Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Albert Gee, MD, a co-author of the April 18, 2018 Specialty Update on Sports Medicine, to select the five most clinically compelling findings from among the 30 studies cited in the article.
Anterior Cruciate Ligament (ACL) Reconstruction
–The conversations about graft selection for ACL reconstruction go on. A meta-analysis of 19 Level-I studies comparing 4-strand hamstring autograft with patellar tendon grafts1 revealed no differences in terms of rupture rate, clinical outcome scores, or arthrometer side-to-side testing at >58 months of follow-up. The prevalence of anterior knee pain and kneeling pain was significantly less in the hamstring group, and that group also exhibited a lower rate of extension deficit.
–Fourteen-year outcomes from a randomized controlled trial (n = 80 patients) comparing autologous chondrocyte implantation (ACI) with microfracture for treating large focal cartilage defects included the following:
- No significant between-group difference in functional outcome scores
- Fairly high treatment failure rates in both groups (42.5% in the ACI group; 32.5% in the microfracture group)
- Radiographic evidence of grade 2 or higher osteoarthritis in about half of all patients
These findings raise doubts about the long-term efficacy of these two treatments.
Rehab after Rotator Cuff Repair
–A randomized trial comparing early and delayed initiation of range of motion after arthroscopic single-tendon rotator cuff repair in 73 patients2 found no major differences in clinical outcome, pain, range of motion, use of narcotics, or radiographic evidence of retear. The early motion group showed a small but significant decrease in disability. The findings indicate that early motion after this surgical procedure may do no harm.
Platelet-Rich Plasma (PRP)
–A systematic review of 105 human clinical trials that examined the use of PRP in musculoskeletal conditions revealed the following:
- Only 10% of the studies clearly explained the PRP-preparation protocol.
- Only 16% of the studies provided quantitative information about the compositi0on of the final PRP product.
- Twenty-four different PRP processing systems were used across the studies.
- Platelet composition in the PRP preparations ranged from 38 to 1,540 X 103/µL.
Consequently, care should be taken when drawing conclusions from such studies.
Meniscal Tear Treatment
–A follow-up to the MeTeOR trial (350 patients initially randomized to receive either a partial arthroscopic meniscectomy or physical therapy [PT]) found that crossover from the PT group to the partial meniscectomy group was significantly associated with higher baseline pain scores or more acute symptoms within 5 months of enrollment. Investigators also found identical 6-month WOMAC and KOOS scores between those who crossed over and those who had surgery initially. These findings suggest that an initial course of PT prior to meniscectomy does not compromise outcomes.
- Chee MY, Chen Y, Pearce CJ, Murphy DP, Krishna L, Hui JH, Wang WE, Tai BC,Salunke AA, Chen X, Chua ZK, Satkunanantham K. Outcome of patellar tendon versus 4-strand hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized trials. Arthroscopy. 2017 Feb;33(2):450-63. Epub 2016 Dec 28.
- Mazzocca AD, Arciero RA, Shea KP, Apostolakos JM, Solovyova O, Gomlinski G, Wojcik KE, Tafuto V, Stock H, Cote MP. The effect of early range of motion on quality of life, clinical outcome, and repair integrity after arthroscopic rotator cuff repair. Athroscopy. 2017 Jun;33(6):1138-48. Epub 2017 Jan 19.
More than 900,000 patients every year undergo knee arthroscopy in the US. Many of those procedures involve a partial meniscectomy to address symptomatic meniscal tears. Surgeons “scoping” knees under these circumstances often encounter a chondral lesion—and most proceed to debride it.
However, in the July 5, 2017 issue of JBJS, Bisson et al. report on a randomized controlled trial that suggests there is no benefit to arthroscopic debridement of most unstable chondral lesions when they are encountered during partial meniscectomy. With about 100 patients ≥30 years old in each group, the authors found no significant differences in function and pain outcomes between the debridement and observation groups at the 1-year follow-up. In fact, relative to the debridement group, the observation group had more improvement in WOMAC and KOOS pain scores at 6 weeks, better SF-36 physical function scores at 3 months, and increased quadriceps circumference at 6 months.
The authors conclude that these findings “challenge the current standards” of typically debriding chondral lesions in the setting of arthroscopic partial meniscectomy. They also surmise that, in conjunction with declining Medicare reimbursements for meniscectomies with chondral debridement, these results “may lead to a reduction in the rate of arthroscopic debridement.”
In a November 16, 2016 JBJS study whose findings have implications for both research and practice, Katz et al. analyzed data from the MeTeOR trial to answer two questions:
- What prompts patients with meniscal tears and knee osteoarthritis who are randomized to physical therapy (PT) in trials comparing PT to arthroscopic partial meniscectomy (APM) to cross over from nonoperative therapy to APM?
- Do those who cross over to APM receive symptom relief that’s comparable to those originally randomized to APM?
After careful multivariate analysis of 48 patients who crossed over in the MeTeOR trial (representing 27% of those originally randomized to PT), the authors identified two factors associated with a higher likelihood of crossover: a baseline WOMAC Pain Score of ≥40 and symptom duration of <1 year. The authors also found that patients who crossed over to APM were just as likely to experience improvement in pain scores as those originally randomized to APM.
From a research standpoint, the authors suggest that future investigators may wish to make “special efforts” to keep patients who present with severe pain and relatively short symptom duration in nonoperative therapy. Clinically, Katz et al. say the findings “underscore the emerging treatment recommendation…to try a PT regimen before opting for APM.”
Many meniscus-preserving arthroscopic treatments for meniscus tears have evolved in recent years, including all-inside repairs. Advantages of all-inside techniques include shorter surgical times and reduced risk of damage to neurovascular tissues. Potential drawbacks include risks of local soft-tissue irritation, chondral injury, synovitis, and implant migration or breakage.
One recent generation of all-inside devices, known as FAST-FIX, consists of two polymer anchors connected by a nonabsorbable polyethylene suture in a preloaded delivery needle. In the July 22, 2015, JBJS Case Connector, Rauck et al. presented two cases in which FAST-FIX anchors came loose postoperatively, causing patients to develop knee pain and mechanical symptoms within two to six months after surgery.
To shed additional light on the anchor pullouts described by Rauck et al., we posted a “Watch” article and spoke with Tim Spalding, FRCS, consultant orthopaedic surgeon at the University Hospital in Coventry, England. Dr. Spalding has used FAST-FIX as his main meniscal-repair system for several years.
To minimize potential risks, Dr. Spalding encouraged surgeons to use the supplied slotted cannula when inserting the FAST-FIX delivery needle. “The slotted cannula helps you manipulate the meniscus and steer the needle to exactly where you want it,” Dr. Spalding said.
Perhaps the most important key to success with FAST-FIX is using it in areas of the meniscus that provide strong holding tissue. According to Dr. Spalding, the best grip site for FAST-FIX anchors is the posterior third of the medial meniscus, while tears of the lateral meniscus, especially those near the popliteal hiatus, represent the biggest grip-hold challenge.
“Anchors are not the magic fix some surgeons think they are,” Dr. Spalding concluded. “When they work, they’re simple, fun to use, and you can suture the meniscus in a few seconds, but this major advance might prompt some surgeons to use it in suboptimal situations or with hasty technique.”
Researchers at the recent annual meeting of the Radiological Society of North America presented data showing that knees undergoing surgery for meniscal tears are at higher risk of developing radiographically evident osteoarthritis one year postsurgery than knees with meniscal damage that do not undergo surgery. Presenter Frank Roemer, MD said the retrospective study found that, relative to non-arthritic knees, the risk of cartilage loss was significantly increased for knees exhibiting any prevalent meniscal damage without surgery (odds ratio = 1.5), and markedly further increased for meniscally damaged knees that had surgery (odds ratio = 13.1).
Nevertheless, many people undergoing meniscal surgery benefit clinically, especially if they experienced locking of the knee before surgery. Also, people found to have “radiographic” osteoarthritis may not experience the pain or mobility limitations seen with clinically evident arthritis. Still, Roemer concluded that patients and their doctors should include the possibility of accelerated onset of arthritis when discussing the pros and cons of meniscal surgery.