage defects of the femur in a stable knee were treated with the microfracture technique. Prospective evaluation of patient outcome was performed for a minimum follow-up of twenty-four months with a combination of validated outcome scores, subjective clinical rating, and cartilage-sensitive magnetic resonance imaging. RESULTS: At the time of the latest follow-up, knee function was rated good to excellent for thirty-two patients (67%), fair for twelve patients (25%), and poor for four (8%). Significant increases in the activities of daily living scores, International Knee Documentation Committee scores, and the physical component score of the Short Form-36 were demonstrated after microfracture (p < 0.05). A lower body-mass index correlated with higher scores for the activities of daily living and SF-36 physical component, with the worst results for patients with a body-mass index of >30 kg/m(2). Significant improvement in the activities of daily living score was more frequent with a preoperative duration of symptoms of less than twelve months (p < 0.05). Magnetic resonance imaging in twenty-four knees demonstrated good repair-tissue fill in the defect in thirteen patients (54%), moderate fill in seven (29%), and poor fill in four patients (17%). The fill grade correlated with the knee function scores. All knees with good fill demonstrated improved knee function, whereas poor fill grade was associated with limited improvement and decreasing functional scores after twenty-four months. CONCLUSIONS: Microfracture repair of articular cartilage lesions in the knee results in significant functional improvement at a minimum follow-up of two years. The best short-term results are observed with good fill grade, low body-mass index, and a short duration of preoperative symptoms. A high body-mass index adversely affects short-term outcome, and a poor fill grade is associated with limited short-term durability.
Activities of Daily Living↗
Variation in orthopaedic surgeons' perceptions about the indications for rotator cuff surgery.
BACKGROUND: Epidemiologic studies have demonstrated substantial variations in per capita rates of many surgical procedures, including rotator cuff repair. The purpose of the current study was to characterize orthopaedic surgeons' attitudes concerning medical decision-making about rotator cuff surgery and to investigate the associations between these beliefs and reported surgical volumes. METHODS: A survey was mailed to randomly selected orthopaedic surgeons listed in the American Academy of Orthopaedic Surgeons directory. Only individuals who had treated patients for a rotator cuff tear, or had referred patients for such treatment, within the previous year were asked to complete the two-page survey. The survey comprised fifteen questions regarding clinical opinion, including four regarding hypothetical cases. Clinical agreement was defined as >80% of the respondents answering similarly. RESULTS: Of the 1100 surveys that were mailed, 539 were returned (a response rate of 49%). Of the 539 respondents, 316 (58.6%) had treated or referred patients with a rotator cuff tear in the previous year. There was a significant negative correlation between the surgeon's estimation of the failure rate of cuff repairs in the United States and that surgeon's procedure volume (r = -0.21, p = 0.0003), indicating that surgeons with a lower procedure volume are more pessimistic about the results of surgery than are those with a higher procedure volume. Arthroscopic, mini-open, and open cuff repairs were preferred by 14.5%, 46.2%, and 36.6% of the respondents, respectively. Surgeons who performed a higher volume of procedures were less likely to perform open surgery (p < 0.0001). There was clinical agreement regarding only four of the nine clinical questions and none of the four questions about the hypothetical vignettes. CONCLUSIONS: We found significant variation in surgical decision-making and a lack of clinical agreement among orthopaedic surgeons about rotator cuff surgery. There was a positive correlation between the volume of procedures performed by the surgeon and the surgeon's perception of outcome, with surgeons who had a higher procedure volume being more enthusiastic about rotator cuff surgery than those who had a lower procedure volume.
Analysis of Variance↗
Magnetic resonance imaging appearance of cartilage repair in the knee.
Assessment of surgically repaired cartilage lesions with standardized cartilage sensitive magnetic resonance imaging was done to evaluate the integrity, morphologic features, and signal of the articular surface, thereby obtaining information about the natural history of these procedures in the knee. Magnetic resonance imaging also assessed the interface between the repaired and native cartilage, changes in the subchondral bone, and the appearance of cartilage over the opposite and adjacent (native) surfaces. One hundred eighty magnetic resonance imaging examinations were obtained in 112 patients who had cartilage-resurfacing procedures, including 86 microfractures and 35 autologous chondrocyte implantations, at a mean of 15 and 13 months after surgery, respectively. Autologous chondrocyte implantations showed consistently better fill of the defects at all times compared with microfracture. The graft hypertrophied in 63% of surgeries. The repair cartilage over the microfracture generally was depressed with respect to native cartilage. Propensity for bony overgrowth was most marked in the microfracture group, with loss of adjacent cartilage evident with progressive followup.
Adolescent↗
Multirater agreement of arthroscopic meniscal lesions.
BACKGROUND: Establishing the validity of classification schemes is a crucial preparatory step that should precede multicenter studies. There are no studies investigating the reproducibility of arthroscopic classification of meniscal pathology among multiple surgeons at different institutions. HYPOTHESIS: Arthroscopic classification of meniscal pathology is reliable and reproducible and suitable for multicenter studies that involve multiple surgeons. STUDY DESIGN: Multirater agreement study. METHODS: Seven surgeons reviewed a video of 18 meniscal tears and completed a meniscal classification questionnaire. Multirater agreement was calculated based on the proportion of agreement, the kappa coefficient, and the intraclass correlation coefficient. RESULTS: There was a 46% agreement on the central/peripheral location of tears (kappa = 0.30), an 80% agreement on the depth of tears (kappa = 0.46), a 72% agreement on the presence of a degenerative component (kappa = 0.44), a 71% agreement on whether lateral tears were central to the popliteal hiatus (kappa = 0.42), a 73% agreement on the type of tear (kappa = 0.63), an 87% agreement on the location of the tear (kappa = 0.61), and an 84% agreement on the treatment of tears (kappa = 0.66). There was considerable agreement among surgeons on length, with an intraclass correlation coefficient of 0.78, 95% confidence interval of 0.57 to 0.92, and P < .001. CONCLUSIONS: Arthroscopic grading of meniscal pathology is reliable and reproducible. CLINICAL RELEVANCE: Surgeons can reliably classify meniscal pathology and agree on treatment, which is important for multicenter trials.
Arthroscopy↗
The effect of anterior cruciate ligament reconstruction on the risk of knee reinjury.
BACKGROUND: Although there is evidence that very active, young patients are better served with anterior cruciate ligament reconstruction, there is a lack of objective data demonstrating that future knee injury is prevented by these procedures. HYPOTHESIS: Anterior cruciate ligament reconstruction protects against reinjury of the knee that would require reoperation. STUDY DESIGN: Retrospective cohort study. METHODS: A cohort of 6576 active-duty army personnel who had been hospitalized for anterior cruciate ligament injury from 1990 to 1996 were identified. Using the Total Army Injury and Health Outcomes Database, the authors followed these individuals for up to 9 years and collected clinical, demographic, and occupational data. These data were evaluated with bivariate and multivariable analyses to determine the effect of anterior cruciate ligament reconstruction on the rate of knee reinjury that required operation. RESULTS: Of the 6576 study subjects, 3795 subjects (58%) underwent anterior cruciate ligament reconstruction and 2781 (42%) did not. The rate of reoperation was significantly lower among the anterior cruciate ligament reconstruction group (4.90/100 person-years) compared with those treated conservatively (13.86/100 person-years; P < .0001). Proportional hazard regression analyses adjusted for age, race, sex, marital status, education, and physical activity level confirmed that anterior cruciate ligament reconstruction was protective against meniscal and cartilage reinjury (P < .0001). Secondary medial meniscal injury was more common than secondary lateral meniscal injury (P < .003). Younger age was the strongest predictor of failure of conservative management leading to late anterior cruciate ligament reconstruction (P < .0001). CONCLUSIONS: Anterior cruciate ligament reconstruction protected against reoperation in this young, active population; younger subjects were more likely to require late anterior cruciate ligament reconstruction. CLINICAL RELEVANCE: Strong consideration should be given to anterior cruciate ligament reconstruction after anterior cruciate ligament injury in young, active individuals.
Adult↗
Knee rating scales.
In the past 2 decades, outcome assessment following knee surgery has focused increasingly on the patient's perspective. While traditional measures of outcome, including physical examination, imaging studies, and measures of knee laxity are complementary, questionnaires have become more important in determining the value of a procedure. Reliability, validity, and responsiveness are all important measurement qualities for health-related quality of life instruments. There are several questionnaires available, both for active patients with disorders of the knee, as well as for older patients with degenerative conditions. Activity level is also an important prognostic variable for patients with disorders of the knee. Clinical researchers should also use a validated activity rating scale to evaluate what patients are doing, in addition to how they are doing.
Athletic Injuries↗
Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury.
PURPOSE: The purpose of the study was to quantify the amount of agreement among orthopaedic surgeons regarding the natural history of the anterior cruciate ligament (ACL)-deficient knee, surgery, and rehabilitation, and the treatment of these patients. TYPE OF STUDY: Physician mail survey. METHODS: Orthopaedic surgeons were randomly selected from the American Academy of Orthopaedic Surgeons (AAOS) directory. Only individuals who treated or referred ACL-insufficient patients for treatment within the past year were asked to complete the 3-page survey. The survey included 25 questions regarding clinical opinion. Clinical agreement was present when 80% or more of the surgeons agreed on the same response option. RESULTS: The total number of surgeons who responded to the survey was 397 (response rate, 54.8%) and the number who had treated or referred ACL-insufficient patients in the past year was 261. Among surgeons who completed the questionnaire, the response rates to the individual questions ranged from 92% to 100%. The mean response rate for all questions was 97.4%. The mean age of the surgeons was 48.4 years, and 35.8% considered their practice to be a subspecialty in sports medicine or knee surgery. For 12 questions (48%), there was clinical disagreement among the surgeons. Surgical volume was associated with clinical opinion for 16 of 25 questions (P < or =.05). CONCLUSIONS: Significant variation is seen in clinical opinion and decision-making regarding ACL injuries among members of the AAOS, particularly regarding whether ACL-deficient patients can participate in all recreational sports activities, that ACL reconstruction reduces the rate of arthrosis, and on the use of braces in the postoperative period. Additionally, surgeons disagreed on the effect of 4 patient characteristics (age over 40, presence of pain, irreparable meniscal tear, injury involving Workers' Compensation) on the decision to perform surgery. Areas of significant clinical uncertainty should be the focus of future research and medical education for orthopaedic surgeons who treat ACL injuries.
Academies and Institutes↗
A comparison of two time intervals for test-retest reliability of health status instruments.
Studies of test-retest reliability for health-related quality of life instruments have used varying intervals between test administrations. There is no evidence available to aid in the selection of the time interval between questionnaire administrations for a study of test-retest reliability for health status instruments. We compared the test-retest reliability at 2 days and 2 weeks for four knee-rating scales and the eight domains of the SF-36. Seventy patients with disorders of the knee who were in a stable state were randomly allocated to repeat the questionnaires at either 2 days or 2 weeks. There were no statistically significant differences in the test-retest reliability (intraclass correlation coefficient and limits of agreement statistics) for the two time intervals.
Adolescent↗
Diagnostic performance of magnetic resonance imaging of the knee differs according to lesion.
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Comment↗
Sideline orthopedic emergencies in the young athlete.
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Adolescent↗
Meniscus repair: considerations in treatment and update of clinical results.
The meniscus plays an important role in the function of the knee. Preservation of the meniscus is preferred if possible when considering treatment of a meniscus tear. A thorough understanding of the anatomy of the meniscus, the structure, the mechanics, and other factors of meniscal healing are critical when evaluating the torn meniscus for a reparative procedure. Many options for meniscus repair exist for the orthopaedist. Options such as open repair or arthroscopically-assisted inside-out techniques have long-term favorable results. The all-inside techniques are attractive because of the decrease in operative time and ease of the technique. Short-term results are positive for the all-inside technique; however, good long-term data on these techniques are lacking. Few well-designed prospective studies exist on any of the meniscus repair techniques. Future directions include the potential use of growth factors and gene therapy to augment meniscus repair.
Arthroscopy↗
Development of arthrosis following dislocation of the shoulder: a case-control study.
The goal of this study was to document whether an association exists between shoulder dislocation and the development of arthrosis and to quantify this association, if present. Patients with osteoarthrosis who had undergone hemi-shoulder or total shoulder arthroplasty (TSA) were studied. Patients who had undergone total knee arthroplasty for arthrosis and who had no history of shoulder symptoms served as control subjects. All patients were asked if they had ever sustained a shoulder dislocation. Ninety-one TSA patients and 282 control subjects responded. The odds ratio for developing arthrosis after a shoulder dislocation was 19.3 (P =.000006). With the 5 patients who had shoulder surgery prior to TSA excluded, the odds ratio was 10.5 (P =.003). The risk of developing severe arthrosis of the shoulder is between 10 and 20 times greater for individuals who have had a dislocation of the shoulder.
Aged↗
Measurement variance in limb length discrepancy: clinical and radiographic assessment of interobserver and intraobserver variability.
The purpose of this study was to assess interobserver and intraobserver variability in the assessment of clinical and radiographic measurement of lower limb length discrepancy. Clinical measurements included direct measurement with a tape measure from anterior superior iliac spine (ASIS) to lateral malleolus and ASIS to medial malleolus as well as block measurement. Slit scanogram radiographic measurement was also evaluated. All three clinical measurements had excellent reliability, but the relatively large mean differences and the large 95% confidence intervals for clinical measurements limit the usefulness of these techniques. Slit scanogram measurement was the most reliable measurement technique. The intraobserver variance of direct slit scanogram measurement included intraclass correlation coefficient of 0.99, mean difference of 0.1 cm, and 95% confidence interval of 0.4 cm. Results were not influenced by patient age or body mass index. Slit scanogram measurement is the preferred method for assessment of limb length discrepancy. The direct slit scanogram measurement described in the text follows the mechanical axis line of the leg in the "at ease" standing position described by Paley. Direct measurement using a measuring tape on a full-length slit scanogram is more reliable than indirect measurement using horizontal lines drawn to a radiolucent ruler that is positioned by a technician, since direct measurement avoids errors due to nonparallel positioning of the limb relative to the ruler, and direct measurement also avoids errors due to non-horizontal lines drawn from standard bony landmarks to the ruler. The ideal radiographic measurement technique would have high reliability and accuracy and would minimize or eliminate radiation.
Adolescent↗
Reliability and accuracy of MRI scanogram in the evaluation of limb length discrepancy.
The purpose of this study was to compare MRI scanogram with traditional radiographic methods for measurement of limb length. The authors hypothesized that MRI scanogram would be as reliable and accurate as radiographic scanogram in measurement of limb length without exposing patients to ionizing radiation. Twelve cadaveric femurs were measured using AP conventional radiographic scanogram, CT scanogram, MRI scanogram, and electronic caliper. Three orthopaedists performed two separate measurements using each technique. Intraobserver and interobserver variability was assessed for each of the three radiographic techniques. Accuracy was assessed by comparison of radiographic measurements to electronic caliper measurements of femur length. The reliability of all three radiographic limb length measurement techniques was excellent (ICC > 0.99). The accuracy of plain radiographic scanogram was slightly superior to CT scanogram and MRI scanogram. The mean absolute differences for radiographic, CT, and MRI scanograms compared with the gold standard, direct caliper measurement, were 0.52 mm, 0.68 mm, and 2.90 mm, respectively. All three scanogram techniques showed excellent reliability and accuracy. Radiographic scanogram remains the gold standard for leg length measurement. MRI scanogram is slightly less accurate compared with radiographic scanogram, but it does not use ionizing radiation. MRI scanogram merits clinical study and comparison with the traditional radiographic scanogram method for measurement of limb length.
Adult↗