FALL 2020
Our orthopedic surgeons, Rodney Benner, MD, and K. Donald Shelbourne, MD, founder of Shelbourne Knee Center.
Getting Patients Back to Activity, Sooner
NEWS KNEE TREATMENT
RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES
AT SHELBOURNE KNEE CENTER, by focusing only on knees we’ve built extensive experience treating ACL tears, meniscus tears and other knee injuries and conditions, both common and rare. Our proven treatments are based on 38+ years of research with 13,000+ patients. This newsletter is just one way we’re working to share with our colleagues what we’ve learned through our research. Our findings also have been published in more than 260 medical journal articles and book chapters.
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Patellar tendon rupture repair with a Dall-Miles cable provides a predictable, successful outcome. The repair works and patients get their complete range of motion back.
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- K. DONALD SHELBOURNE, MD Orthopedic surgeons K. Donald Shelbourne, MD, and Rodney Benner, MD, have performed more than 100 patellar tendon rupture repairs using end-toend suturing of the tendon edges combined with retinacular repair and augmentation with a braided cable (Dall-Miles cable).
Faster Healing and Better Long-Term Outcomes The Shelbourne Knee Center research program enables us to continually improve knee treatments. We track patient outcomes and study factors related to those outcomes, then update treatments based on what we’re learning. The research-based treatment protocols we’ve developed help patients heal faster and with better long-term outcomes. For example: n Our return to sport rate after ACL reconstruction is 85–90% n Our ACL reconstruction patients return to sport in as little as 3 months after surgery, with an average of 4–6 months after surgery n 76% of our patients with knee osteoarthritis didn’t need total knee arthroplasty after completing our specialized physical therapy program. For more information, visit www.fixknee.com.
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CL Tears: Impact of A Surgical Timing on Quadriceps Strength
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INNOVATIVE TREATMENT FOR
PATELLAR TENDON RUPTURE WITHOUT PROPER surgical repair, a patellar tendon rupture is extremely disabling. The rarity of this knee injury, which occurs in less than 0.5% of the population annually, and the variable length of the patellar tendon when the leg is extended or flexed increase the difficulty of repair. “If you don’t repair a patellar tendon rupture so that the tendon can be at the proper length, then the patient either can’t bend the knee or ruptures the repair,” says K. Donald Shelbourne, MD, an orthopedic
Optimizing Outcomes Via 38+ Years of Research
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surgeon at Shelbourne Knee Center.
A Predictable, Successful Surgical Outcome Dr. Shelbourne and orthopedic surgeon Rodney Benner, MD, have performed more than 100 patellar tendon rupture repairs using endto-end suturing of the tendon edges combined with retinacular repair and augmentation with a braided cable (Dall-Miles cable). Developed at Shelbourne Knee Center and backed by research,1,2 this innovative
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INNOVATIVE TREATMENT FOR
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and increase quadriceps control. surgical technique is suitable for Rehabilitation progresses to optimize patellar tendon ruptures due to ROM and strength within the limits primary injury or at the graft harvest of the Dall-Miles cable. About six site after anterior cruciate ligament to eight weeks after surgery, the (ACL) reconstruction. cable is removed and “Patellar tendon rehabilitation continues rupture repair ADVANTAGES OF with the goal of with a Dall-Miles PATELLAR TENDON achieving ROM equal to cable provides RUPTURE REPAIR USING the non-involved leg a predictable, 1 DALL-MILLES CABLE and strengthening the successful • Proper tendon length quadriceps. outcome,” says • Limited immobilization Two Shelbourne Dr. Shelbourne. “The • Permits aggressive Knee Center repair works and postoperative rehabilitation studies confirm the patients get their • Prevents repair ruptures predictable, successful complete range of outcome of patellar motion back.” tendon rupture repair with a Dall-Miles cable. Restoring ROM Since the Dall-Miles cable safely permits immediate range of Outcomes Studies motion (ROM) and strengthening The first study involved 10 patients without stressing the repair site, who underwent patellar tendon immobilization is limited to walking repair between 1995 and 1998 (5 for until the patient achieves quadriceps a primary injury and 5 at the graft control (about two weeks). harvest site after ACL reconstruction).1 Patients at Shelbourne Knee RESULTS: n Center follow an aggressive 1 week postoperatively, postoperative rehabilitation protocol, all patients had full extension n guided by one of the center’s eight Mean quadriceps strength physical therapists. 1 year postoperatively: The immediate postoperative 72%+/-11% of the non-involved leg n protocol includes use of a continuous Patella infera or re-rupture after passive motion machine and exercises surgery: None. to restore ROM, control swelling See the bar chart on this page for
AVERAGE POSTOPERATIVE KNEE FLEXION 1 150 125
133°
100
112°
75 DEGREES
138°
88°
50 25 0
2 weeks
1 month
TIME Average non-involved knee flexion: 141°
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3 months
6 months
average postoperative knee flexion. 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 RESULTS: n All patients had early flexion loss, but 11 of 13 maintained full terminal hyperextension throughout treatment n Mean postoperative side-to-side flexion deficit: • 33° at 1 month • 6° at 3 months • 3° at latest follow-up at a mean of 4.8 years after tendon repair n Flexion at the latest follow-up (International Knee Committee Documentation criteria): • 10 patients: Normal • 3 patients: Nearly normal n Extension at the latest follow-up (International Knee Committee Documentation criteria): • 12 patients: Normal • 1 patient: Nearly normal n Mean isokinetic quadriceps strength compared to the other side: • 68.7% at 3 months after repair • 100.0% at latest follow-up n Mean modified Noyes subjective score: 89.8 ± 9.2 at a mean of 2 years after repair. The rarity of patellar tendon ruptures means that most orthopedic surgeons see this injury once a year or less. “If you’d like to discuss treatment of a patellar tendon rupture, we’d be happy to consult with you,” says Dr. Shelbourne. “If you prefer not to take care of these patients on your own, we’d be happy to see them.” REFERENCES 1. Shelbourne KD, Darmelio MP, Klootwyk TE. Patellar tendon rupture repair with Dall-Miles cable. Am J Knee Surg. 2001;14:17-21. 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. Epub 2012 Jun 15.
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CHRONIC VS. ACUTE ACL TEARS
IMPACT OF SURGICAL TIMING ON QUADRICEPS STRENGTH QUADRICEPS STRENGTH plays a large role in returning patients to pre-injury function after an anterior cruciate ligament (ACL) reconstruction. Yet little was known about the impact of surgical timing on strength. “We wanted to be able to tell patients what to expect in terms of preoperative quadriceps strength and the progression of quadriceps strength postoperatively based on whether they have an acute or chronic ACL tear,” says Rachel Slaven, PT, DPT, a physical therapist at Shelbourne Knee Center. Slaven and another physical therapist, Scot Bauman, PT, DPT, conducted a research study to answer these questions.
Study Methods Slaven and Bauman retrospectively reviewed data on 2,829 Shelbourne Knee Center patients (1,178 females; 1,651 males) who underwent ACL reconstruction using a contralateral patellar tendon graft from 1994 to 2020.1 Patients were separated based on the time from injury to surgery (acute ≤ 4 months and chronic ≥ 6 months). The average time from injury to surgery was 1.7 months for the acute group and 19.3 months for the chronic group. All patients participated in a preoperative rehabilitation protocol
focused on range of motion, gait, leg control and swelling. Postoperatively, patients followed the protocol developed by Shelbourne et al., including full weight bearing, early return of full extension/flexion equal to the opposite side and swelling reduction.2 Data included: n Isokinetic strength testing at 180°/seconds and 60°/seconds for strength: • Preoperatively • Postoperatively at 1, 2, 3, 4, 6, 9 and 12 months n Preoperative strength: • A ratio of involved side compared to uninvolved side n Time to return to preoperative strength: • Days required to achieve strength ≥ 90% of preoperative leg strength.
Chronic Tears: Better Strength “We found that people who had chronic ACL tears actually went into surgery with better preoperative strength and were able to achieve strength faster postoperatively compared to those with acute ACL tears,” says Slaven. Study results show statistically significantly better results for chronic than acute ACL reconstruction patients for:
HOW SURGICAL TIMING AFFECTS STRENGTH
85
PERCENT
REFERENCES 1. Slaven R, Bauman S. The effects of surgical timing on preoperative and postoperative quadriceps muscle strength following an anterior cruciate ligament reconstruction. 2020. Abstract. 2. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18(3):292-299.
TIME TO RETURN TO PREOPERATIVE STRENGTH
85.5%
84.7%
84.1%
79.5%
75 70
n
Chronic ACL Tear Acute ACL Tear
90
80
Preoperative strength ime to return to preoperative T strength n Strength 1 month postoperatively. Thus, consideration of surgical timing of ACL reconstruction as it relates to the return of quadriceps strength is important. Surgical timing does not impact the progression of limb symmetry postoperatively. Slaven, Bauman and the other physical therapists at Shelbourne Knee Center regularly conduct and present their own research studies, and also participate in the center’s overall research program. They submitted this study to the Combined Sections Meeting of the American Physical Therapy Association (APTA), the APTAsponsored Indiana and Kentucky Combined Fall Conference, and the American Association of Orthopedic Surgeons. The planning committees for these meetings will be reviewing the submissions over the next few months. n
74%
75.2%
60 Preoperative Strength at 60°/seconds
128 days
Acute ACL tear at 180°/ seconds
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Preoperative Strength at 180°/seconds
Chronic ACL tear at 180°/ seconds
1 Month Postoperative Strength at 60°/seconds
143 days
120
125
130
135
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Orthopedic surgeons K. Donald Shelbourne, MD, founder of Shelbourne Knee Center (left), and Rodney Benner, MD, discuss a case.
OPTIMIZING OUTCOMES VIA 38+ YEARS OF RESEARCH WHEN ORTHOPEDIC Surgeon K. Donald Shelbourne, MD, began his practice in 1982, the mother of a 15-year-old girl whose anterior cruciate ligament (ACL) he had reconstructed asked him a question he couldn’t answer. “She wanted to know what was going to happen to her daughter’s knee in 20 years. I had no idea,” he says. So Dr. Shelbourne began a research program to find out what would happen down the road. For 38 years now, he’s been collecting data on patient outcomes and factors related to those outcomes, and continually improving treatment for patients at Shelbourne Knee Center based on research results. “What we’re doing gives our patients the best chance
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of having a good outcome, based on our data and research,” says Dr. Shelbourne. The research program covers more than 13,000 patients and focuses mainly on three areas: n ACL reconstruction n Nonoperative treatment of knee osteoarthritis n Knee arthroscopy. “We constantly look at data from our patients to see how we’re doing and challenge ourselves to get even better results,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. As a medical student at Indiana University School of Medicine, Dr. Benner worked in the practice’s research program part-time.
Treatment Innovations for ACL Reconstruction Key improvements in treatment of ACL tears based on research results include: n Preoperative rehabilitation focused on regaining full range of motion (ROM) n Accelerated ACL rehab protocol. Preoperative rehabilitation became part of the ACL reconstruction process after our research revealed the importance of full ROM and returning the knee to a normal state (except for the ACL tear) before surgery in a good outcome.1,4 Early data followed 502 patients who underwent surgery between 1982 and 1994 at a mean of 14.1 years postoperatively. Results
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KEEPING ATHLETES IN PLAY The Shelbourne Knee Center Research Program has helped more ACL reconstruction patients return to sport, faster. Shelbourne Knee Center National average 100
14
90 80
12 months or more
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70 60
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50
50–60%
40
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30
4
20
MONTHS
PERCENT
Using dashboards filled with data on ACL and TKA patients, Dr. Shelbourne, Dr. Benner and the physical therapists can counsel patients about the typical treatment path and recovery after surgery. Filters include demographic information as well as factors that influence recovery. In ACL reconstruction, for example, those factors include graft source, primary or revision surgery, patellar tendon width and intercondylar notch width.
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85–90%
10 0 RETURN TO SPORT1
showed that the loss of 3° to 5° of knee extension adversely affected subjective and objective results after surgery, especially when coupled with meniscectomy and articular cartilage damage.4 The preoperative protocol focuses on restoring knee extension, then flexion, equal to the normal knee and then strengthening for good leg control and everyday function. The accelerated ACL rehabilitation protocol eliminates swelling problems with bedrest and knee elevation above the heart for the first five days.1 The program includes: n Full extension exercises beginning the day of surgery n Hospital stay for 23 hours n Weight-bearing allowed as tolerated for bathroom privileges n Emphasizing ROM exercises for flexion while maintaining full knee extension n Strengthening exercises after full extension and flexion are achieved.
Nonoperative Treatment for Knee OA Based on our ACL research showing the importance of ROM, Shelbourne Knee Center developed
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Data Dashboards
4–6 months
0 TIME TO RETURN TO SPORT2
the Knee Rehabilitation Program for Osteoarthritis (OA). Like ACL preoperative rehabilitation, this starts with knee extension, then flexion, followed by strengthening. Results from 396 patients in the OA rehab study show significant improvements in knee extension, flexion, and Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective scores for pain, symptoms, activities of daily living, sport and quality of life. For 76% of patients, improvements were so great that they avoided TKA.3 Read more about the Knee Rehabilitation Program for OA on page 6.
How We Do Our Research Dr. Shelbourne and Dr. Benner work with Shelbourne Knee Center’s eight physical therapists and athletic trainers to develop and conduct research. The research team also includes: n Research Manager Adam Norris n Research Manager/Medical Writer Tinker Gray, MA, ELS n Two research coordinators, Heather Garrison and Diane Davidson. Shelbourne Knee Center invites all patients to be part of research,
which includes: n Annual email surveys n Objective evaluations (for surgical patients) done during free follow-up visits: • X-rays • Physical examination • Physical testing. The team reviews research results regularly and updates treatments based on results. Also, the team shares results through international, national and regional presentations and by publishing in medical journals. REFERENCES 1. Biggs A, et al. Rehabilitation for patients following ACL reconstruction: A knee symmetry model. North Am J Sports Phys Ther. 2009;4:2-12. 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. Benner RW, Shelbourne KD, Bauman SN, et al. Knee Osteoarthritis: Alternative Range of Motion Treatment. Orthop Clin North Am. 2019 Oct;50(4):425-432. doi: 10.1016/j. ocl.2019.05.001. Epub 2019 Aug 5. 4. Shelbourne KD, Gray T. Minimum 10Year Results After Anterior Cruciate Ligament Reconstruction: How the Loss of Normal Knee Motion Compounds Other Factors Related to the Development of Osteoarthritis After Surgery.” Am J Sports Med. 2009;41(7):1526-1533.
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EFFECTIVE NONOPERATIVE TREATMENT FOR KNEE OA DEMAND FOR TOTAL knee arthroplasty (TKA) is expected to soar and is likely to exceed the supply of joint replacement surgeons in the coming years. Shelbourne Knee Center’s research-backed Knee Rehabilitation Program for Osteoarthritis (OA) is an effective nonsurgical treatment for most patients with knee OA. Led by Rodney Benner, MD, the Knee Rehabilitation
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Program for OA is based on Shelbourne Knee Center’s long-term data on ACL reconstruction patients. These data show the importance of full range of motion (ROM) in good long-term outcomes.1 Unlike other rehab programs based on strengthening, the Knee Rehabilitation Program for OA focuses on ROM, followed by strengthening. “We worked with our physical therapists to determine the functional improvements we could make to improve symptoms before surgery, with the goal of not needing the surgery,” says Dr. Benner. “If the patient does need surgery, going in with the best ROM and strength leads to good outcomes and a faster, easier recovery.”
Rehab Program Empowers Patients Laura Bray-Prescott, PT/LATC, is one of the physical therapists who provided input on the Knee Rehabilitation
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Shelbourne Knee Center’s in-house team of physical therapists and athletic trainers helps conduct research in addition to working with patients. From left: Scot Bauman, Rachel Slaven, Bill Clausen, Laura Bray-Prescott, Sarah Eaton and Jennifer Christy. Not pictured: Darla Baker and Alana Gillenwater.
KNEE REHABILITATION FOR OA: IT WORKS Of patients who participated in the Knee Rehabilitation Program for Osteoarthritis, 76% avoided TKA. Patients who avoided surgery were followed for one year and maintained their improvements through that period.2
24% 76%
Needed TKA
Avoided TKA
pain and facilitate physical therapy. Devices such as the IdealStretch or Elite Seat are also used. Other visits help ensure that patients continue to do the exercises correctly. The frequency of visits depends on the patient’s progress and location. Patients who are doing well and don’t live in Indianapolis might come in every 2–4 weeks. Patients who live closer and aren’t making as much progress might come in once a week. At every visit, the physical therapist spends 45 minutes with the patient.
Post-Rehab Management and Results
Program for OA and works with these patients, who complete most of their therapy at home. The program focuses on improving extension first, followed by flexion. Once the patient has achieved maximum ROM, strengthening begins. During the first visit, Bray-Prescott or another physical therapist teaches the patient how to do the exercises and observes the patient as he/she does them. “We make sure patients have a good understanding of what they’re doing and why they’re doing it, and that they’re doing it correctly,” she says. After the first visit, patients do their exercises at home, 3–5 times a day. “Most of our patients love doing therapy at home,” says Bray-Prescott. “They miss less work, have less travel and feel more in control.” For patients with a long-term stiff knee, a cortisone injection or pain medicines are often used to manage
Patients who follow the rehab protocol correctly usually see improvements in the first month. Those with a longterm stiff knee may need about 2 months to feel better. Shelbourne Knee Center discharges patients from the Knee Rehabilitation Program for OA after 2–4 months, but patients need to continue the daily exercises and strengthening at least 3 times a week. “Based on data from our OA rehab study, this nonoperative treatment is a good alternative for patients with knee OA,” says Dr. Benner. Data in the study cover 396 patients enrolled between January 2013 and October 2017. Three-quarters of the patients improved enough with the Knee Rehabilitation Program for OA to avoid TKA. At one month after program completion, patients had improvements in ROM and Knee Injury and Osteoarthritis Outcome Score (KOOS), and they maintained these improvements through one year after program completion.2 REFERENCES 1. S helbourne DK. Thirty-five Years of ACL Reconstruction, presentation at Andrews University, February 2018. 2. B enner RW, Shelbourne KD, Bauman SN, et al. Knee Osteoarthritis: Alternative Range of Motion Treatment. Orthop Clin North Am. 2019 Oct;50(4):425-432. doi: 10.1016/j.ocl.2019.05.001. Epub 2019 Aug 5.
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NONPROFIT
U.S. POSTAGE PAID Indianapolis, IN
1500 N Ritter Ave #500, Indianapolis, IN 46219
PERMIT #PI-1345
MEET OUR TEAM ORTHOPEDIC SURGEONS • K. Donald Shelbourne, MD • Rodney Benner, MD CLINICAL TEAM • Jean Fouts, RN, BSN • Lee Linenberg • Sara Hopkins, NP
Sharing Our Rare Knee Injury Expertise RARE KNEE INJURIES often have devastating consequences. Yet their low incidence rate makes determining optimal treatment difficult. Because we specialize only in knees, Shelbourne Knee Center sees 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 patella tendonosis • Failed ACL surgery • Knee dislocations • Patellar tendon rupture • Patellar femoral 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 case with one of our orthopedic surgeons, please email skckneecare@ecommunity.com.
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PHYSICAL THERAPISTS AND ATHLETIC TRAINERS • Bill Clausen, MPT • Emma Sterrett, LAT, ATC • Laura Bray-Prescott, PT/LATC • Scot Bauman, PT, DPT • Darla Baker, PT, DPT ATC/L • Sarah Eaton, PT, DPT, ATC, LAT • Jennifer Christy, BS • Rachel Slaven, PT, DPT • Alana Gillenwater, PT, DPT RESEARCH TEAM • Adam Norris • Tinker Gray, MA, ELS • Heather Garrison • Diane Davidson • Kanitha Phalakornkule, Data Scientist
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