SPRING 2022
NEWS
KNEE TREATMENT RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES
TORN ACL + TORN MENISCUS: TWO-STAGED PROCEDURE IMPROVES FUNCTION
Following simultaneous anterior cruciate ligament (ACL) reconstruction and repair or removal of a locked bucket-handle meniscus tear, patients were having difficulty regaining full range of motion (ROM). “After surgery, patients had a stable knee, but it was stiff and not functional,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. Dr. Shelbourne developed a
two-staged meniscus repair and ACL reconstruction procedure to solve this problem. The meniscus is repaired immediately, and the ACL is reconstructed after the patient regains ROM. Patients complete physical therapy focused on regaining full ROM equal to the non-involved knee after meniscus repair for two to three months before undergoing ACL reconstruction. Post-ACL
reconstruction, they participate in Shelbourne Knee Center’s accelerated ACL post-op rehab program. (Read more at: www.bit.ly/ ACLrehabSKC.) This innovative approach gives patients a functional knee and has enabled Dr. Shelbourne to evaluate meniscus healing and determine the optimal treatment for meniscus tears. CONTINUED ON NEXT PAGE
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TORN ACL + TORN MENISCUS: TWO-STAGED PROCEDURE IMPROVES FUNCTION Research Supports the Two-Staged Approach The first study Dr. Shelbourne did compared 16 athletes treated with the two-staged procedure (Group 1) and 16 matched athletes treated with simultaneous repair or removal of a locked buckethandle meniscus tear and ACL reconstruction (Group 2). No patients in Group 1, and four patients in Group 2, required a second procedure or a cast to regain full ROM equal to the noninvolved knee.1 Another study evaluated 52 patients with 55 meniscus repairs who underwent meniscus repair by trephination, followed by ACL reconstruction after the patient had obtained full range of motion. In trephination, the needle going through the meniscus into the capsule creates blood channels for healing. Trephination avoids the risks of meniscus repair with sutures. At the time of ACL reconstruction: • 30 menisci (55%) appeared healed • 19 menisci (34%) were partially healed • 6 menisci (11%) showed no healing (4 of which were removed).2 At an average follow-up of 4.3 +/- 3.1 years, 36 of the 43 (83.7%) meniscus tears with no bleeding in the peripheral rim or the inner edge of the tear (the white-on-white zone) remained asymptomatic. All other repaired meniscus tears remained asymptomatic. The researchers concluded that locked bucket-handle meniscus tears heal at a high rate when repaired as an isolated procedure, even when full weight-bearing and activity before reconstruction is allowed and when the tear is in a white-on-white zone.
NEWS
2 KNEE TREATMENT
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“
WHETHER TO TREAT A MENISCUS TEAR DEPENDS ON MANY FACTORS, INCLUDING THE TYPE OF TEAR, HOW SYMPTOMATIC IT IS, AND ITS CAPACITY FOR HEALING.
”
K. Donald Shelbourne, MD.
Pre-op Therapy Improves Outcomes Pre-op rehab for ACL reconstruction, focused on improving range of motion before strengthening, has been standard care at Shelbourne Knee Center since the Center’s research showed the importance of returning the knee to a normal state (except for the ACL tear) prior to surgery. Doing so reduces recovery time and allows patients to more easily achieve their goals.3 After surgery, patients participate in the accelerated ACL post-op rehab program, which also focuses on improving range of motion before strengthening. (Read more at: www.bit.ly/ACLprehabSKC.) “The two-staged procedure with pre- and post-op rehab gives patients with an ACL tear and a locked bucket-handle meniscus tear the best chance of a normal knee in the long term,” says Dr. Shelbourne.
Treatment of Other Types of Meniscus Tears Most meniscus tears that occur with ACL tears are asymptomatic4
and don’t require repair. (Read more at: www.bit.ly/ACLmeniscusSKC.) This includes bucket-handle tears that are not locked. “Even most symptomatic meniscus tears will get better on their own with proper physical therapy,” says Dr. Shelbourne. Unnecessary meniscus repair is common and can jeopardize ACL rehab by restricting weight-bearing and ROM. It also can lead to possible complications: • Damage to articular surfaces • Repair device left in meniscus causing symptoms. “The decision whether to treat a meniscus tear depends on many factors, including the type of tear, how symptomatic it is and its capacity for healing,” says Dr. Shelbourne. For example, most lateral meniscus tears can be left in situ, he says, based on data from patients at Shelbourne Knee Center.5,6 For more information, call 888-FIX-KNEE or email skckneecare@ecommunity.com. REFERENCES 1. Shelbourne KD, Johnson GE. Locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency. Am J Sports Med. Nov-Dec 1993; 21(6); 779-782. 2. O’Shea JJ, Shelbourne KD. Repair of locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency. Am J Sports Med. Mar-Apr 2003;31(2):216-20. doi: 10.1177/03635465030310021001. 3. Biggs A, et al. Rehabilitation for patients following ACL reconstruction: A knee symmetry model. N Am J Sports Phys Ther. 2009 Feb;4(1):2-12. 4. Shelbourne KD, Benner RW. Correlation of joint line tenderness and meniscus pathology in patients with subacute and chronic anterior cruciate ligament injuries. J Knee Surg. 2009 Jul;22(3):187-90. 5. Fitzgibbons RE, Shelbourne KD. “Aggressive” nontreatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction. Am J Sports Med. 1995 Mar-Apr;23(2):156-9. 6. Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction. Arthroscopy. 2004 Apr;20(4):346-51.
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BETTER OUTCOMES FOR PATELLAR TENDON RUPTURES
A PATELLAR TENDON RUPTURE is a disabling injury that prevents the patient from achieving full knee extension. This rare injury, occurring in less than 0.5% of the population annually, has two main causes: •A primary injury in patients in their 30s or 40s, usually from a mistimed landing while playing basketball or tripping down steps •R upture of the tendon at the graft harvest site after anterior cruciate ligament (ACL) reconstruction. The rarity of patellar tendon rupture and the variable length of the tendon when the knee is bent or straight make this injury difficult to treat. “When the patient is asleep in surgery and the knee is straight, it’s easy for the surgeon to put the tendon back to the patella. Then many surgeons put the leg into a cast or immobilize it in another way for six weeks. The tendon heals too tight and the patient can’t bend the knee or breaks the repair,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. Most orthopedic surgeons see one or no patellar tendon ruptures each year. Dr. Shelbourne and orthopedic surgeon Rodney Benner, MD, have performed more than 100 patellar tendon rupture repairs.
An Innovative Surgical Technique To combat the shortcomings of other surgical techniques for patellar tendon ruptures and produce better outcomes for
patients, Dr. Shelbourne developed an innovative surgical technique. This technique involves using endto-end suturing of the tendon edges combined with retinacular repair and augmentation with a braided cable (Dall-Miles cable). Suitable for patellar tendon rupture due to a primary injury or at the graft harvest site after ACL reconstruction, this technique has several advantages over other patellar tendon rupture repair techniques. Using the Dall-Miles cable enables the tendon to be repaired at the proper length with limited immobilization. Also, the cable permits aggressive postoperative rehabilitation and prevents repair rupture. “Patellar tendon rupture repair with a Dall-Miles cable provides a predictable, successful outcome,” says Dr. Shelbourne. “The repair works and patients get their complete range of motion back.”
An Aggressive Rehabilitation Protocol Immobilization for patients at Shelbourne Knee Center is limited to walking until the patient achieves quadriceps control (about two weeks). Each patient completes an aggressive postoperative rehabilitation protocol, guided by one of the Center’s physical therapists/ athletic trainers. The immediate postoperative protocol includes use of a continuous passive motion machine and exercises to restore range of motion (ROM), control swelling and increase quadriceps control. Rehabilitation progresses to optimize ROM and strength within the limits of the Dall-Miles cable. After the cable is removed, usually six to eight weeks
postoperatively, rehabilitation continues. The goal at this point is to achieve ROM equal to the noninvolved leg and to strengthen the quadriceps.
Two Studies Provide Evidence Research on patients who underwent patellar tendon rupture repair with a Dall-Miles cable at Shelbourne Knee Center confirm the predictable, successful outcome of this surgical technique and the Center’s rehabilitation protocol.1,2 The first study involved 10 patients who underwent patellar tendon rupture repair between 1995 and 1998 (5 for a primary injury and 5 at the graft harvest site after ACL reconstruction).1 The second study involved 13 patients who experienced patellar tendon ruptures out of 5,364 ACL reconstructions at Shelbourne Knee Center from 1982 to 2008 (incidence of 0.24%).2 For both studies, the researchers reported good objective results for flexion, extension and quadriceps strength and good subjective results. Patellar tendon rupture repair with a Dall-Miles cable was effective for patellar tendon ruptures due to a primary injury and at the graft harvest site after ACL reconstruction. REFERENCES 1. Shelbourne KD, Darmelio MP, Klootwyk TE. Patellar tendon rupture repair using Dall-Miles cable. Am J Knee Surg. Winter 2001;14(1):17-20. 2. Benner RW, Shelbourne KD, Urch SE, Lazarus D. Tear patterns, surgical repair, and clinical outcomes of patellar tendon ruptures after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft. Am J Sports Med. 2012 Aug;40(8):1834-41. doi: 10.1177/0363546512449815.
Shelbourne Knee Center
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NONPROFIT
U.S. POSTAGE PAID Indianapolis, IN
1500 N Ritter Ave #500, Indianapolis, IN 46219
PERMIT #PI-1345
TO CONSULT WITH ONE OF OUR SURGEONS, CALL
888-FIX-KNEE | 317-924-8636 Our orthopedic surgeons, K. Donald Shelbourne, MD, founder of Shelbourne Knee Center, and Rodney Benner, MD.
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
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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 TEAM ORTHOPEDIC SURGEONS K. Donald Shelbourne, MD n Rodney Benner, MD n
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 RESEARCH TEAM n Scot Bauman, PT, DPT n Adam Norris n Heather Garrison n Diane Davidson, BS, MBA, CCRC
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