Microfracture of the knee

Image of cartilage defects

Microfracture is a surgical technique that has been developed to treat chondral defects, which are damaged areas of articular cartilage of the knee. It is a common procedure used to treat patients with full thickness damage to the articular cartilage that goes all the way down to the bone. This arthroscopic procedure was first introduced about 20 years ago as a treatment method that uses the body's own healing abilities and provides an enriched environment for tissue regeneration on the chondral surface.
Since its development, the microfracture procedure has been used by its originator to treat more than 2000 patients. Of these patients, 75 to 80% experienced significant pain relief and improvement in the ability to perform daily activities and participate in sports. Fifteen percent noticed no change, and five percent continued to have joint deterioration.

What are the signs and symptoms of an articular cartilage injury that may be treated with the microfracture technique?

• Intermittent swelling - Loose fragments floating in the knee can cause swelling to occur.
  
• Pain - Pain with prolonged walking or climbing stairs can occur.
  
• Giving way - The knee may occasionally buckle or give way when weight is placed upon it.
  
• Locking or catching - Loose, floating pieces of cartilage may catch in the joint as it bends, causing the knee to lock or have limited motion.
• Noise - The knee may make noise (called crepitus) during motion, especially if the cartilage on the back of the kneecap is damaged. This noise is often described as "snap, crackle, and pop". 

After articular cartilage damage has been diagnosed, what factors are indications for microfracture?

The general indications for microfracture are:

• The patient has a full-thickness defect (loss of articular cartilage down to the bone) in either a weightbearing area between the femur and tibia or in an area of contact between the back of the patella and the groove it slides in.
  
• The patient has unstable cartilage covering the underlying bone.
  
• The patient has degenerative changes in a knee that is normally aligned.

Important factors to consider for use of the microfracture procedure are:

• The patient's age (as a relative indication)
• The patient's activity level
• Whether or not the patient has acceptable alignment of the knee. "Knock-kneed" or "bowlegged" patients may not be good cadidates for this procedure.
  

When is microfracture not recommended for a patient?
Microfracture is not recommended when:

• the patient's knee is poorly aligned.
• the patient's chondral defect is not all the way through the full thickness of the cartilage.
• the patient is not willing to follow a strict and rigorous rehabilitation protocol.
• the patient is older (generally over 65) and might have difficulty with crutch use and the rehabilitation process.
• the patient has disease-induced arthritis, cartilage disease, or any disease affecting the immune system (e.g. rheumatoid arthritis). 

The Surgical Procedure: Microfracture

The microfracture procedure is done arthroscopically. The surgeon visually assesses the defect and performs the procedure using special instruments that are inserted through three small incisions on the knee. After assessing the cartilage damage, any unstable cartilage is removed from the exposed bone. The surrounding rim of remaining articular cartilage is also checked for loose or marginally attached cartilage. This loose cartilage is also removed so that there is a stable edge of cartilage surrounding the defect. The process of thoroughly cleaning and preparing the defect is essential for optimum results.

Multiple holes, or microfractures, are then made in the exposed bone about 3 to 4mm apart. Bone marrow cells and blood from the holes combine to form a "super clot" that completely covers the damaged area. This marrow-rich clot is the basis for the new tissue formation. The microfracture technique produces a rough bone surface that the clot adheres to more easily. This clot eventually matures into firm repair tissue that becomes smooth and durable. Since this maturing process is gradual, it usually takes two to six months after the procedure for the patient to experience improvement in the pain and function of the knee. Improvement is likely to continue for about 2 to 3 years.

What types of complications may occur?
Most patients progress through the postoperative period with little or no difficulty. Some patients may develop mild transient pain, most frequently after microfracture has been performed on the patella (kneecap) and trochlear groove (the groove on the femur in which the patella glides during motion). Small changes in the articular surface of this patellofemoral joint may produce a grating or "gritty" sensation, particularly when a patient discontinues use of the knee brace and begins normal weightbearing through a full range of motion. Patients rarely have pain at this time, and this grating sensation typically resolves on its own in a few days or weeks.
Similarly, if a steep perpendicular rim was made in the trochlear groove, patients may notice "catching" or "locking" as the ridge of the patella rides over this area during joint motion. Some patients may even notice these symptoms while using the continuous passive motion machine (CPM), a device that gently moves the joint while the patient is lying down. If this locking sensation is painful, the patient is advised to limit weightbearing and avoid the bothersome joint angle for an additional period. These symptoms usually dissipate within 3 months.
Typically, swelling and joint effusion (fluid in the joint) disappear within 8 weeks after a microfracture procedure. Occasionally, a recurrent effusion develops between 6 and 8 weeks after surgery for a defect on the femur; usually when a patient begins to put weight on the injured leg. This effusion may mimic the preoperative or immediate postoperative effusion, although it is usually painless. It usually resolves within several weeks. Rarely is a second arthroscopy required for recurring effusions.

The rehabilitation program after microfracture is crucial to optimize the success of the surgical technique. The program is designed to promote the ideal physical environment in which the bone marrow cells can transition into the appropriate cartilage-like cell lines. When the ideal physical environment is combined with the ideal chemical environment produced by the marrow clot, a repair cartilage can develop that fills the original defect.
The specific rehabilitation program for each patient following a microfracture will vary depending upon the following factors:

• The location of the defect
  
• The size of the defect
• Whether any other surgical procedure, such as an anterior cruciate ligament reconstruction, was done at the same time as microfracture

Following are examples of some rehabilitation programs.

Rehabilitation Protocol for Patients with Chondral Defects on the Femur or Tibia

• The patient is started on a continuous passive motion (CPM) machine immediately in the recovery room. Ideally, the patient should use the machine for 6 to 8 hours every 24 hours. Range of motion is increased as tolerated until full range of motion is achieved with the machine.
• If a CPM machine is not used, the patient begins passive flexion/extension (straightening and bending) of the knee with 500 repetitions three times a day.
• The use of crutches, with only light touch-down weight allowed on the involved leg, is prescribed for 6 to 8 weeks. Patients with small defect areas (less than 1cm in diameter) may be allowed to put weight on the leg a few weeks sooner.
• Brace use is rarely recommended for patients with chondral defects on the femur or tibia.

Limited strength training also begins immediately after microfracture surgery.

• Standing one-third knee bends with a great deal of the weight on the uninjured leg begin the day after surgery.
• Stationary biking without resistance and a deep-water exercise program begin 1 to 2 weeks after surgery.
• After 8 weeks the patient progresses to full weight bearing and begins a more vigorous program of active knee motion.
  
• Elastic resistance cord exercises can begin about 8 weeks following surgery.
• Free weights or machine weights can be started when the early goals of the rehabilitation program have been met, but no sooner than 16 weeks after surgery.
• Patients must not resume sports that involve pivoting, cutting, and jumping for 4 to 6 months after a microfracture procedure. Full activity may be resumed once the physician has examined the knee and given approval for the patient to return to sports activity.

Rehabilitation Protocol for Patients with Patellofemoral Chondral Defects

• All patients treated with microfracture for patellofemoral defects must use a brace set for 0° to 20° of flexion for at least 8 weeks. It is essential to limit compression of the new surfaces in the early postoperative period, so that the maturing marrow clot will not be disturbed. The brace should be worn at all times except when passive motion is allowed.
• Patients are placed into a CPM machine immediately following surgery. The goal is to obtain a pain-free and full passive range of motion soon after surgery during those periods when the brace is removed.
• When the patient wears a brace, strength training is allowed, but only in the 0° to 20° range immediately after surgery in order to limit compression of the affected chondral surfaces. The joint angles of these patients are observed carefully at the time of surgery to determine where the defect makes contact with the opposing surface, either on the patella or on the trochlear groove of the femur. These areas are avoided during strength training for approximately 4 months.
• Patients are allowed to put weight on the involved leg as tolerated, but it must be limited to the angles of flexion that do not compress the treated surfaces. For this reason the patient must wear a brace locked in limited flexion.
• After 8 weeks, the knee brace is gradually opened to allow increased flexion of the knee, a process that takes about a month. Brace use is generally discontinued at about 12 weeks. Some patients, however, like to continue to wear the brace for strenuous exercise for a few more months up to about 6 months.
• After brace use is discontinued, strength training advances progressively.
• The doctor must examine the knee before the patient is released to full activity. 

 Is microfracture a "cure" for osteoarthritis?

No, microfracture is a technique to help form a new surface to cover chondral defects. If successful, it minimizes pain and swelling, and helps the joint function more normally.

Is the new tissue that forms after the microfracture identical to the original articular cartilage?

No, the new tissue is a "hybrid" of articular-like cartilage plus fibrocartilage. Experience shows that this hybrid repair tissue is durable and functions similarly to articular cartilage.

Can microfracture be used in joints other than the knee?

Yes, there are reports of microfracture being used in the shoulder, the hip, and the ankle. The long-term effectiveness of the technique in these other joints is unknown. This is because there are no long-term studies available similar to those that have been done to evaluate the procedure in the knee.


Here is a clip from you tube showing a microfracture procedure of the knee.  

Click here.

Here is my online presentation regarding age related conditions of the knee and shoulder.  It includes a description of the microfracture procedure. Microfracture starts slide number 133.

Thanks, 

JTM, MD





References
1. Steadman JR, Rodkey WG, Rodrigo JJ: "Microfracture": Surgical technique and rehabilitation to treat chondral defects. Clin Orthop Rel Res, in press, October 2001.

2. Rodrigo JJ, Steadman JR, Silliman JF, Fulstone HA: Improvement of full-thickness chondral defect healing in the human knee after debridement and microfracture using continuous passive motion. Am J Knee Surg 7:109-116, 1994.

3. Frisbie DD, Trotter GW, Powers BE, et al: Arthroscopic subchondral bone plate microfracture technique augments healing of large osteochondral defects in the radial carpal bone and medial femoral condyle of horses. J Vet Surg 28:242-255, 1999.

4. Steadman JR, Rodkey WG, Singleton SB, et al: Microfracture Procedure for Treatment of Full-thickness Chondral Defects: Technique, Clinical Results and Current Basic Science Status. In: Harner CD, Vince KG, Fu FH (eds). Techniques in Knee Surgery. Media, PA, Williams & Wilkins 23-31, 1999.

5. Steadman JR, Rodkey WG, Singleton SB, Briggs KK: Microfracture technique for full-thickness chondral defects: technique and clinical results. Oper Tech Orthop 7:300-304, 1997.

Should surgery come before the sling?

I attended the AAOS Meeting in New Orleans.   Here is a study of interest in the treatment of clavicle fractures.   

Surgery may be better for displaced clavicle fractures

Clavicle fractures, common injuries in active adults, are conventionally treated with arm immobilization in a sling. But according to the results of a study presented  at the AAOS 2010 Annual Meeting, surgical treatment of clavicle fractures may have some advantages over conservative measures in patients with a high level of activity.

Fig. 1 Postoperative anteroposterior radiograph of a clavicle fracture that was stabilized with a 3.5mm reconstruction plate. Courtesy of Kaisa J. Virtanen, MD

The data suggest that nonsurgical and surgical treatment of displaced midshaft clavicle fractures provide equal functional outcomes, as well as relief of pain at rest and activity at 1-year follow-up.  

Nonsurgical treatment, however, had a relatively high risk of nonunion.

Although conservative treatment with sling immobilization should be considered first in most patients, the study’s results suggest that surgical treatment may be more effective for physically active adults due to the reduced risk of nonunion and an acceptable risk of complications.

Comparing surgical, nonsurgical measures

Between August 2004 and October 2007, 60 patients were enrolled in the prospective, randomized, controlled trial performed at Helsinki University Töölö Hospital in Finland. All patients were aged 18 to 70 years and had a completely displaced middle third clavicle fracture with no cortical contact between main fragments. Fractures were treated within 7 days after injury. 

Potential study participants were identified and enrolled as they arrived in the emergency department. Patients were randomized to either the nonsurgical group (32 patients) or the surgical group (28 patients).

Patients in the nonsurgical group wore an arm sling for 3 weeks and were advised to perform the pendulum movement, in which the patient bends forward at the waist and lets the injured arm hang down toward the ground. The patient then makes small clockwise and counterclockwise circles, letting momentum move the hand.

Patients in the surgical group underwent surgical treatment with plate osteosynthesis within 7 days of the injury (Fig. 1). After surgery, the arm was immobilized in a sling for 3 weeks, and physical therapy using the pendulum movement was started on postoperative day one. 

The following outcome measures were used:

• Constant-Murley Shoulder Outcome Score (CSS)—pain, function, range of motion, and strength
• Disability of the Arm, Shoulder and Hand (DASH)—physical function and symptoms
• pain at rest and activity as measured by the visual analog score (VAS)
• union rate
• complications or adverse events

“Surprising” number of nonunions

At 1 year follow-up after injury, 26 patients remained in the surgical group and 25 patients in the nonsurgical group.

The study found no clinically significant difference in CSS or DASH scores, or in pain at rest or activity.  The differences in DASH scores and pain between the surgical and nonsurgical [groups] were statistically significant, but not clinically significant.

The nonsurgical group had five nonunions, while the surgical group had none. No patients in the surgical group—and only 3 of 25 patients in the nonsurgical group—had symptoms above acceptable levels (VAS scores more than 24 at rest). In addition, mean DASH scores of both groups were below 10 points, indicating that most patients achieved tolerable pain relief and subjective function regardless of whether they received nonsurgical or surgical treatment.

The rate of complications and adverse events was acceptable. One patient in the nonsurgical group underwent surgery at 4 months because of plexus irritation. No patients had postoperative infections, while two complications occurred in the surgical group—a refracture after a new fall and a broken plate. 

Even though the authors expected more nonunions in the nonsurgical group than in the surgical group, the high incidence of nonunion in the nonsurgical group surprised them. This could be explained by the relatively low number of patients in this study.

The study suggests that equal functional outcomes can be obtained at 1-year follow-up with either nonsurgical or surgical treatment of displaced midshaft clavicle fractures. In physically active adults, surgical treatment may secure the union with acceptable risk of complications.

My thoughts...

A very interesting study that favors the surgical treatment of certain clavicle fractures. 

Thanks,

JTM, MD

 

Biceps Tendon Ruptures at the Elbow

New study finds early surgical treatment improves level of recovery in both function and strength

 

People who suffer from injuries to the distal biceps tendon may benefit from earlier surgical intervention and new surgical techniques, according to a review article published in the March 2010 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). Located in the front of the elbow, the distal biceps tendon attaches to the lower end of the biceps muscle, and is responsible for two primary motions:

• allowing the elbow to bend (elbow flexion), and

• allowing the arm to turn the palm upward (supination).

The study reported individuals who undergo surgery soon after their injuries experience faster and more complete recoveries than patients who are treated nonsurgically, as well as those whose surgeries are delayed.

Over the last 10 years there has been an increase in techniques to repair the distal biceps tendon.  Newer techniques allow for smaller incisions and often use one incision, instead of two. Moreover, the use of hardware can often return the strength of the tendon to within 90 percent to 95 percent of its original strength.

The study revealed surgical treatment offered a 30 percent greater improvement in elbow flexion and a 40 percent greater improvement in supination when compared to non-surgical treatment. Upper extremity endurance was also improved in patients treated surgically.

The results of the study also indicate surgery is most effective, and much simpler, when completed within two weeks of the initial injury.

Early diagnosis and treatment of these injuries make surgical repair more straightforward.  The ability to locate the end of the tendon in surgery is easier within the first two weeks, and if the tendon is repaired during this two-week period, the patient should regain the majority of his or her elbow flexion and forearm supination strength. After two weeks, the tendon tends to scar, making it more difficult to bring the tendon back to its original attachment.

Injuries to the distal biceps tendon most often occur as the result of a single trauma involving lifting or moving heavy weights, and may occur more frequently in patients over the age of 30 years, as well as those who smoke and individuals who take anabolic steroids.

Because other muscles initially may compensate for some of the loss of function following a trauma, these injuries occasionally can be difficult to detect initially, causing treatment to be delayed in some cases, she said. A detailed medical history is one of the primary components used to detect these injuries. Patients who injure their arm during exercise or other activity should be aware of the following warning signs which may point to an injury of the distal biceps tendon:

• a “popping” sensation in the arm and bruising around the elbow at the time of injury;

• a change in the contour or shape of the biceps muscle; and

• pain and weakness in flexion and supination of the injured arm

People can help prevent biceps injuries by:

• avoiding smoking and anabolic steroid use, which decrease blood flow to the tendon, increasing the likelihood of injury;

• avoiding lifting heavy weights using a biceps curl; and

• exercising caution when moving heavy objects, especially in individuals who smoke, take steroids, or are older than 30.

When a biceps injury does occur, no matter which surgical technique is used, one of the most important factors in successful treatment is ensuring the surgery is not delayed.

There are multiple ways to repair the tendon surgically, and the specific technique used is based on the experience of the surgeon and the latest biomechanical studies on strength and stability of various repairs.  For a healthy, active individual, it is best to seek medical attention quickly and to be evaluated by an orthopaedic surgeon if a tear is suspected, in order to ensure the best possible outcome.

Every year  I perform between 15-20 distal biceps tendon repairs.  This year is no different.  I prefer the 2 small incision technique since, in my experience, it is safe and reliable.  Here are some pictures of how that procedure is performed.

 

The ruptured tendon is delivered into the wound, trimmed and a suture is woven throught he end of the tendon below.

 The tendon may also be attached to the bone tunnel with metal anchors or implants.  I tend not to use these at this time as I am not convinced that such a repair is superior to or safer than the 2 incision technique.  

Technology is great if it is safer and superior to currently accepted and practiced techniques.

Thanks,

JTM, MD

Knee Replacement in Elderly Patients Shown to Improve Balance

Multiple benefits to surgery reported for patients with advanced osteoarthritis 

Total knee replacement (TKR) successfully relieves pain and improves function in patients with advanced knee arthritis, according to a study presented today at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). The surgery also significantly improves dynamic balance among elderly patients.

Impaired balance and increased tendency to fall are common complaints among the elderly suffering from severe osteoarthritis (worn cartilage). The purpose of the study was to determine whether TKR had any effects on balance measures, in correlation with functional balance and quality of life. This is especially important because falls are the leading cause of injury for senior adults in the U.S., and hip fractures that result from falls can be lethal for elderly patients.

“Balance is critical to the elderly, especially those with knee problems. This study reinforced our hypothesis about how an osteoarthritic patient’s function is compromised not only due to pain, but also by balance,” said Leonid Kandel, MD, study author and orthopaedic surgeon, Department of Orthopaedic Surgery, Hadassah Mount Scopus Hospital, Jerusalem, Israel.

The study examined 63 patients, with a mean age of 73, who had total knee replacements and participated in follow-up evaluations after one year. The study measured accurately static and dynamic balance with a new computerized system called the Balance Master. The study found:

• Significant improvement in dynamic balance one year after surgery;

• Significant progress in balance-determined motor tests; and

• Strong statistical correlation between the balance and the Oxford Knee Score functional questionnaire and the quality of life questionnaire SF-36.

One year after surgery, the correlation between patients’ improved balance and their ability to walk and perform daily activities was stronger than the correlation between their reduced pain and their ability to walk and do daily activities.

“We are learning that pain relief may not be the only benefit that improves function after knee replacement,” explained Dr. Kandel. “This improved balance is a significant quality-of-life change in elderly patients.”

Elderly individuals considering knee replacement should talk to their orthopaedic surgeon about the rehabilitation process and ways to improve balance following surgery. Other questions to consider prior to surgery can be found at www.orthoinfo.org.

Thanks,

JTM, MD

Aspartame and Joint Pain?

A patient with multiple joint pains comes into the office for evaluation.  He asks about aspartame poisoning as a potential cause of his complaints.   I was not familiar with this as a cause of joint pain and I did some research.  His reference was a website that you can find here. 

After some additional research, I found a reference summarizing current medical opinion on the Mayo Clinic website. 

By Mayo Clinic staff

More than ever, people are consuming large amounts of sugar as part of their daily diet. But in excess, sugar can take its toll. Eating large amounts of sugar adds extra calories, which can cause weight gain. So many people opt for artificial sweeteners — also referred to as sugar substitutes or low-calorie sweeteners — as a way to enjoy their favorite foods without as many calories.

What are artificial sweeteners?

Artificial sweeteners are chemicals or natural compounds that offer the sweetness of sugar without as many calories. Because the substitutes are much sweeter than sugar, it takes a much smaller quantity to create the same sweetness. Products made with artificial sweeteners have a much lower calorie count than do those made with sugar. Artificial sweeteners are often used as part of a weight-loss plan or as a means to control weight gain. 

People with diabetes may use artificial sweeteners because they make food taste sweet without raising blood sugar levels. But keep in mind that if you do have diabetes, some foods containing artificial sweeteners, such as sugar-free yogurt, can still affect your blood sugar level due to other carbohydrates or proteins in the food. Some foods labeled "sugar-free" — such as sugar-free cookies and chocolates — may contain sweeteners, such as sorbitol or mannitol, which contain calories and can affect your blood sugar level. Some sugar-free products may also contain flour, which will raise blood sugar levels. Also, remember that foods containing sugar substitutes may also contain calories that may undermine your ability to lose weight and control blood sugar.

Sweet choices

The Food and Drug Administration (FDA) has approved the following low-calorie sweeteners for use in a variety of foods. The FDA has established an "acceptable daily intake" (ADI) for each sweetener. This is the maximum amount considered safe to eat each day during your lifetime. ADIs are intended to be about 100 times less than the smallest amount that might cause health concerns.

Artificial sweetener	ADI*	Estimated ADI equivalent**	OK for cooking?
Aspartame (NutraSweet, Equal)	50 milligrams (mg) per kilogram (kg)	18 to 19 cans of diet cola	No
Saccharin (Sweet'N Low, SugarTwin)	5 mg per kg	9 to 12 packets of sweetener	Yes
Acesulfame K (Sunett, Sweet One)	15 mg per kg	30 to 32 cans of diet lemon-lime soda***	Yes
Sucralose (Splenda)	5 mg per kg	6 cans of diet cola***	Yes

*FDA-established acceptable daily intake (ADI) limit per kilogram (2.2 pounds) of body weight.
**Product-consumption equivalent for a person weighing 150 pounds (68 kilograms).
***These products usually contain more than one type of sweetener.

Safety of artificial sweeteners

Artificial sweeteners are often the subject of stories, presented in the popular press and on the Internet, claiming that they cause a variety of health problems, including cancer. According to the National Cancer Institute, however, there's no scientific evidence that any of the artificial sweeteners approved for use in the United States cause cancer. And numerous studies confirm that artificial sweeteners are safe for the general population. 

Aspartame does carry a cautionary note, however. It isn't safe for people who have the rare hereditary disease phenylketonuria (PKU). Products that contain aspartame must carry a PKU warning on the label.

Still empty calories

Just removing sugar from cookies and chocolates doesn't make them low-calorie, low-fat foods. If you eat too many, you'll still get more calories than you may need, and you may not get enough nutritious foods. Unlike fruits, vegetables and whole grains, sugar-free soft drinks, candy and desserts often provide few — if any — beneficial nutrients.
Use artificial sweeteners sensibly. It's OK to substitute a diet soda for a regular soda, for example, but diet soda shouldn't be the only beverage you drink.

My thoughts:

When something like aspartame, seems to cause every disease known to mankind, one has to look carefully at the supporting data.  While too much of anything is not good for you, I cannot find anything that scientifically supports aspartame as a cause of joint pain.  We cannot know everything and additional research is important.

Just because the FDA says it is OK does not mean much.  Think about how may medications have been on the market only to be recalled after people develop side effects. 

In addition, just because people says they have problems related to a compound or implant, does not mean that it is really the culprit.  Think about silicone breast implants. 

For this patient, however, the best test is to stop all use of aspartame, and see what happens to the joint pain.

I am not sure this proves anything about aspartame, but it does suggest that patients should be wary of what they read on the Internet.  If you don't believe me, just check your email SPAM folder.

Thanks,

JTM, MD

A Sporting Chance for Active Total Knee Replacement Patients

Study finds implant durability not affected by high-impact sports participation
 

Total knee arthroplasty (TKA) patients may be able to participate in high-impact sports without increasing risk of early implant failure, according to a new study presented today at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). 

In addition, the authors observed better clinical scores in the group of patients who participated in activities discouraged by the Knee Society (KS) than those of the control group.

The Knee Society recommends TKA patients avoid activities that cause high stress loads on the implant and may increase the risk of early failure. Such activities include high-impact aerobics, football, soccer, baseball, basketball, jogging and power lifting, among others.

“Recent studies have shown that as many as one in six total knee replacement patients participate in non-recommended activities,” said Sebastian Parratte, M.D., PhD, an orthopaedic surgeon from the Mayo Clinic in Rochester, MN and the Aix-Marseille University, Center for Arthritis Surgery, Hospital Sainte-Marguerite in Marseille, France. “This study offers some reassurance to those patients who choose to return to an active lifestyle after surgery.”

Researchers evaluated outcomes of 218 patients between the ages of 18 and 90 who underwent primary knee arthroplasty at the Mayo Clinic and reported performing heavy manual labor or practicing a non-recommended sport following surgery. The “sport group” was matched by age, gender and BMI to a control group of 317 patients who underwent the same procedure using an identical implant and followed recommended activity guidelines.

Clinical and radiologic results were measured using Knee Society (KS) scores and implant survivorship was evaluated using multivariate analysis according to the Cox model.

At an average follow-up of seven-and-a-half years after surgery, the study found:

• No significant radiological differences and no significant differences in implant durability could be demonstrated between the sport group and the control group;

• The sport group showed slightly higher KS Knee and function scores compared to the control group;

• The control group experienced a 20 percent higher revision rate for mechanical failure (loosening, wear or fracture) compared to the sport group;

• After accounting for all variables, including co-morbidities, the sport group had a 10 percent higher risk of mechanical failure compared to the control group.

These results were quite surprising to Dr. Parratte and his team.

“We hypothesized that high-impact activities would not increase the risk of implant failure, but we did not foresee that such activities might actually improve clinical results,” he said. “It is clear that more research is necessary to evaluate the short and long-term effect of high-impact activities on the durability and function of modern TKA implants.”

He added that, although the industry is not ready or able at this point to revise its recommendations, that possibility may exist in the not-too-distant future. In the meantime, he noted that surgeons and patients should continue to follow all industry recommendations relating to recovery following joint replacement surgery.

Learn more.

About Joint Replacement

Joint replacement, also known as arthroplasty, is considered by many to be one of the most successful medical innovations of the 20th century. Total joint replacement is a surgical procedure in which the patient’s natural joint is replaced with an artificial one, made of a combination of plastic, metal, and/or ceramic.

The most common reasons for this surgery are pain and stiffness that limits normal activities such as walking and bending and that cannot be satisfactorily treated with medications or other therapies. Therefore, joint replacement surgery often provides a significantly improved quality of life to patients who would otherwise have to live with severe pain.

In 2007, there were 550,161 total knee replacements performed in the United States, and that number is on the rise—particularly as the Baby Boomer population continues to age. Because of this trend, it is important to optimize patient outcomes.

My thoughts:

I still recommend that patients with total knee replacements restrict their physically demanding sports activity.  As studies become available, that may change.  For now, total knee patient should avoid activities that involved running, shifting, rapid pivoting and jumping on the knee.

(That means you, Ed. No racquetball.)

Thanks,

JTM, MD