Shelbourne Knee Center: Winter 2023 Newsletter

KNEE TREATMENT NEWS

RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES

or severe (100%) patellofemoral osteoarthritis.

BEST ACL GRAFT DOESN’T INCREASE RISK OF PATELLOFEMORAL OSTEOARTHRITIS

The patellar tendon is considered the gold standard of graft choices for anterior cruciate ligament (ACL) reconstruction, but some studies have suggested a link between patellar tendon graft (PTG) harvest and increased incidence of patellofemoral osteoarthritis. A recent study by Shelbourne Knee Center of its patients found that using a contralateral or ipsilateral PTG in ACL reconstruction does not lead to increased risk of patellofemoral osteoarthritis.1

The study involved 193 ACL reconstruction patients treated at Shelbourne Knee Center with a PTG (95 ipsilateral and 98 contralateral) for ACL reconstruction. Researchers used graded standard Merchant’s radiographs at baseline and 15 to 25 years post-op to analyze the rates of patellofemoral osteoarthritis and compare patients treated with a contralateral versus an ipsilateral PTG. They divided patients into four groups based on joint space narrowing: none, mild (up to 50%), moderate (50-99%)

While most imaging centers and emergency departments use the sunrise view for knee imaging, Shelbourne Knee Center uses the more accurate Merchant view. In the Merchant view, the knees are bent at 45 degrees and the muscles are relaxed, allowing the patella to settle into the trochlear groove. In the Sunrise view, the knees are at maximum flexion. “The Sunrise view doesn’t provide an adequate view of the patellofemoral joint,” says Laura Bray-Prescott, PT/ LATC, a physical therapist/athletic trainer and research team member at Shelbourne Knee Center. “The Merchant view shows how the patella sits in the femur. The difference between the Sunrise and Merchant views can be like night and day.”

No Increased Risk

Study results show that the rates of patellofemoral osteoarthritis are not higher when a PTG is used during ACL reconstruction. The researchers found no statistically significant differences in:

• Any grade of patellofemoral osteoarthritis rate when comparing the uninvolved normal knee from the ipsilateral group to the contralateral graft donor knee of the contralateral group (9.5% vs 13.3%)

• Rates of moderate to severe patellofemoral osteoarthritis between the two groups.1

This study is part of Shelbourne Knee Center’s research program, which tracks patient outcomes and studies factors related to

NORMAL MERCHANT VIEW

PATELLOFEMORAL OSTEOARTHRITIS AFTER ACL RECONSTRUCTION¹

PATELLOFEMORAL OSTEOARTHRITIS

those outcomes to determine how to improve treatment for knee problems. The research program has data on more than 13,000 patients.

Bray-Prescott says that two factors account for not finding a link between use of a PTG and increased incidence of patellofemoral osteoarthritis among Shelbourne Knee Center patients: postponing surgery until completion of pre-op rehabilitation and an accelerated post-op rehabilitation program.

Both pre- and post-op rehabilitation focus on eliminating or significantly reducing swelling and improving range of motion (ROM) before strengthening. Patients work with one of the Center’s physical therapists/athletic trainers.

“We emphasize range of motion. A lot of people will brace patients or limit weight-bearing after ACL reconstructions, but if patients are not getting their full extension back in the first two months, they are not going to get it back,” says BrayPrescott. “That leads to a stiff joint which leads to arthritic changes.”

Bray-Prescott and physical therapist Bill Claussen presented the study at the American Physical Therapy Association Combined Sections Meeting (February 23-25, 2023, in San Diego).

REFERENCES

1. Bauman S, Claussen W, Benner RB, Shelbourne KD. Does Patellar Tendon Graft Harvest for ACL Reconstruction Lead to an Increased Rate of Patellofemoral Arthritis?

Unpublished data, 2022.

2. Shelbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med. 2000;28:651-8.

3. Shelbourne KD, Beck MB, Gray T. Anterior Cruciate Ligament Reconstruction With Contralateral Autogenous Patellar Tendon Graft: Evaluation of Donor Site Strength and Subjective Results. Am J Sports Med. 2014;43:648-53.

Solving Rehabilitation Challenges

Rehabilitation results for ACL reconstruction patients treated with PTGs are far superior to those of patients treated with hamstring and cadaver grafts, when done well. But widespread use of PTGs has been hampered by lack of understanding of how to properly rehabilitate ACL reconstructions that use PTGs.

Through its research program, Shelbourne Knee Center has developed a proven rehabilitation process that enables patients to achieve nearly full extension and flexion by two to three months post-op:

• Full extension: 98% of patients

• Full flexion: 92%.3

With hamstring and cadaver grafts, patients rarely achieve full range of motion or full strength and are left with knees that aren’t symmetric.

Pre-op Rehabilitation

Before surgery, patients work with their personal physical therapist/athletic trainer to achieve:

• Full ROM

• Little or no swelling

• Normal walking

• Appropriate strength and leg control

Post-op Rehabilitation

The accelerated ACL post-op rehabilitation protocol begins during the patient’ s 23-hour hospital stay. It includes:

• Eliminating swelling by lying down with the knee above the heart for the first seven days. Use of a Cryo-Cuff and a continuous passive motion (CPM) machine also help to eliminate swelling.

• Full extension exercises beginning the day of surgery.

• Weight-bearing is allowed as tolerated for bathroom privileges.

• Emphasis is on range of motion exercises for flexion while maintaining full knee extension.

• Strengthening exercises begin when full extension and flexion is achieved.

Patients complete most of their physical therapy at home, with guidance from their physical therapist/athletic trainer and periodic visits to Shelbourne Knee Center.

* Shelbourne Knee Center patients

ACCELERATING RECOVERY WITH THE IDEALKNEE ™

their input in the final design. The device, which has been available since January 2019, is manufactured and marketed by TS Ideal Products.

MORE EFFECTIVE AND MORE COMFORTABLE

“The IdealKnee provides better leverage over the knee than the IdealStretch and allows the user to apply significant force with minimal effort,” says Sharpe. The new device can be used on a treatment table, in a chair, on the floor or in bed.

WHEN JEFF SHARPE was doing rehab after surgery for a meniscus tear, he used the prototype of a new device, the IdealKnee,™ to regain full knee extension. “My doctors were amazed at how quickly I was back playing soccer with full range of motion,” says Sharpe, owner of TS Ideal Products.

Restoring range of motion (ROM) before and after knee surgery is crucial to optimal postsurgical outcomes. “You can’t fully recover from any knee surgery and expect long-term success without regaining full ROM,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. Some patients can even avoid knee surgery by improving their ROM.

Restoring ROM has been a key part of treatment for knee injuries and problems at Shelbourne Knee Center for many years. Dr. Shelbourne

developed the IdealKnee to make it easier for patients to restore knee extension and safely return to their normal activities.

PATIENTS INFORM DEVICE DESIGN

The IdealKnee is based on another product Shelbourne Knee Center has been using, the IdealStretch™. The IdealStretch focuses on the hamstrings and also stretches the calves, illiotibial band, hips and groin.

Dr. Shelbourne modified the IdealStretch to create a new device that focuses on treating flexion contractures and other conditions that prevent full knee extension. They’re common postsurgery and also can be caused by injuries or osteoarthritis.

Patients at Shelbourne Knee Center tested various prototypes of the new device, and Dr. Shelbourne incorporated

With a strap that is positioned above the knee, away from any incision, the IdealKnee also is more comfortable for postsurgical patients. The lightweight device, available at www.idealknee.com or on Amazon, is affordable and ideal for home use. It can be used for any problem related to knee extension and on a regular basis to maintain full ROM after completing rehab.

Shelbourne Knee Center is currently using both the IdealKnee and the IdealStretch and is determining which device works best for which patients. “Both devices allow us to improve care for our patients and help them accelerate their recovery,” says Dr. Shelbourne. Patients try both devices during physical therapy in the clinic and see which feels like it works extension better. They can buy either device for home use.

For more information about the IdealKnee and our rehab program, call 888-FIX-KNEE.

• Dr. Shelbourne is an unpaid consultant forthe IdealKnee.

Sarah Eaton, PT, DPT, ATC, LAT, shows a patient how to use the IdealKnee.

Rare Knee Injuries: Research-Backed Treatment

TREATMENTS AT SHELBOURNE

KNEE CENTER are based on nearly 40 years of research and follow-up with more than 13,000 patients. The practice’s two surgeons, K. Donald Shelbourne, MD, and Rodney Benner, MD, have had their research published in more than 160 medical journals and over 100 book chapters. Because we specialize only in

knees, we see more rare knee injuries than most orthopedic practices, and we welcome the opportunity to discuss these cases with our colleagues.

Through our Rare Knee Injury Research Program, we’ve begun to identify outcomes and factors related to those outcomes for the following injuries:

• Arthrofibrosis

• Chronic patellar tendinosis

• Failed ACL surgery

• Knee dislocations

• Patellar tendon rupture

• Patellofemoral instability

• Quadriceps tendon rupture.

Whether you would like to discuss a case or make a referral, patients will benefit from our research-backed treatment protocols. Referrals enable us to expand our research to further improve treatment for rare knee injuries.

To discuss a rare knee injury or other case with one of our orthopedic surgeons, email skckneecare@ecommunity.com or call 888-FIX-KNEE (317-924-8636)

MEET OUR

ORTHOPEDIC SURGEONS

n K. Donald Shelbourne, MD

n Rodney Benner, MD

CLINICAL TEAM

n Jean Fouts, RN, BSN

n Lee Linenberg, CA

n Emily Guy, PA

PHYSICAL THERAPISTS AND ATHLETIC TRAINERS

n Bill Claussen, MPT

n Emma Sterrett, LAT, ATC

n Laura Bray-Prescott, PT/LATC

n Darla Baker, PT, DPT ATC/L

n Sarah Eaton, PT, DPT, ATC, LAT

n Jennifer Christy, PT

n Alana Gillenwater, PT, DPT

n Bryanna McKinstry, PT

n Noah Runyon, PT

RESEARCH TEAM

n Scot Bauman, PT, DPT

n Adam Norris

n Heather Garrison

n Diane Davidson, BS, MBA, CCRC

Our orthopedic surgeons, K. Donald Shelbourne, MD, founder of Shelbourne Knee Center, and Rodney Benner, MD.

TO CONSULT WITH ONE OF OUR SURGEONS, CALL 888-FIX-KNEE