SPRING 2021
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.
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.
3
ffective Treatment E for Degenerative Meniscus Tears
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RECONSTRUCTING ACLs
WITHOUT DISRUPTING GROWTH WITH MORE KIDS playing competitive sports earlier and yearround, anterior cruciate ligament (ACL) tears in skeletally immature adolescents are on the rise. “Kids are exposed to the potential for injury at a much higher level than ever before,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. Concerns about disrupting growth make performing ACL reconstruction in patients with open growth plates controversial. Yet, Shelbourne Knee Center has been successfully reconstructing ACLs in skeletally immature adolescents for more than 25 years—without growth plate disruption.
Bedrest After TKA Improves Recovery
6
reating T Patellofemoral Dislocation
131 Cases, No Growth Disruption The latest Shelbourne Knee Center study involved 131 adolescents at Tanner Stage 3 or 4 who underwent primary ACL reconstruction using a contralateral patellar tendon graft (PTG) at the center between 1995 and 2015.1 The average patient age was 14.1 years (58 females and 73 males). “Our results showed that if surgery and rehabilitation are done properly, ACL reconstruction in these patients allows for return of stability, range of motion, strength and ability to return to activity,” says Bill Claussen, MPT, who conducted the study with Dr. Shelbourne. Claussen CONTINUED ON NEXT PAGE
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are Knee R Injury Research Program
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RECONSTRUCTING ACLs
WITHOUT DISRUPTING GROWTH is one of nine physical therapists and athletic trainers at Shelbourne Knee Center and the rehabilitation department coordinator. While this study only collected data at two and five years, previous studies, including one published in Sports Health, have shown that young athletes return to full sport in an average of 5.3 months.2
A Consistent Process Dr. Shelbourne performs the same ACL reconstruction procedure, honed over 38 years and 7,000+ ACL reconstruction surgeries, in all patients. In skeletallyimmature patients, he meticulously places the bone plugs proximal to the physes and ensures that the graft is not over-tensioned. “PTGs are best for young athletes,” he says. “Hamstring tendons aren’t as strong and don’t heal as well as PTGs do. That’s an even bigger problem in adolescents with open growth plates who have many years of competition ahead of them.” In addition, the same accelerated ACL post-op rehab protocol, which focuses on restoring full and equal range of motion (ROM) and then strength, is used in all patients. “Surgery restores stability and our
LEVEL 8 ACTIVITY AT 2 YEARS
rehab program restores ROM and strength,” says Claussen.
Favorable Study Results Researchers recorded results and subsequent graft-tear rates through five years postoperatively.1 Methods were: n The International Knee Documentation Committee (IKDC) standards to assess ROM n KT1000 manual maximum difference between the knees to record stability n Isokinetic test at 60°/second to evaluate quadriceps muscle strength n The Cincinnati Knee Rating Scale (CKRS) and IKDC subjective survey to evaluate subjective results. The mean preoperative stability was 4.4 mm, improving to 1.5 mm and 1.8 mm at two and five years, respectively, postoperatively. All patients achieved normal knee extension and 95% achieved normal flexion at five years postoperatively. By two years postoperatively, all patients had achieved full strength. Mean IKDC and CKRS scores improved and 95% of patients had
NORMAL KNEE ROM
MEAN STRENGTH
INVOLVED VS. NONINVOLVED KNEE EXTENSION 125
97%
2 years postoperatively
100
100%
5 years postoperatively
30
40
50
60
70
80
90
100
PERCENT
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PERCENT
20
70 65 60
5 years postoperatively
95%
2 years postoperatively
80
92%
5 years postoperatively
10
103%
85
75
0
101%
90
FLEXION 2 years postoperatively
NO: 5%
YES: 95%
MEAN IKDC AND CKRS SCORES Mean IKDC scores
Mean total CKRS scores
Preoperatively
59
71.2
2 years postoperatively
92.9
94.4
5 years postoperatively
89.4
93.5
returned to at least Level 8 activity (participating in jumping, pivoting and twisting sports at the recreational level) by the two-year follow-up. The ACL graft-tear rate was 6.9% with a mean time to re-tear of 22 months postoperatively.
Continued Follow-Up Claussen presented the study at the American Physical Therapy Association’s virtual Combined Sections Meeting in February 2021. Shelbourne Knee Center will continue to follow these patients for up to 30 years postoperatively. “Our experience in ACL reconstruction in skeletally-immature adolescents enables us to safely and effectively treat these patients,” says Dr. Shelbourne. REFERENCES 1. Claussen W, Shelbourne KD. Results following ACL reconstruction with contralateral patellar tendon graft in patients with open growth plates, 2020. Unpublished data. 2. Shelbourne KD, Sullivan AN, Bohard K, et al. Return to Basketball and Soccer After Anterior Cruciate Ligament Reconstruction in Competitive School-Aged Athletes. Sports Health. 2009 May; 1(3): 236–241.
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EFFECTIVE TREATMENT FOR DEGENERATIVE MENISCUS TEARS DEGENERATIVE MENISCUS TEARS are the most common reason for knee arthroscopy, yet whether these tears benefit from surgery is controversial, according to an evidence-based, expert consensus statement on the treatment of degenerative meniscus tear published in Arthroscopy: The Journal of Arthroscopic & Related Surgery (February 2020).1 K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center, was one of 20 international experts who provided input on the consensus statement. Many degenerative meniscus tears are asymptomatic and are only diagnosed during evaluation for another knee problem. Whether symptomatic or asymptomatic, initial—and usually the only— treatment for degenerative meniscus tears at Shelbourne Knee Center is conservative, as the consensus statement recommends. “Up to 75% of knee arthroscopies are performed because the patient is over 40 and the X-ray isn’t bad enough for total knee arthroplasty,” says Dr. Shelbourne. “These procedures are unnecessary. These patients just need proper therapy.”
Conservative Treatment Works Most patients with symptomatic degenerative meniscus tears obtain relief without surgery. Physical therapy is the mainstay of treatment at Shelbourne Knee Center. Other initial treatments include activity modification and rest, medications and steroid injections. The order of treatments depends on
the severity of the symptoms and the patient’s preferences. “We engage in shared decision-making to figure out what will work best,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center.
Surgery as the Last Resort Surgery is the last resort for a degenerative meniscus tear. “Because we deal with knee problems all the time, we’re uniquely positioned to tease out factors that make it more or less likely that surgery will be effective,” says Dr. Benner. For example, if an injection helps temporarily but the pain recurs, this is a good indication that surgery is likely to be effective. If meniscal repair does become necessary, preoperative physical therapy helps ensure a better outcome and a faster recovery. Shelbourne Knee Center research shows that restricting weightbearing for six weeks after surgery isn’t necessary.3 Restoring full range of motion and allowing weight bearing helps patients recover faster. Postoperative physical therapy is designed to: n Control swelling n Restore knee extension and flexion n Improve knee strength. “We focus on the optimal treatment for each individual. If surgery is the best option, our research-backed process ensures the best outcome,” says Dr. Shelbourne. REFERENCES 1. Hohmann E, Angelo R, Arciero R, Bach B, et al. Degenerative Meniscus Lesions: an expert consensus statement using the modified
Healing with Physical Therapy Research data from Shelbourne Knee Center show that about 80% of all meniscus tears will become asymptomatic with appropriate physical therapy.2 Medications or a steroid injection can be given to relieve pain enough for the patient to participate in physical therapy. Shelbourne Knee Center’s physical therapy protocol for meniscus tears focuses on: • Preventing or eliminating swelling • Regaining full range of motion • Strengthening the leg • Restoring normal walking. With the guidance of one of the center’s nine physical therapists and athletic trainers, patients complete most exercises at home. They come into the office for a few visits.
Delphi technique. Arthroscopy. 2020 Feb;36(2):501-512. 2. Shelbourne Knee Center research data. Accessed 11/5/20. 3. Shelbourne KD, Patel DV, Adsit WS, Porter DA. Rehabilitation after meniscal repair. Clin Sports Med. 1996 Jul;15(3):595-612. Accessed 6/2/20.
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BEDREST
AFTER TKA IMPROVES RECOVERY DELAYED AMBULATION after total knee arthroplasty (TKA) decreases pain and swelling and facilitates recovery without increasing complications, according to a Shelbourne Knee Center study.1 “One of the most important aspects of patient recovery postTKA is being able to tolerate physical therapy,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. “Our study showed that bedrest during days 1 through 7 post-op, when done the right way, facilitates improved range of motion and leg control without increasing common complications.”
Results Support Bedrest The study, conducted by Sarah Eaton, PT, DPT, ATC, LAT, and Dr. Benner, involved 641 TKAs performed by Dr. Benner in 463 patients between 2012 and 2018: 1
285 unilateral TKAs 95 bilateral TKAs (190 knees) n 83 staged bilateral TKAs (166 knees). Eaton and Dr. Benner identified 22 complications in 20 patients (3.4%): 1 n Deep vein thrombosis (DVT): 2 (0.3%) n Joint infections: 4 (0.6%) n Manipulations under anesthesia (MUA) for flexion loss: 5 (0.8%) n Scar resections for extension loss: 2 (0.3%) n Heart/lung related problems: 6 (0.9%) n Hospital readmission for pain: 1 (0.2%) n Medial femoral condylar fracture: 1 (0.2%) n Patellar dislocation: 1 (0.2%). Shelbourne Knee Center’s rates of DVT, infection and MUA were lower than or similar to those seen in the current literature.1
DVT RATE
n n
INFECTION RATE
0.6
“We assumed that our complication rate was as low or lower than average,” says Eaton. “Now when patients and caregivers ask us about the rate of specific complications, we can use these data to answer their questions.” Eaton is one of nine physical therapists and athletic trainers at Shelbourne Knee Center.
Better ROM and Less Stiffness The range of motion (ROM) loss of <1% for Shelbourne Knee Center patients is lower than the rate seen in the current literature. A systematic review by Zachwieja et al. reported a 1.3–5.8% prevalence rate of stiffness after TKA.7 Average ROM for Shelbourne Knee Center patients was: n One-week postoperatively: 0-2-104 degrees n Two-weeks postoperatively:
MUA FOR FLEXION LOSS
0.7
5
0.7% 0.52%
0.5
0 Literature 2,3,4
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1.5 PERCENT
0.1
2
0.2 PERCENT
PERCENT
0.3
0.22%
Shelbourne Knee Center
3
0.44%
2.5
0.3%
0.2
4.3%
3.5
0.4 0.3
4
0.6% 0.5
0.4
4.9%
4.5
0.6
0.1 0 Shelbourne Knee Center
Teo et al.5
Anis et al.6
1 0.5
0.8%
0 Shelbourne Knee Center
Werner et al. 8
Issa et al.9
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0-1-112 degrees One-month postoperatively: 0-0-117 degrees. “Our study showed that putting TKA patients on bedrest for the first seven days postoperatively improved recovery of ROM,” says Dr. Benner. n
Sharing Research Results Eaton presented a poster about the study at the Indiana American Physical Therapy Association virtual conference in September 2020. She also did a poster presentation at the American Physical Therapy Association’s virtual Combined Sections Meeting in February 2021. REFERENCES 1. Eaton S and Benner R. Effects of 1-week bedrest on complication rate and range of motion following total knee arthroplasty. Presented at the Indiana American Physical Therapy Association virtual conference, September 2020. 2. Lee SY, Ro DH, Chung CY, Lee KM, Kwon SS, Sung KH, Park MS. Incidence of deep vein thrombosis after major lower limb orthopedic surgery: analysis of a nationwide claim registry. Yonsei Med J. 2015 Jan;56(1):139-145. 3. Dua A, Desai SS, Lee CJ, Heller JA. National trends in deep vein thrombosis following total knee and total hip replacement in the United States. Ann Vasc Surg. 2017 Jan;38:310-314. 4. Dai WL, Lin ZM, Shi ZJ, Wang J. Venous thromboembolic events after total knee arthroplasty: which patients are at a high risk? J Knee Surg. 2020 Oct;33(10): 947-957. 5. Teo BJX, Yeo W, Chong HC, Tan AHC. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong). 2018 May-Aug;26(2): 2309499018785647. 6. Anis HK, Mahmood BM, Kilka AK, Mont MA, Barsoum WK, Molloy RM, Hiquera CA. Hospital volume and postoperative infections in total knee arthroplasty. J Arthroplasty. 2020 Apr; 35(4):1079-1083. 7. Zachwieja E, Perez J, Hardaker WM, Levine B, Sheth N. Manipulation under anesthesia and stiffness after total knee arthroplasty. JBJS Rev. 2018 Apr;6(4):e2. 8. Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated
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 Claussen, Laura Bray-Prescott, Sarah Eaton and Jennifer Christy. Not pictured: Darla Baker, Alana Gillenwater and Emma Sterrett.
Rehab Begins During Bedrest The TKA postoperative rehabilitation protocol is based on research on Shelbourne Knee Center’s ACL patients, which showed the importance of improving ROM before strengthening.10 TKA patients begin rehabilitation during the seven-day bedrest period, with the goals of decreasing swelling, increasing ROM, promoting normal leg control and promoting normal gait with an assistive device. Patients wear TED hose and use a Knee Cryo/Cuff and a continuous passive motion (CPM) machine with the knee elevated. The Knee Cryo/Cuff provides compression and cold therapy to help control swelling. K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center, developed the device in collaboration with Aircast. To minimize swelling, patients only walk to the bathroom. Three times daily, they perform physical therapy exercises to maximize ROM and maintain proper quadriceps/leg control. A personal physical therapist or athletic trainer guides each patient through rehab. “Specializing in knees enables us to provide expert and consistent care,” says Sarah Eaton, PT, DPT, ATC, LAT.
with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015 Sep; 30(9)(Suppl): 72-5. 9. Issa K, Rifai A, Boylan MR, Pourtaheri S, McInerney VK, Mont MA. Do various factors affect the frequency of manipulation under anesthesia after
primary total knee arthroplasty? Clin Orthop Relat Res. 2015 Jan;473(1): 143-47. 10. Biggs A, Jenkins WL, Urch SE, Shelbourne KD. Rehabilitation for patients following ACL reconstruction: a knee symmetry model. North Am J Sports Phys Ther. 2009 Feb;4(1):2-12.
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PATELLAR DISLOCATION
Quadriceps tendon
Lateral collateral ligament
Medial collateral ligament
Patellar ligament
NORMAL POSITION OF PATELLA
PATELLA DISPLACED
TREATING PATELLOFEMORAL DISLOCATION PATELLOFEMORAL DISLOCATION accounts for fewer than 3% of knee injuries seen by most orthopedic surgeons. Evaluating patellofemoral dislocation and determining whether surgical or non-surgical management is the best treatment for a particular patient is difficult due to anatomical complexity and challenges in determining the cause of the instability.
A Nuanced Plan “These patients require a nuanced evaluation and treatment plan that’s developed by knee specialists who
NEWS
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see a high volume of patellofemoral dislocation,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. Dr. Benner and K. Donald Shelbourne, MD, also an orthopedic surgeon at Shelbourne Knee Center, have performed surgery on more than 700 patients with patellofemoral dislocation. In patients with instability due to an anatomic predisposition, dislocation often occurs in both knees and can be caused by mild trauma, daily activities or major trauma. Other patients experience patellofemoral dislocation after a
traumatic injury in an otherwise normal knee. The best treatment depends upon the cause of the instability.
Research-Based Algorithm Shelbourne Knee Center’s algorithm for managing patellofemoral dislocation starts with determining whether there are any predisposing factors associated with the patellar dislocation and physical and radiographic evaluation of both knees. Using a plain radiograph-based classification system developed at Shelbourne
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Knee Center,1 Dr. Benner and Dr. Shelbourne classify the patellofemoral dislocation according to symmetry between the knees and evidence of predisposing anatomy. The radiographs are the bilateral Merchant view and 60-degree lateral view of both knees.
Surgical Versus Non-Surgical Treatment The classification and the impact of instability on the patient’s life help Dr. Benner and Dr. Shelbourne determine the best treatment. For patients with first-time dislocations, Shelbourne Knee Center’s researchbased rehabilitation program is usually the initial treatment. “Soft tissues will heal on their own,” says Dr. Benner. “We help the patient reduce swelling and then regain range of motion through our rehabilitation program. Once the patient can straighten the knee, he/she transitions to low-impact exercise and strengthening to return strength to normal.” Surgery is usually indicated to prevent further dislocation for patients with: n Predisposing anatomical factors for patellar dislocation n First-time patellofemoral dislocation with asymmetry and a malaligned patella n Multiple patellofemoral dislocations. If surgery is indicated, the patient’s classification is used to determine the best procedure. Surgical patients complete preoperative physical therapy to prepare for surgery and postoperative physical therapy to control swelling, regain range of motion and regain leg strength and function. REFERENCES 1. Benner RW, Shelbourne KD, Bailey JM. A novel radiograph system for classifying patellofemoral instability based on symmetry and predisposing anatomy. Unpublished abstract. Shelbourne Knee Center, 2020. 2. Shelbourne KD, Urch SE, Gray T. Results of medial retinacular imbrication in patients with unilateral patellar dislocation. J Knee Surg. 2012 Nov;25(5):391–6.
Patellofemoral Dislocation Classification System In developing the patellofemoral dislocation classification system, Shelbourne Knee Center classified 290 patients who were treated operatively for patellofemoral instability/dislocation between February 2003 and May 2019 based on their preoperative radiographs.1 Researchers evaluated the Merchant view radiograph for symmetry between the knees for placement of the patella in the trochlear groove. They considered evidence of linear displacement, lateral tilt and patella-alta in determining predisposing anatomy. Researchers divided patients into one of four classifications.
FOUR TYPES OF PATELLOFEMORAL DISLOCATION Type I:
Type II:
Type III:
Type IV:
Symmetrical radiographs and no predisposing anatomy
Asymmetrical lateral tilt/displacement on the involved knee compared to the uninvolved knee, with no predisposing anatomy
Symmetrical radiographs, but evidence of predisposing anatomy
Combined asymmetry and evidence of predisposing anatomy
Postoperatively, researchers compared preoperative and postoperative radiographs to determine if surgery successfully corrected for the identified asymmetry and/or predisposing anatomy. They measured interrater reliability between the operating surgeon and a research associate with a blinded sample group of 51 patellofemoral instability patients and intrarater reliability with a blinded sample group of 50 patients treated for patellofemoral instability who were age/sex matched to patients without patellofemoral instability.
RESULTS
Intrarater reliability was 96% (n=100) and interrater reliability was 98% (n=51). Patients were classified as: • Type I: 12% (n=35) • Type II: 33% (n=95) • Type III: 8% (n=22) • Type IV: 48% (n=138). Comparing preoperative and postoperative radiographs, 99% of patients’ surgery corrected for the intended asymmetry and/or predisposing anatomy. Researchers concluded that this novel classification system may help facilitate communication between providers, guide further research into surgical options and assist surgeons in treatment decision-making.
PROCEDURES PERFORMED BY TYPE OF PATELLOFEMORAL DISLOCATION
Type 1
Medial Imbrication/ Lateral Release
Trillat
Trillat and Distalization
Distalization
32
2
1
0
Type II
82
12
1
0
Type III
9
2
5
6
Type IV
39
63
29
7
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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 n
K. Donald Shelbourne, MD
n
Rodney Benner, MD
CLINICAL TEAM
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: n Arthrofibrosis n Chronic patella tendonosis n Failed ACL surgery n Knee dislocations n Patellar tendon rupture n Patellar femoral instability n 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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n
Jean Fouts, RN, BSN
n
Lee Linenberg
n
Sara Hopkins, NP
PHYSICAL THERAPISTS AND ATHLETIC TRAINERS n
Bill Claussen, MPT
n
Emma Sterrett, LAT, ATC
n
Laura Bray-Prescott, PT/LATC
n
Scot Bauman, PT, DPT
n
Darla Baker, PT, DPT ATC/L
n
n
Sarah Eaton, PT, DPT, ATC, LAT Jennifer Christy, PT
n
Rachel Slaven, PT, DPT
n
Alana Gillenwater, PT, DPT
RESEARCH TEAM n
Adam Norris
n
Tinker Gray, MA, ELS
n
Heather Garrison
n
Diane Davidson
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