Current practice in the management of anterior cruciate ligament injuries in the United Kingdom

OBJECTIVE

To outline the current practice in the management of anterior cruciate ligament (ACL) injuries in the United Kingdom.

METHODS

A postal questionnaire designed to include various clinical scenarios was sent out to the 321 orthopaedic surgeons in the United Kingdom who, being affiliated to one of the specialist societies of the British Orthopaedic Association, namely the British Association for Surgery of the Knee (BASK) or the British Orthopaedic Sports Trauma Association (BOSTA), have a manifested interest in treating such injuries.

RESULTS

The response rate was 60% (192/321). Most surgeons diagnose and operate on less than 50 ACL injuries a year. The following results were obtained: 58% (76/132) use bone-patellar tendon-bone autografts, whereas 33% (44/132) use semitendinosis/gracilis autografts; 84% (108/129) would not incorporate the ACL remnant in the reconstruction; 14% (19/135) would perform an ACL reconstruction in an 8 year child with an acute rupture; 30% (42/141) would perform an ACL reconstruction in a 14 year old with an acute ACL rupture.

CONCLUSIONS

There is wide variation in the management of acute and chronic ACL injuries among orthopaedic surgeons in the British Isles. Future research and randomised controlled trials should address the issues that this investigation has raised.

The development of a disease-specific quality of life measurement tool for osteoarthritis of the shoulder: The Western Ontario Osteoarthritis of the Shoulder (WOOS) index

OBJECTIVE

The purpose of this study was to develop and validate a disease-specific quality of life measurement tool for osteoarthritis (OA) of the shoulder.

METHODS

An instrument which could be used as the primary outcome measure in clinical trials involving patients with OA of the shoulder was developed using a specific methodological protocol: (1) identification of a specific patient population; (2) item generation; (3) item reduction; (4) pre-testing of the prototype questionnaire and (5) determining the validity, reliability and responsiveness of the final questionnaire.

RESULTS

The final instrument contains 19 items, each with a visual analog response option for the four domains (six questions for pain and physical symptoms, five questions for sport, recreation and work, five questions for lifestyle function and three questions for emotional function). Ten of the 19 questions had not been identified previously on other shoulder measurement tools. The instrument proved to be valid by demonstrating predicted correlations with previously published shoulder measures, global health status measure and range of motion. The new instrument was also more responsive than other shoulder measurement tools, a global health status measure and range of motion.

CONCLUSIONS

Since the patient's own perception of changes in health status is the most important indicator of the success of treatment we suggest that this measurement tool be used as the primary outcome in clinical evaluation of various treatments for OA of the shoulder and monitoring patients over time.

Association among neuromuscular and anatomic measures for patients with knee osteoarthritis

OBJECTIVE

To investigate neuromuscular and anatomic factors involved in varus gonarthrosis by identifying measures associated with degenerative changes.

DESIGN

Descriptive study. Individual measures that explained substantial portions of the variability in ratings of knee joint-degenerative changes in patients with knee medial compartment osteoarthritis.

SETTING

Outpatient orthopedic clinic and biomechanics and muscular assessment laboratory.

PATIENTS

Volunteer sample of 20 subjects (age range, 59 +/- 9 yr) with no history of neurologic disease.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

We assessed degenerative changes, varus alignment, standing balance, and knee proprioception. Weight-bearing radiographs were used to assess the extent of degenerative changes and the degree of varus alignment. Single-limb standing balance control was assessed through tests performed on a force platform. Knee proprioception was assessed with an isokinetic dynamometer, using a joint angle replication test.

RESULTS

Forward-stepwise multiple linear regression indicated that the extent of degenerative changes could be best predicted from a linear combination of the independent variables, varus alignment, and standing balance (R =.80, F(2,17) = 14.81, p =.0002). Sixty-four percent of the variability in ratings of degenerative changes was explained by alignment and standing balance measures (37% by varus alignment, 27% by standing balance). Alignment and balance measures were poorly correlated (r =.12, p =.63), further suggesting that they provided different information about gonarthrosis.

CONCLUSIONS

Although varus alignment is widely accepted as a clinically important factor in gonarthrosis, and is the focus of many treatment efforts, our results suggest that objective measures of standing balance are also important. As a result, the potential impact of rehabilitation to improve the control of standing balance should be further evaluated in this patient population.

Knee bracing after ACL reconstruction: effects on postural control and proprioception

PURPOSE

To evaluate the effects an anterior cruciate ligament (ACL) brace has on various measures of knee proprioception and postural control.

METHODS

Thirty subjects (mean age 27 +/- 11 yr) having undergone unilateral ACL reconstruction were tested with and without wearing their own custom-fit brace on their involved limb. Proprioception was assessed using joint angle replication tests completed on an isokinetic dynamometer. Postural control was assessed using a series of single-limb standing balance tests completed on a force platform. The balance tests included: 1) standing on the stable platform with eyes open, 2) standing on a foam mat placed over the platform with eyes open, 3) standing on the platform with eyes closed, and 4) standing on the platform after landing from a maximal single-limb forward hop.

RESULTS

The brace provided a small but statistically significant improvement in proprioception (mean reduction in error scores between target and reproduced angles = 0.64 +/- 1.4 degrees, P = 0.02). For the postural control tests, there was a significant brace condition by test situation interaction (P = 0.02), with the brace providing a small but statistically significant improvement during the test completed on the stable platform with eyes open (mean reduction in center of pressure path length = 4.2 +/- 8.4 cm, P = 0.02) but not during the other more challenging test situations. Additional post hoc analyses indicated that the relationship between knee proprioception and postural control measures were low and not significant (r = 0.003 to 0.19, P > 0.32), consistent with the suggestion that changes in knee proprioception can occur in the absence of substantial changes in postural control. Also, standing balance tests that challenged the somatosensory contribution to postural control (i.e., those completed on foam, or with eyes closed) were significantly related to single-limb forward hop distances (r = -0.4, P < 0.05), whereas performance during the proprioception test was not (r = 0.1, P > 0.50).

CONCLUSIONS

In general, bracing appears to improve performance during tasks characterized by relatively limited somatosensory input but not during tasks characterized by increased somatosenory input. The small magnitude of the improvements, coupled with their apparent lack of carry over to more difficult and functionally relevant tasks, questions the clinical benefit of the present effects of bracing.

The effect of exercise on anterior-posterior translation of the normal knee and knees with deficient or reconstructed anterior cruciate ligaments

Exercise may result in increased laxity in the knee. Anterior translation in 40 normal knees, 33 consecutive anterior cruciate ligament-deficient knees, and 30 randomly chosen anterior cruciate ligament-reconstructed knees was measured using the KT-1000 arthrometer before and after the participants ran for 15 minutes on a neutral-incline treadmill. A single observer blinded to the status of each knee tested all participants. There was a significant increase in anterior translation in the normal (mean, 0.75 mm), anterior cruciate ligament-deficient (mean, 0.62 mm), and anterior cruciate ligament-reconstructed knees (mean, 0.25 mm) after exercise. In addition, the amount of anterior translation after exercise was significantly different when these groups were compared with each other. Post hoc analysis using Tukey's procedure indicated that anterior translation in the anterior cruciate ligament-reconstructed knee was significantly less than in the normal and anterior cruciate ligament-deficient knees. Therefore, repetitive loading exercise contributes to an increase in anterior translation in normal, anterior cruciate ligament-deficient, and anterior cruciate ligament-reconstructed knees, and the anterior cruciate ligament-reconstructed knee does not respond to repetitive loading in the same manner as a normal knee.

Transfusion practice in elective orthopaedic surgery

. The transfusion requirements of 2233 patients who underwent total hip or knee joint arthroplasty procedures at nine Canadian hospitals during 1995-1996 were evaluated. Although 64% of patients were eligible for participation in an autologous blood donation (ABD) programme, only 8% predonated blood. Patients who were eligible for ABD were younger (62 years vs. 70 years) and had fewer medical illnesses (18% vs. 44%) than those who did not predonate. The rate of allogeneic transfusion was 9.0% (95% confidence interval 4.9-13.1%) in patients who predonated as compared with 24.1% (95% confidence interval 22.2-25.9%) in those who did not. Risk factors for the occurrence of an allogeneic transfusion were type of procedure (primary or revision hip arthroplasty), lower baseline haemoglobin, lower body weight, older age and presence of rheumatoid arthritis (P < 0.001). Only patients without risk factors were predicted to have a less than 10% risk of receiving an allogeneic transfusion. Use of preventive strategies was minimal. Two models designed to predict the occurrence of an allogeneic transfusion were evaluated. If allogeneic transfusion rates are to be reduced, eligible patients should be encouraged to participate in ABD programmes. For patients who are ineligible, other preventative strategies should be introduced.

Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control

OBJECTIVE

To evaluate the effects of a functional knee brace specifically designed for patients with varus gonarthrosis on measures of proprioception and postural control.

SUBJECTS

Fourteen men and six women (aged 59+/-9 yr) with measurable varus alignment and osteoarthritis of the knee medial compartment.

METHODS

Proprioception was assessed in the sitting position using an isokinetic dynamometer and was quantified as the ability to replicate target knee-joint angles. Postural control was assessed with a force platform using tests of single-limb standing balance performed, while the patient was standing on a stable surface and standing on foam, and was quantified as the total length of the path of the centre of pressure. All tests were performed with and without the patient's own custom-fit valgus brace.

RESULTS

Proprioception was significantly improved following application of the brace [mean difference=0.7 degrees, 95% confidence interval (CI)=0.2 to 1.1 degrees ). Postural control was not significantly affected by the use of the brace during the stable surface test (mean difference=2.6 cm, 95% CI=-4.3 to 9.5 cm) or the foam surface test (mean difference=0.9 cm, 95% CI=-7.5 to 9.4 cm).

CONCLUSION

Although enhanced proprioception may be partially responsible for reported improvements with the use of a brace, the present findings call into question the functional importance of the small changes observed.

Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial

BACKGROUND

The optimum regimen of epoetin alfa for prevention of allogeneic blood transfusion is unknown.

OBJECTIVE

To determine whether a modified regimen of epoetin alfa reduces allogeneic blood transfusion in patients undergoing hip arthroplasty.

DESIGN

Randomized, double-blind, multicenter trial comparing two modified dose regimens of epoetin alfa with placebo.

SETTING

13 teaching hospitals and 4 community hospitals in Canada.

PATIENTS

201 patients undergoing primary hip arthroplasty who had a hemoglobin concentration of 98 to 137 g/L and did not predonate blood.

INTERVENTION

Patients were assigned in a 3:5:5 ratio to receive four weekly doses of epoetin alfa, 40 000 U (high-dose; n = 44) or 20 000 U (low-dose; n = 79), or placebo (n = 78), starting 4 weeks before surgery. All patients received oral iron supplementation, 450 mg/d, for 42 or more days before surgery.

MEASUREMENTS

The primary end point was allogeneic transfusion. Secondary end points were thromboembolic events and change in reticulocyte count and hemoglobin concentration.

RESULTS

Both modified epoetin alfa regimens significantly reduced the need for allogeneic transfusion: Five (11.4%) patients in the high-dose group (P = 0.001) and 18 (22. 8%) patients in the low-dose group (P = 0.003) had transfusion, compared with 35 (44.9%) patients in the placebo group. The hematologic response was substantial in patients who received epoetin alfa. In the high-dose group, low-dose group, and placebo group, the preoperative increase in reticulocyte count was 58.8, 37. 0 and 1.8 x 10(9) cells/L (P < 0.001), respectively, and the increase in hemoglobin concentration was 19.5, 17.2, and 1.2 g/L (P < 0.001). The incidence of thromboembolic events did not differ among groups.

CONCLUSIONS

Both modified epoetin alfa regimens were effective compared with placebo in reducing allogeneic transfusion in patients undergoing hip arthroplasty. Patients who received high-dose epoetin alfa had the lowest transfusion rate.

The efficacy of femoral nerve block in pain reduction for outpatient hamstring anterior cruciate ligament reconstruction: a double-blind, prospective, randomized trial

The purpose of this study was to assess the efficacy of intraoperative femoral nerve block (FNB) in the reduction of postoperative pain following anterior cruciate ligament (ACL) hamstring reconstruction. Patients undergoing primary ACL reconstruction with hamstring tendon graft under general anesthetic who had signed an informed consent were included in the study. Patients were stratified to 4 surgeons and randomized to FNB with 0.25% bupivacaine or placebo of normal saline injected into the femoral nerve sheath before reversal of the general anesthetic. All patients received an intra-articular injection of bupivacaine at the beginning of their operative procedure. A single technique that included the use of a peripheral nerve stimulator was used for all FNBs. All patients were discharged on the day of surgery and given prescriptions for Tylenol 3. The Short-Form McGill Pain Questionnaire (SF-MPQ), a visual analog scale (VAS) for pain, and a medication diary recording Tylenol 3 usage were completed by patients in the recovery room, on the night of surgery, and on postoperative days 1, 2, and 3. There were complete data for 61 patients (FNB, 29; placebo, 32). An analysis of variance (ANOVA) test of the data showed no significant difference between the FNB and placebo group for pain reduction over the combined study period for both the SF-MPQ and VAS. However, the ANOVA does suggest that, on the night of surgery, there was a significant reduction in pain as measured with the VAS in the FNB group. A Student t test performed on the night of surgery data (SF-MPQ, P = .131; VAS, P = .0114; Tylenol 3, P = .076) showed a statistically significant difference between the FNB (39.4+/-21.0 mm) and placebo (56.8+/-24.6 mm) measured by VAS. Because this represented a difference of only 1.74 cm on a 10-cm VAS, it is unlikely to be clinically relevant. No difference was found in the amount of analgesic required on any day postoperatively. In conclusion, FNB may reduce pain on the night of surgery. However, this may not be clinically significant. FNB is not recommended at this time for use in outpatient ACL reconstruction with hamstring graft.

Management of injuries to the anterior cruciate ligament: results of a survey of orthopaedic surgeons in Canada

OBJECTIVE

To identify the approaches to management of anterior cruciate ligament (ACL) injury by Canadian orthopedic surgeons.

METHODS

A questionnaire was mailed to 234 physicians randomly chosen from the Canadian Orthopaedic Association directory to obtain the following information: 1) how orthopaedic surgeons diagnose acute hemarthroses; 2) how patients in any of three common ACL injury scenarios would be managed; 3) what variations exist in surgical technique; and 4) how patient variables such as age, gender, and alignment influence the decision-making process.

RESULTS

The return rate was 72%, and 56% of respondents were from academic centers. Patients such as those described in the protocol are routinely managed by 80% of the respondents. The diagnosis of acute hemarthrosis is predominantly made by means of clinical examination and radiographs. Magnetic resonance imaging (MRI) is used occasionally by 43% and routinely by 6% of those who responded; arthroscopy is used routinely by 24%. For the competitive athlete with a complete ACL tear, 64% would recommend reconstruction and 33% would recommend bracing and rehabilitation. For reconstruction, 59% would use bone-patellar tendon-bone (B-PT-B) autograft and 32% would use hamstring tendon autograft; 40% would incorporate the ACL stump during reconstruction. Of the respondents, 77% would advocate ACL reconstruction for competitive athletes with chronic ACL injury. Of these, 63% would use B-PT-B autograft and 27% would use hamstring tendons. If bracing and rehabilitation failed, 98% would recommend ACL reconstruction. In ACL reconstruction, synthetic augmentation would be used by 12% in chronic cases and by 16% in acute cases. In making the decision to perform ACL reconstruction, 53% consider limb alignment to be important and 67% consider moderate patellofemoral pain to be important. Seventy-one percent are influenced by patellofemoral pain when choosing a surgical technique, with a trend toward semitendinosis autograft rather than B-PT-B autograft reconstruction. For the 8-year-old child with an acute ACL injury, 63% of the respondents would recommend rehabilitation and bracing. For the 14-year-old, 45% would recommend rehabilitation and bracing and 37% would recommend ACL reconstruction after physeal closure.

CONCLUSION

The results of the survey indicate that, with respect to some of the issues, there is a wide variation in management of acute and chronic ACL injuries among Canadian orthopedic surgeons. Future research and randomized, controlled clinical trials should be directed toward these areas.

Tourniquet versus no tourniquet use in routine knee arthroscopy: a prospective, double-blind, randomized clinical trial

PURPOSE

The purpose of this study was to determine the effects of tourniquet use for routine knee arthroscopy based on both subjective and objective functional outcome measures.

TYPE OF STUDY

The study was a prospective, double-blind, randomized clinical trial.

MATERIALS AND METHODS

There were 120 patients randomized to tourniquet inflation (300 mm Hg) or no tourniquet inflation during routine knee arthroscopy. Patients recorded their average pain on a visual analog scale and their narcotic use for the previous 24 hours, for the first 5 postoperative days. Patients also completed a preoperative and postoperative (2 week, 6 week, 3 month) Western Ontario and McMaster University Osteoarthritis Index (WOMAC), 6-minute walk, 30-second stair climb, 1-leg standing vertical leap, range of motion, and isokinetic strength testing. Time to return to work and sport was documented.

RESULTS

No statistically significant difference was found between tourniquet-up and tourniquet-down groups for the WOMAC quality of life measure, functional tests, isokinetic muscle strengthening, or time to return to work or sport (t test/repeated measures analysis of variance). However, there was a trend for less early postoperative pain and slightly better isokinetic strength testing at 2 weeks in the tourniquet-down group. Visualization was rated by surgeons to be 3 times better in the tourniquet-up group, although mean operative time did not differ between the groups.

CONCLUSION

The use of a pneumatic tourniquet at 300 mm Hg does not significantly effect overall patient quality of life or functional outcome following routine knee arthroscopy.

The lax shoulder in females. Issues, answers, but many more questions

A review of the existing data on shoulder laxity in females reveals there are insufficient data to confirm the commonly held belief that shoulders in females are more lax than shoulders in males. Laxity is not synonymous with instability. Although females may have increased generalized joint laxity relative to males, generalized joint laxity does not correlate with shoulder laxity. There is conflicting data regarding shoulder laxity and gender. A review of patients with multidirectional instability who were treated operatively showed that 55% of the patients were female (N = 94) and 45% were male (N = 77), but the number or gender of patients who were treated nonoperatively was not reported. Multidirectional instability is reviewed in the context of the lax shoulder in the female. Initial treatment should be nonoperative, emphasizing physical therapy and dynamic stabilization of the shoulder. If nonoperative treatment fails, open or arthroscopic inferior capsular shift stabilization is recommended. Additional basic science and clinical trials are needed to determine whether thermal capsulorrhaphy should be considered in the treatment of patients with multidirectional instability of the shoulder.

Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder

Our purpose was to compare the effectiveness of traditional treatment with immediate arthroscopic stabilization in young patients who have sustained a first traumatic anterior dislocation of the shoulder. Forty skeletally mature patients younger than 30 years of age were randomly allocated to immobilization for 3 weeks followed by rehabilitation (group T) or arthroscopic stabilization (within 4 weeks of injury) followed by an identical immobilization and rehabilitation protocol (group S). A blinded research assistant performed all follow-up evaluations. The dominant arm was involved in 35% of subjects. The injury occurred in a sporting event in 70% of subjects. At 24 months, there was a statistically significant difference in the rate of redislocation (T = 47%, S = 15.9%, P = .03). An intention-to-treat analysis comparing disease-specific quality of life using the validated Western Ontario Shoulder Instability (WOSI) index showed statistically significantly better results in the surgically treated group at the 33 months (T = 633.93 v S = 287.1, P = .03) and no significant difference in range of motion. At an average 32 months follow-up, a significant reduction in redislocation and improvement in disease-specific quality of life is afforded by early arthroscopic stabilization in patients less than 30 year of age with a first, traumatic, anterior dislocation of the shoulder.

The effect of bracing on varus gonarthrosis

BACKGROUND

The purpose of this study was to compare a custom-made valgus-producing functional knee (unloader) brace, a neoprene sleeve, and medical treatment only (control group) with regard to their ability to improve the disease-specific quality of life and the functional status of patients who had osteoarthritis in association with a varus deformity of the knee (varus gonarthrosis).

METHODS

The study design was a prospective, parallel-group, randomized clinical trial. Patients who had varus gonarthrosis were screened for eligibility. The criteria for exclusion included arthritides other than osteoarthritis; an operation on the knee within the previous six months; symptomatic disease of the hip, ankle, or foot; a previous fracture of the tibia or femur; morbid obesity (a body-mass index of more than thirty-five kilograms per square meter); skin disease; peripheral vascular disease or varicose veins that would preclude use of a brace; a severe cardiovascular deficit; blindness; poor English-language skills; and an inability to apply a brace because of physical limitations such as arthritis in the hand or an inability to bend over. Treatment was assigned on the basis of a computer-generated block method of randomization with use of sealed envelopes. The patients were stratified according to age (less than fifty years or at least fifty years), deformity (the mechanical axis in less than 5 degrees of varus or in at least 5 degrees of varus), and the status of the anterior cruciate ligament (torn or intact). The patients were randomly assigned to one of three treatment groups: medical treatment only (control group), medical treatment and use of a neoprene sleeve, or medical treatment and use of an unloader brace. The disease-specific quality of life was measured with use of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and function was assessed with use of the six-minute walking and thirty-second stair-climbing tests. The primary outcome measure consisted of an analysis of covariance of the change in scores between the baseline and six-month evaluations.

RESULTS

One hundred and nineteen patients were randomized. The control group consisted of forty patients (thirty-one men and nine women; mean age, 60.9 years); the neoprene-sleeve group, of thirty-eight patients (twenty-seven men and eleven women; mean age, 58.2 years); and the unloader-brace group, of forty-one patients (twenty-eight men and thirteen women; mean age, 59.5 years). Nine patients withdrew from the study. At the six-month follow-up evaluation, there was a significant improvement in the disease-specific quality of life (p = 0.001) and in function (p< or =0.001) in both the neoprene-sleeve group and the unloader-brace group compared with the control group. There was a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to pain after both the six-minute walking test (p = 0.021) and the thirty-second stair-climbing test (p = 0.016). There was a strong trend toward a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to the change in the WOMAC aggregate (p = 0.062) and WOMAC physical function scores (p = 0.081).

CONCLUSIONS

The results indicate that patients who have varus gonarthrosis may benefit significantly from use of a knee brace in addition to standard medical treatment. The unloader brace was, on the average, more effective than the neoprene sleeve. The ideal candidates for each of these bracing options remain to be identified.

The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI)

The purpose of this study was to develop a valid, reliable, and responsive disease-specific quality of life measurement tool for patients with shoulder instability. Development included 1) identification of a specific patient population; 2) generation of issues specific to the "disease" ("items") from reviewing the literature, interviewing health caregivers, and interviewing patients representing all demographics, disease type and severity, and treatments; 3) item reduction using patient-generated frequency-importance products and correlation matrices; and 4) pretesting the prototype instrument on 2 groups of 10 patients. The final instrument, the Western Ontario Shoulder Instability Index, has 21 items representing 4 domains. The instrument attributes (validity, reliability, and responsiveness) were evaluated. Construct validation demonstrated that this index correlated predictably with other measures. Reliability was very high at 2 weeks and 3 months, and the index was more responsive (sensitive to change) than five other shoulder measurement tools (the Disabilities of the Arm, Shoulder and Hand scale; The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; the UCLA Shoulder Rating Scale; the Constant Score; and the Rowe Rating Scale), a global health instrument (the SF12), and range of motion. Since the patient's perception of changes in health status is the most important indicator of the success of a treatment, we suggest that this measurement tool be used as the primary outcome measure to evaluate treatments in this patient population, although it can also be used for monitoring patients' progress in clinical practice.

The cost-effectiveness of routine pathology consultation in knee arthroscopy

Regulations in Ontario, Canada, as in most provinces and states in North America, require human tissues (with few exceptions) removed at surgery to be sent to a pathology laboratory for examination and report. We hypothesized that this practice is inconsistently followed and that routine pathological consultation is costly and rarely results in a change in treatment for patients undergoing knee arthroscopy. Chiefs of pathology, orthopaedic surgeons, and orthopaedic operating room nurse managers in Ontario hospitals that perform arthroscopic knee surgery were surveyed for compliance. We determined cost using pathology department procedure codes and evaluated effectiveness as the correlation between the postoperative diagnoses of orthopaedic surgeons and pathologists for 1,036 consecutive knee arthroscopy cases. In only one case (0.1%) was it felt that pathology consultation had the potential to significantly alter patient care. The total cost of pathology consultation for the 1,036 cases reviewed was $234,147.00 (mean cost per case, $226.00). Ninety percent of hospitals do not comply with the regulations regarding the processing of these tissues. Poor compliance is justified by the lack of diagnostic value and the need to contain health care costs.

The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child

The purpose of this study was to evaluate the outcome of transphyseal ligament reconstruction in skeletally immature children with midsubstance anterior cruciate ligament (ACL) disruption. Five consecutive patients (mean age, 12.9 years; range, 8 to 14 years) with radiographically documented "wide" open growth plates and a minimum of 5 cm of expected remaining growth, underwent intra-articular reconstruction of the ACL. Operative treatment included three ACL reconstructions using hamstring tendons and two with quadriceps patellar tendon. All involved a centrally placed 6-mm or smaller tibial drill hole through an open physis and graft placement in an over-the-top position on the femur. At an average follow-up of 7.4 years (range, 4.5 to 9.9 years), no patient had a positive anterior drawer, Lachman, or pivot shift test. On KT-1000 arthrometer testing, all patients had 3 mm or less of increased anterior-posterior displacement (mean +/- SD = 1.0 +/- 1.6 mm). Magnetic resonance imaging showed that four tibial physes had fused in a symmetric fashion and one was still open. Orthoroentgenograms showed that no patient had a significant leg length discrepancy (-0.8 mm +/- 3.4 mm). The mean increase in height postoperatively was 17.7 cm (range, 7.6 to 31.0 cm). Overall, using the International Knee Documentation Committee (IKDC) evaluation form, there were four patients with grade A and one with grade C. The one patient with a poor IKDC grade had sustained a subsequent patellar dislocation with osteochondral fracture. In conclusion, ACL reconstruction using small drill holes placed through open tibial physes does not seem to adversely affect outcome or future growth.

Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review

OBJECTIVE

To determine the optimal treatment of acute Achilles tendon ruptures.

DATA SOURCES

A comprehensive search for all of the English articles published between 1959 and 1997.

STUDY SELECTION

All of the articles were reviewed independently by at least three of the four authors to decide on eligibility based on predetermined criteria. Disagreements were discussed and then settled, if necessary, by a majority vote.

DATA EXTRACTION

Eligible studies were reviewed independently, and data were extracted by using standardized coding forms. Inconsistencies in data extraction were settled by discussion and majority vote. The main outcomes extracted were strength, time to return to work, frequency of return to sports, rerupture rate, and complications. Complications were divided into major, moderate, and minor categories.

DATA SYNTHESIS

The overall rerupture rate was 2.8% for operatively treated and 11.7% for nonoperatively treated patients (p < 0.001). The rate of minor and moderate complications in operatively treated patients was 20 times that of nonoperatively treated patients. The difference in rates for major complications was not statistically significant.

CONCLUSIONS

Although operative treatment provides a reduced rerupture rate compared with nonoperative treatment, the minor and moderate complication rate of operative treatment is 20 times greater. Treatment should be individualized to the concerns and health of the patient. Future clinical trials are necessary to determine the optimal method of both operative and conservative treatment.

What is the best way of assessing outcome after total knee replacement?

Variable definitions of outcome have been used in the past to assess the results after total joint replacement surgery. These differ in their approach to the measurement of outcome but all must be valid (they measure what they are designed to measure), reliable (they consistently produce the same score), and responsive (able to detect changes that may occur during a period). Responsiveness is crucial to distinguish those patients who benefit from a procedure from those who do not, and a more responsive test will theoretically be able to identify more subtle changes in patient status. The responsiveness of 6 different scoring systems was compared. The results are based on a cohort of 71 patients undergoing total knee arthroplasty in a 7-month period. Responsiveness was determined by performing a paired t test among each patient's scores at 0, 3, and 6 months. The size of the resulting t value represented the comparative responsiveness of the 6 tests. The highest value achieved was with the Western Ontario and McMaster Universities osteoarthritis index and the Knee Society clinical rating scale. The worst scores were achieved by Short Form-36 and time trade off, a utility method of measurement. If small differences between groups of patients are to be shown, measures of outcome that are more responsive to patient change should be used.

Factors determining pulmonary function in adolescent idiopathic thoracic scoliosis

Adolescent idiopathic thoracic scoliosis may lead to severe pulmonary impairment and early death, but the responsible factors are poorly understood; pulmonary function is only weakly related to the angle of scoliosis. We performed a cross-sectional study using multivariate analysis to identify the individual and additive influence of different features of spinal deformity and nonstructural factors on pulmonary impairment. Pulmonary function was assessed by measuring lung volumes and diffusing capacity, with a priori selection of vital capacity (expressed as percentage of predicted, % VC) as the primary index of pulmonary impairment. Radiologic and physiologic measurements were made independently in 66 subjects who had not previously had spinal surgery. Angle of scoliosis (p = 0.01) was one of four features of spinal deformity associated with reduced % VC; greater number of vertebrae involved (p = 0.007), cephadal location of the curve (p = 0.04), and loss of the normal thoracic kyphosis (p = 0.002) made an equal and additive contribution to pulmonary impairment. Spinal deformity led to reductions in VC, primarily by reducing TLC. Spinal column rotation, respiratory muscle strength, and duration of the curvature were not related to pulmonary function (p > 0.05). We conclude that features of the spinal deformity are the major determinants of pulmonary impairment in idiopathic thoracic scoliosis but that the relationship between deformity and impairment is complex. The severity of pulmonary impairment cannot be inferred to a clinically useful extent from the angle of scoliosis alone.