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Learn Exactly How I Evaluate and Treat the Knee

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After many years in the making, I am super excited to announce that my online program teaching you exactly how I evaluate and treat the knee is now available!

Many of my readers have taken my online shoulder program and LOVED it. The testimonials speak wonders. I am humbled yet proud of how well received that program has been over the years. When I first started the program, I had no idea what to expect, but I think many people agreed with me at the time that online education was the future.

Not a month has gone by since I started ShoulderSeminar.com that people haven’t asked me “when is the knee version coming out?”

Well, today is the day!

 

Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee

reinold macrina online knee seminar

I have teamed up with my co-owner and Director of PT at Champion, Lenny Macrina, to build an online program that teaches you exactly how we evaluate and treat the knee. Together, we’ve put together what we think is an amazing resource for rehabilitation specialists.

The program includes 7 modules of detailed information on anatomy, basic science, healing responses, evaluation, treatment progressions, nonoperative rehabilitation, surgical techniques, and postoperative rehabilitation.

You’ll learn exactly how we approach:

  • Clinical Evaluation of the Knee
  • Treatment Progressions for the Knee
  • Anterior Cruciate Ligament
  • Patellofemoral
  • Meniscus
  • Articular Cartilage
  • Osteoarthritis

evaluation and treatment of the knee

Best of all, you can learn at your own pace in the comfort of your own home. No more nodding off in the back of a room and losing an entire weekend. I am a firm believer that you will learn more and be able to apply the information much better when learning in small chunks at your own pace. Finish the program in a few days or several weeks, it’s up to you!

Each module contains a video introducing the material, a detailed presentation on the topic, several journal articles that we hand selected to learn the material, and discussion questions. This is an in depth course that will take your understanding of the knee to the next level.

CEU applications have been submitted to the Federation of State Boards of Physical Therapy for approval with several states. The course is approved for 22.5 hours of CEU credit through the NATA for Athletic Trainers. We provide all the information needed if you need to apply to another board for approval.

 

reinold macrina eval treat knee

 

Start Mastering the Knee Today!

The course is value at $349.99.  That’s less than a typical CEU course and I promise you’ll get way more out of this one!

Visit OnlineKneeSeminar.com or click below to learn more and start the program today!

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Muscle Impairments in People with Knee Arthritis

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Knee ArthritisA recent paper reviewing the muscle impairments associated with knee arthritis was published in Sports Health that I thought did a great job overviewing the current evidence on the subject.  Alnahdi, Zeni, and Snyder-Mackler discussed several factors associated with muscle impairments and knee arthritis.

I thought I would take this article and combine it with some of my thoughts and recommendations from the “The MOVE Consensus” published several years ago in Rheumatology.

There are a lot of muscle impairments associated with arthritis, proper knowledge of these impairments should allow us to develop more appropriate rehabilitation and fitness programs for individuals with knee arthritis.

 

Quadriceps Strength

Quadriceps weakness and muscle impairment is well documented in the literature.  Previously published papers report strength deficits of the quad ranging from 11-56% when compared to healthy controls.  Even more disparity exists when assessing eccentric strength, with deficits up to 76% in some reported publications.

This loss of strength, especially eccentrically, can have several implications on functional deficits.  Think about how many daily tasks involve concentric and eccentric control of the quad – standing from a chair, getting up off the ground, ascending and descending stairs – all of these activities (and more) become limited and contribute to overall dissatisfaction with arthritis patients.

 

Quadriceps Atrophy and Inhibition

There are two main factors associated with loss of quad strength in patients with knee arthritis – atrophy and muscle inhibition.  The quad has been shown to exhibit a 12% reduction in cross sectional area, representing atrophy, in patients with knee arthritis.  This atrophy obviously contributes to loss of strength, however inhibition of volitional control of the quadriceps has also been found.

Again, the exact mechanism is still unknown but some potential reasons that the altered ability to contract muscle probably relates to alterations in the afferent discharge of knee receptors.  This could be altered due to degenerative changes in joint structures, effusion, pain, inflammation, and laxity.

 

Other Lower Extremity Strength Deficits

The loss of quadriceps strength has been one of the most commonly cited impairments associated with knee arthritis.  Much emphasis has been placed on the quad, however impairment of other muscles have also been identified.  Several papers have been published that demonstrate that patients with knee arthritis also have a:

  • 4-38% reduction in hamstring strength
  • 16% reduction in hip extension strength
  • 26-40% reduction in hip flexion strength
  • 27-40% reduction in external rotation strength
  • 20-43% reduction in internal rotation strength
  • 22-24% reduction in abduction strength
  • 26% reduction in adduction strength

This are pretty big strength deficits that seem to occur in every plane of motion.  I would imagine this again represents a general level of deconditioning associated with the development of knee arthritis.  Muscular weakness and imbalances can have a significant impact on the ability to develop and withstand forces without compensatory movement patterns that increase force applied to the static joint structures.

 

Bilateral Deficits

Interestingly, strength deficits of the quad are not isolated to the involved leg.  The contralateral leg has also been shown to exhibit a 16-26% deficit in quad strength compared to healthy controls.  This deficit isn’t as severe as the involved side but shows that both extremities should be examined carefully.  Volitional control has also been shown to be reduced bilaterally, with greater inhibition on the involved knee.

The reason behind this contralateral deficit is not completely known, however it could again represent general weakness and deconditioning of the patient.

 

The Chicken or the Egg?

If strength and volitional control is so poor in several muscle groups bilaterally in patients with knee arthritis, the classic “which came first, the chicken or the egg” question comes to mind.  Does knee arthritis have such a dramatic impact on muscle impairments of the body or did these impairments precede, and potentially facilitate, the develop of knee arthritis?

There have some studies published that prospectively showed that weaker quadriceps strength was correlated to the development of knee arthritis.  This makes sense to me, as it certainly appears that several of the above factors could be related to general deconditioning of the patient.

Perhaps there is a reason that we see bilateral deficits with the involved knee showing greater impairments.   Maybe knee arthritis begins with a certain level of weakness, imbalances, and overall deconditioning.  Then overtime, this deconditioning is superimposed with inhibition from the natural consequences of knee arthritis, such as effusion, pain, and inflammation.

 

Clinical Implications

After reviewing this well written article, I think we can summarize the following:

  • Quadriceps strength is significantly impaired in subjects with knee arthritis
  • Both activation deficit and atrophy contribute to this weakness
  • Impairments also occur with the hamstrings and hip muscles
  • Strength and activation impairments are seen bilaterally, though the involved side shows greater impairments
  • Strength is a major determining factor for functional activities
  • Strength is predictive of the development of knee arthritis

 

The authors also included a summary of the recommendations from Roddy et al and The MOVE Consensus, which I would summarize as:

  • Both strengthening and aerobic exercise can reduce pain and improve function in patients with knee and hip osteoarthritis, with few contraindications, and are essential in the management of osteoarthritis.
  • Improvements in strength and proprioception gained from exercise may reduce the progression of osteoarthritis, although adherence is the principle predictor of long-term outcome from exercise.

 

In addition to these recommendations, I would suggest that we also include the following principles for the development of rehbailitation and fitness programs for people with arthritis:

  • Exercise and strengthening of the entire lower extremity, with emphasis on quadriceps strength and muscle imbalances, are an essential part of exercise programs for those with arthritis
  • Any deficits and imbalances of the hip should also be addressed
  • Exercise programs should be performed bilaterally, with emphasis on areas of greatest muscle impairment
  • Any exercise program should focus on strengthening, dynamic stabilization, and neuromuscular control of the lower extremities
  • Programs to should be developed to also enhance mobility in people with arthritis
  • Any deficits in muscle impairments should be correlated to altered movement dysfunctions
  • Programs should be developed that reduce specific muscle impairment, mobility concerns, and movement impairments

 

Hopefully we can all make a positive impact on people suffering from knee arthritis.   Understanding and improving some of the muscle impairments, strength deficits, and muscle imbalances associated with knee arthritis is imperative.  Keep these findings and recommendations in mind next time you are working with someone with knee arthritis, don’t just focus on pain control and quad strength, look at the bigger picture!

 

 

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What has the Biggest Impact on Outcomes Following ACL Reconstruction Surgery?

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Loss of knee extensionIt is no surprise that loss of motion is one of the biggest factors in patient satisfaction following ACL reconstruction surgery, specifically loss of knee extension.  In addition to the limitations in functional activities that occur with loss of knee extension, we have also discussed some of the risk factors of loss of motion following ACL reconstruction.

Loss of knee extension has a dramatic impact on gait, muscle activity, and normal tibiofemoral and patellofemoral arthrokinematics.

Imagine not being able to straighten your knee out.  You can’t lock out your knee for stability.  You naturally will shift your weight to the other extremity and overload your other knee, hip, and probably even your back.  Your quad and hamstring never get to shut off and relax.  Your patellar tendon will probably be on fire, and your patella will always be engaged and taking stress.

I can definitely see why patient satisfaction would be poor if you had long term loss of motion following ACL reconstruction!

Impact of Loss of Motion on the Development of Arthritis

In addition to poor patient satisfaction, recent research has shown that loss of motion following ACL reconstruction also results in the development of osteoarthritis.  In a recent study in AJSM, Shelbourne et al followed 780 patients for a mean of over 10 years.  They showed that of the group of patients that had normal motion on follow up examination, 29% exhibited signs of osteoarthritis on radiographs.  Conversely, 47% of the group that showed loss of motion had developed osteoarthritis.

This makes perfect sense as your arthrokinematics, center of rotation of the joint, and tibiofemoral and patellofemoral contact pressure will be altered.

How Much Loss of Extension is Significant?

More importantly, the authors also showed that even a loss of 3-5 degrees of motion had a significant impact on both patient satisfaction and the development of early arthritis.  Those subjectives that exhibited greater than a 5 degree loss of motion had an even more dramatic impact.

According to DeCarlo and Sell, the average amount of knee extension in healthy individuals is 5 degrees of hyperextension, with 95% of individuals demonstrating some amount of hyperextension in the knee.

Taking this into consideration, we should challenge the common belief that 0 degrees of knee extension is “normal.”  Individuals with 5 degrees of knee hyperextension that only restored their knee to 0 degrees of extension after ACL reconstruction surgery have a significantly greater chance of developing early osteoarthritis.

Clinical Implications

Based on these recent studies, there are bunch of clinical implications that we should all consider.  Here are just a few that I thought of right away:

  • Timing of ACL reconstruction surgery and pre-operative rehabilitation is important to settle down the knee, reduce swelling, and most importantly restore range of motion.
  • Knee extension should be restored as soon as possible after surgery, and should be one of the focuses of the initial postoperative phase
  • Even a small 3-5 degree loss of either extension of flexion range of motion has a significant impact
  • Most patients will have a certain degree of hyperextension, restoring a person to 0 degrees of knee extension is likely not enough
  • For those training post-ACL rehab clients, keep this in mind if the individual does not have full motion.  Advancing to exercises with high tibiofemoral and patellofemoral compressive and sheer forces before achieving full knee motion should be performed with caution.
  • Each patient should be assessed individually and range of motion should be restored to their unique assessment
This information also shows the importance of skilled therapy following ACL reconstruction, despite some of the studies that may show that home exercise is equally as effective.  If loss of the motion has the biggest impact on outcomes following ACL reconstruction, the development of osteoarthritis, and the subsequent health care costs, this strengthens the need for skilled manual therapy during the postopertaive rehabilitation process.

In regard to what to do with the tight person, here’s how I assess and treat loss of knee extension range of motion, but in the meantime I would love to hear what you think about this information and what you do with these patients.

 

Viscosupplementation for the Treatment of Knee Arthritis

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Viscosupplementation is becoming a popular treatment for knee arthritis.  As rehabilitation and fitness specialists, it is important to have a clear understanding of what viscosupplementation is and what it means for our patients and clients that may be dealing with knee osteoarthritis.  There are many options, benefits, and even side effects that we should be aware of.

An Overview of Viscosupplementation for the Treatment of Knee Arthritis

Viscosupplementation is an intra-articular injection of hyaluronic acid into the knee joint by an physician.  Hyaluronic acid (also known as hyaluron and hyaluronate) is a natural substance normally found in the synovial fluid of our joints. Its function is to act as a joint lubricant and shock absorber. It has been found that patients with knee arthritis have less hyaluronic acid in their joint.(1)

The theory behind the injections is that by injecting hyaluronic acid into the knee joint, the knee will have the necessary amount of hyaluronic acid and will also help the body stimulate production of more hyaluronic acid in the joint.  This will improve patient symptoms of pain and allow for better functional mobility.

Here is an image from Genzyme, the makers of Synvisc, describing the benefit of viscosupplementation:

viscosupplementation

Viscosupplementation injections were first approved as a treatment for knee arthritis by the FDA in 1997.  The important point to remember is these injections are a treatment, not a drug or a cure for arthritis.  Hyaluronic acid injections, derived mostly from rooster combs, can provide several months of pain relief, and are given typically in a series of 3-5 injections. However, they do NOT provide any immediate effect on pain.  Success is greater for patients with mild to moderate osteoarthritis. Viscosupplement  injections can be repeated every 6 months if necessary.

 

Viscosupplementation Options

Currently, there are five approved viscosupplements known as the brand names Hyalgan, Synvisc, Orthovisc, Euflexxa, and Supartz.  Each vary slightly:

  • Hyalgan: First FDA approved viscosupplement; manufactured by Sanofi-Aventis; series of 3-5 injections at once per week; up to 6-7 months relief
  • Synvisc: Manufactured by Genzyme; 3 injections a week apart; 6 month relief; now with SynviscOne, a single injection for 6 month relief
  • Orthovisc: Manufactured by DePuy; Only viscosupplement not from an avian source; 4 injections with 6 month relief
  • Euflexxa: Manufactured by Ferring Pharmaceuticals; 3 injections, 6 month relief
  • Supartz: Manufactured by Smith & Nephew; 5 injections; Only viscosupplement approved to state it provides up to 12 months relief; also 3 injection series, providing 6 months relief (2)

 

Side Effects of Viscosupplementation

There are few side effects to these injections. Most often, there can be a local injection site reaction of redness and pain. A “hot knee” or a pseudo sepsis can also occur up to 72 hours after injection. NSAIDS, steroids, and/or arthrocentesis may be used to treat this. On a rare occasion, allergic reactions may occur. In general, this is a very safe treatment for knee arthritis.

 

Benefits of Viscosupplementation

A study done by Bannuru et al (3) published in 2009, compared hyaluronic acid injections to cortisone injections for treatment of painful knee OA. They found that after two weeks, the cortisone group had significantly less pain. At four weeks, both groups pain levels were the same. Finally at eight weeks, the hyaluronic acid group was significantly better than the group receiving cortisone.  This is an important point to remember when patients ask about these injections. Viscosupplements can work well, but will NOT have an immediate result.

There are also studies comparing viscosupplements to saline injections (3) that have shown no difference between groups. Therefore, I tell my patients that there is a chance these injections may or may not help, but they are safe and may prolong the need for surgical intervention.

References

  1. Felson DT. An update on the pathogenesis and epidemiology of osteoarthritis. Radiol Clin North Am 2004; 42:1-9.
  2. www.hyalgan.com; www.synviscone.com; www.orthovisc.com; www.euflexxa.com; www.mykneeandme.com
  3. Bannuru et al. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: A systematic review and meta-analysis. Arthritis Rheum 2009; Nov 30; 61 (12):1704-1711
  4. Lundsgaard et al. Intra-articular sodium hyaluronate 2 mL versus physiological saline 20 mL versus physiological saline 2 mL for painful knee osteoarthritis: a randomized clinical trial. Scand J Rheumatol. 2008 Mar-Apr;37(2):142-50.

Trevor WinneggeTrevor Winnegge Pt,DPT,MS,OCS,CSCS  has been practicing PT for over 10 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he uses many of these pearls of wisdom regarding viscosupplementation for the treatment of knee arthritis.

 

 

Risk Factors Associated with Loss of Range of Motion Following ACL Reconstruction

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image One of the most common postoperative complications following ACL reconstruction is loss of range of motion, particularly loss of knee extension.  Recent studies have shown that up to 25% of all ACL reconstructions will have a loss of knee extension range of motion postoperatively.  That seems like a pretty significant amount of people to me.

Biomechanically, loss of knee extension range of motion has some fairly serious implications.  In addition to increased patellofemoral issues and potential wear and tear to the articular cartilage, loss of knee extension creates an environment that does not allow the knee to lock into the “screw home” mechanism.  In turn, you can’t lock out your knee and your quadriceps has to fire at all times to stabilize the knee.  Over time, these patients tend to struggle with quadriceps strength gains and return to functional activities.

All this considered, as rehabilitation specialists, one of our prime concerns when working with ACL reconstructions patients has to be restoring full passive knee extension as soon as possible.  People familiar with my protocols will know that this is emphasized immediately after surgery (newsletter subscribers get a copy of my accelerated ACL reconstruction protocol for free).

Understanding risk factors that are associated with loss of motion following ACL reconstruction will allow us to identify specific patients that are at great risk.

It has been documented that preoperative range of motion is highly correlated with postoperative range of motion, meaning that the more motion you have going into surgery, the more you’ll have after surgery.  This has led to a trend of delaying surgery to allow the knee to “quite down,” so to say, and allow for the reduction of effusion and inflammation. 

A new study set to be published in an upcoming issue of the American Journal of Sports Medicine has also identified that the presence of a bone bruise also correlates with loss of motion.  In this study, 75% of patients with preoperative loss of motion and 46% of patients with a bone bruise on the lateral femoral condyle and lateral tibial plateau presented with delayed range of motion recovery.  Considering that past studies have shown bone bruises to be present in 70-80% of ACL injuries, this is a significant finding.

image

Clinical Implications

My personal belief is not that one has to wait a certain amount of days before they have surgery, but rather that they have to wait until they are “ready” for surgery.  What does that mean to me?  Well, here is my criteria of a knee that is “ready” for surgery:

  • Minimal effusion and inflammation
  • Full knee extension and good flexion range of motion
  • Volitional control of the quadriceps – i.e. they can actively contract the muscle with out an extension lag
  • Normal gait without an antalgic limp or quad-avoidance pattern

Patients with bone bruises tend to have more pain, swelling, and inflammation.  These patients may require a little longer preoperative period to assure that their knee is “ready.”  Again, I feel that he duration should be individualized.  But, the results of this study make sense to me.

I would also recommend trying to find out if your patient had a bone bruise.  Ask the surgeon or even the patient.  Try to get a copy of the operative note and MRI radiology report.  This is valuable information as you will know what to expect if your patient appears to be struggling postoperatively.  We should be extra cautious that these patients restore extension range of motion as soon possible after surgery.  Perhaps these are the patients that get a few more visits scheduled during the early phases of rehabilitation or get prescribed more frequent stretching as part of their home exercise program.

What do you think?  How would you treat someone with a bone bruise differently?

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Meniscus Repair or Meniscectomy? Comparison of Long Term Outcomes

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image There is an interesting study about to come out in an upcoming article in the American Journal of Sports Medicine comparing the outcomes of arthroscopic meniscus repair and partial meniscectomy. 

The authors compared 42 patients undergoing meniscal repair to 39 patients undergoing partial meniscectomy at a mean of 8.8 years after surgery.  The authors specifically evaluated osteoarthritic progress, loss of knee function, and influence on sports activities.  The authors did a good job controlling the study by excluding knees with instability and only including medial meniscus tears.  However, the study was no completely randomized, the decision to perform a repair versus meniscectomy was based on the type of meniscus tear present.

 

Arthroscopic Meniscus Repair Surgery Video

There are some pretty neat videos on YouTube of meniscus repairs, thought this would be a good place and time to include one here:

 

Results

Results of the study were interesting:

  • 81% of patients having a meniscus repair did not show any significant osteoarthritis at the time of follow up, while 60% of meniscectomy patients did show osteoarthritic changes.
  • Functional scores showed no difference between the two procedures, however 94% of meniscal repair patients returned to their previous level of sport activity compared to only 44% of the meniscectomy group.
  • There was a significant drop in sport activity in the meniscectomy group only.

 

Clinical Implications

Personally, I wasn’t very surprised at the large difference between groups.  It is obvious that the mensical repair procedures are fair superior to partial meniscectomy.  It is well established that preserving as much as the meniscus as possible will yield greater results over time.  The menisci play a very important role in shock absorption and the normal biomechanics of the knee. 

There are many pros and cons to both procedures, and the postoperative recovering is certainly longer following meniscal repair, however the results of this study certainly show that pros should outweigh the cons.  It should be noted that sometimes a repair is not always feasible and meniscal damage of this nature will likely result in osteoarthritic changes over time, potentially explaining the results of this study.

What I take away from this study is more educational that clinical.  I am not sure that there is anything we can do differently to enhance outcomes in meniscectomy patients based on this study, but the results do underscore the dramatic importance of the meniscus on knee function.

Imagine that it was fairly common to perform a COMPLETE meniscectomy only a few decades ago!

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The Use of Glucosamine and Chondroitin Sulfate for Knee Arthritis

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A recent review from the January 2009 issue of the Journal of Arthroscopy reviewed the use of glucosamine and chondroitin sulfate for knee osteoarthritis.  Considering the vast amount of people suffering from knee arthritis and the increasing cost of medical care for these patients, the use of any type of supplement to reduce symptoms is welcome.

Research into the efficacy of glucosamine and chondroitin sulfate is certainly not new with studies dating back to 1969.  However, the literature has been filled with many poorly controlled studies, some of which were funded by glucosamine manufacturers!This particular paper reviewed the results of 23 studies that involved double-blind, placebo-controlled, randomized control trials as well as several meta-analyses.

The effectiveness of Glucosamine and Chondroitin Sulfate

The overall results of the review show that there are inconsistent results, but that the results do favor improvement of pain and joint function in patients with arthritis.  The authors also note that one of the most consistent trends between studies involved the length of use of the supplement.  The best results from glucosamine appear to occur after several months of use.  Studies are referenced that show positive results in 3-6 months and even up to 9 months.

In general, if you looked hard enough, you could probably find more articles that say that the use of glucosamine is effective than you could find saying it is not effective.  I realize and agree that there is not overwhelming evidence in support of glucosamine or outlined the exact mechanism of symptom improvement.  However, when we start to run out of options for our patients, I would say there is enough evidence to support it’s use, as long as the supplement is safe.

The Safety of Glucosamine and Chondroitin Sulfate

A potentially more important finding of the current review was that the use of glucosamine and chondroitin sulfate appears to be safe, at least as safe as placebo supplementation.  To me, this is the most important finding for me clinically.  If we are going to recommend the use of a supplement with inconsistent findings, as long as the supplement is safe I have no problem recommending a patient try glucosamine.

Recommended Use of Glucosamine and Chondroitin Sulfate

I have spent a lot of time over the last several years trying to find a consensus statement on the use of glucosamine and chondroitin sulfate.  Unfortunately, this does not appear to exist.  I have taken information from many sources, including the excellent recommendations of noted orthopedist Dr. Frank Noyes of Cincinnati Sports Medicine and information from the Osteoarthritis Research Society International to provide the following information.  I recommend that you read Dr. Noyes’ recommendations, it is a great resource.  Also, realize that you should consult with your own personal physician before taking any supplements and that glucosamine may not be indicated for you personally.  The below information are just basic guidelines for healthcare providers when considering the use of glucosamine:

  • Cosamin DSGlucosamine should be taken with chondroitin sulfate to maximize it’s effectiveness
  • Supplements that include magnesium and vitamin C may help the absorption rate of glucosamine and chondroitin sulfate.
  • To date, the specific brand that has received the highest recommendations appears to be Cosamin DS.
  • Dosage should vary based on body weight:
    • If less than 120 lbs: G 1000mg + CS 800mg
    • Between 120-200 lbs: G 1500mg + CS 1200mg
    • If greater than 200 lbs: G 2000mg + CS 1600mg
  • Supplements should be taken for at least 3 months for noticeable results.  If no response within 6 months, may discontinue.

I have found decent results from the use of glucosamine in my patients, have you?

C VANGSNESSJR, W SPIKER, J ERICKSON (2009). A Review of Evidence-Based Medicine for Glucosamine and Chondroitin Sulfate Use in Knee Osteoarthritis Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25 (1), 86-94 DOI: 10.1016/j.arthro.2008.07.020

Image by scottfeldstein

 

Autologous Chondrocyte Implantation or Microfracture?

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The current issue of AJSM has two great articles regarding articular cartilage repair  procedures that go very well together.  I think this is an amazing aspect of orthopedics as we are making ground on developing ways to restore normal cartilage.  The Cartilage Defectimplications of this are staggering.  If you share an interest in articular cartilage repair, I recommend you read the special issue of JOSPT on articular cartilage and meniscal repair procedures that I guest edited, specifically my guest editorial and my article on postoperative rehabilitation following articular cartilage repair procedures.

 

Autologous Chondrocyte Implantation Compared to Microfracture

The first study is a comparison of outcomes between microfracture and second-generation autologous chondrocyte implantation (ACI).  80 patients with grade III-IV cartilage defects of the femoral condyle or trochlea were enrolled in the study and split evenly between groups.  The second-generation ACI procedure used Hyalograft C. 

microfracture pickingBoth groups showed significantly greater results at the 5 year post-op mark, however, the ACI group showed greater improvements in the International Knee Documentation Committee objective and subjective scores.  Even more interestingly, the return to sports rate between groups was similar at the 2-year mark and remained stable for the ACI group, but decreased for the microfracture group.

 

Results of Autologous Chondrocyte Implantation in Patients with Failed Prior Treatment

The second study prospectively assess the results of 126 patients undergoing ACI after a failure of a previous articular cartilage repair procedure.  This is a very large and prestigious study by the STAR group (Study of the Treatment of Articular Repair), which consists of all the best cartilage repair surgeons in the country.  The past procedures included predominantly debridement (48%) and microfracture (27%), as well as subchondral drilling, abrasion arthroscopy, and osteochondral autograft.

Results of the study were good with 76% of subjects showing successful results for a long duration.  All measurements showed a statistically significant and clinically meaningful improvements after ACI.  However, these results are lower than many of the previously reported outcomes following ACI when used as the first surgical procedure.  Here are photos of before (top) and after (bottom) of ACI for a femoral condyle defect (left) and patella defect (right):

ACI implant on condyle and patella

 

Clinical Implications

Putting the results of these two studies together leads to a very interesting and meaningful result.  While ACI and microfracture may yield similar post-op results at the 2-year follow-up, the ACI procedure continues to show durable results while the microfracture group slowly deteriorates over time.  This is significant when looking at these two studies together.  Although ACI appears to be a valuable surgical procedure for failed articular cartilage repair procedures, results of ACI used as the primary procedure are better than when used secondary after another procedure (such as microfracture) fails.  Based on these results, it may be better to have the ACI in the first place rather than try a microfracture.

These results make sense, as the ACI procedure has been shown to result in Type II collagen tissue similar to native articular cartilage while the microfracture is predominantly Type I collagen.  Think of the ACI procedure as restoring cartilage while the microfracture just creates a “scab” of a fibrin clot that simply covers the defect.  Because this tissue is inferior to Type II collagen, it does not hold up as well to weightbearing and functional loading.  Unfortunately the negative of the ACI procedure is a long rehab course and longer time to return to full activities, but based on these studies the slight delay may be worth it to prevent future complications.

Have you seen these results in your clinic?  Would you agree or disagree?  There are a lot of pros and cons with both procedures.  Hopefully as we continue to improve our knowledge and techniques all repair procedures will show better results.

E. Kon, A. Gobbi, G. Filardo, M. Delcogliano, S. Zaffagnini, M. Marcacci (2008). Arthroscopic Second-Generation Autologous Chondrocyte Implantation Compared With Microfracture for Chondral Lesions of the Knee: Prospective Nonrandomized Study at 5 Years The American Journal of Sports Medicine, 37 (1), 33-41 DOI: 10.1177/0363546508323256

K. Zaslav, B. Cole, R. Brewster, T. DeBerardino, J. Farr, P. Fowler, C. Nissen (2008). A Prospective Study of Autologous Chondrocyte Implantation in Patients With Failed Prior Treatment for Articular Cartilage Defect of the Knee: Results of the Study of the Treatment of Articular Repair (STAR) Clinical Trial The American Journal of Sports Medicine, 37 (1), 42-55 DOI: 10.1177/0363546508322897

 

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