WINTER 2022
NEWS
KNEE TREATMENT RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES
ACL RECONSTRUCTION:
RESEARCH-BACKED BEST PRACTICES AN EXCLUSIVE FOCUS on knees and 39+ years of practice-based outcomes research have enabled the doctors at Shelbourne Knee Center to fine-tune their anterior cruciate ligament (ACL) reconstruction and rehabilitation process, comprised of optimized surgical strategies and pre- and postoperative physical therapy regimens. K. Donald Shelbourne, MD, and Rodney Benner, MD, have had their research published in more than 160 medical journals and over 100 book chapters. Dr. Shelbourne has been recognized as one of the most influential authors of clinical articles on ACL reconstruction globally. Compared to all other clinicians and researchers, he has authored the greatest number of top 100 most-cited articles on the topic, per a recent study in The Orthopaedic Journal of Sports Medicine.1 In this article, Shelbourne
Knee Center shares its researchbacked best practices for treating ACL injuries. “ACL reconstruction isn’t just an operation,” says Dr. Shelbourne. “It requires a process to help patients recover range of motion (ROM), strength and function.” The Shelbourne Knee Center ACL reconstruction and rehabilitation process includes: • Preoperative physical therapy focused on regaining full ROM, decreasing swelling, maintaining leg control and normalizing walking patterns • Use of a graft that allows for normal stability, unrestricted rehabilitation and a return to desired activities • Postoperative physical therapy that minimizes complications and allows a full return of ROM, strength and function. This process has reliably enabled
patients to achieve two normal knees and facilitated a return-tosport rate of 85-90%,2 compared to a 50–60% average for most orthopedic practices.3
Full ROM Before Surgery Limited ROM reduces the ability of patients to return to sports and function normally, and increases symptoms, such as pain. A groundbreaking study by Dr. Shelbourne and Tinker Gray, MA, found that even a small loss of knee extension, more than 3° when compared to the opposite normal knee, can have a negative impact on subjective and objective outcomes long term after surgery.4 Preoperative rehabilitation became part of Shelbourne Knee Center’s surgical process after this research also revealed the benefits of full ROM before surgery.2,4 The CONTINUED ON NEXT PAGE
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flexion while maintaining full knee extension • Strengthening exercises on the graft side to regain strength and function.
ACL RECONSTRUCTION:
RESEARCH-BACKED BEST PRACTICES
KEEPING ATHLETES IN PLAY The Shelbourne Knee Center Research Program has helped ACL reconstruction patients return to sport, faster. Shelbourne Knee Center 100 14 National average 90 80
12
85–90%
60
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50
50–60%
40
6
30
4
20
MONTHS
PERCENT
12 months or more
10
70
10 0 RETURN TO SPORT2
PTG: Earlier Return to Sport “The patellar tendon autograft (PTG) is the gold standard for ACL reconstruction,” says Dr. Shelbourne. “Using a contralateral PTG gives patients the best chance of predictably getting back to normal and returning to sport.” A contralateral PTG allows for unrestricted rehabilitation and earlier return to sport when compared to other graft options.5 The center’s physical therapists and athletic trainers, along with the research-backed rehabilitation protocols, have solved the challenge of contralateral PTG rehabilitation by achieving symmetry for ROM and strength.
NEWS
0 TIME TO RETURN TO SPORT5
preoperative protocol focuses on: 1. Restoring knee extension and flexion equal to the opposite knee 2. Decreasing swelling 3. Strengthening to maintain good leg control and function 4. Normalizing walking patterns.
2 KNEE TREATMENT
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4–6 months
REFERENCES 1. Tang N, Zhang W, George DM, Su Y, Huang T. The Top 100 Most Cited Articles on Anterior Cruciate Ligament Reconstruction: A Bibliometric Analysis. Orthop J Sports Med. 2021 Feb 8;9(2). 2. B iggs A, Jenkins WL, Urch SE, Shelbourne KD. Rehabilitation for Patients Following ACL Reconstruction: A Knee Symmetry Model. N Am J Sports Phys Ther. 2009;4(1):2-12. 3. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-1552. 4. S helbourne KD, Gray T. Minimum 10-Year Results After Anterior Cruciate Ligament 5. S helbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med. 2000;28:651-658.
At Shelbourne Knee Center, by one week postoperative, ACL reconstruction patients have normal extension (95% of patients), and by three months, have nearly normal flexion (97% of patients). Also at this three month point, patients show to have symmetric strength between knees and nearly 90% of their preoperative normal strength value. Reaching these values early allows patients to have a successful outcome, including the ability to return to sport before six months. The center’s accelerated postoperative protocol eliminates swelling problems with a relative bedrest period with the knee elevated above the heart for seven days while using a Cryo-Cuff and a continuous passive motion machine.2 The protocol includes: • Full extension exercises beginning the day of surgery • 23-hour hospital stay • Weight bearing as tolerated for bathroom use only • Emphasizing ROM exercises for
WINTER 2022
39 Years of PatientOutcomes Research Over the course of 39 years, the Shelbourne Knee Center Research Program has collected data on patient outcomes and factors related to those outcomes for more than 15,759 patients. Along with ACL reconstruction (7,069 procedures), the research program focuses on nonoperative treatment of knee osteoarthritis and knee arthroscopy. The research process includes annual email surveys and objective evaluations (for surgical patients) during free follow-up visits. Along with Dr. Shelbourne and Dr. Benner, the research team includes the center’s physical therapists and athletic trainers, two research managers and two research coordinators. “We constantly look at our data to see how we’re doing and challenge ourselves to get even better results,” says Dr. Benner.
EXAMINING CAUSES OF REINJURY POST ACL RECONSTRUCTION POSTERIOR TIBIAL SLOPE (PTS) may contribute to reinjury after anterior cruciate ligament (ACL) reconstruction, but the type of graft used has much more impact on the reinjury rate than PTS. The reinjury rate was much lower with a patellar tendon graft (PTG) than with a hamstring graft, according to studies conducted at Shelbourne Knee Center1 and the North Sydney Orthopaedic and Sports Medicine Centre in Australia.2
PTG: More Durable Researchers at Shelbourne Knee Center studied 2,763 primary ACL reconstruction patients treated with contralateral PTG. At a mean follow-up of 11.6 years, they found a slightly higher increase in re-tears with PTS >10° and no increase in the contralateral tear rate. The mean age at surgery was 24.2 + 10.1 years.1 In the Australian study, 181 primary ACL reconstruction patients were treated with a hamstring graft. At 20-year follow-up, researchers found that a PTS >12° was the strongest predictor of graft tear and contralateral ACL injury. Graft survival in adolescents was just 22%. The mean age of patients at surgery was 26 years.2 Both studies used radiographs to measure PTS. “Hamstring grafts don’t work well for young athletes,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. “Using contralateral PTGs, we found a slightly higher increase in re-tears with PTS >10°. It’s not that much of a risk factor.”
Low Overall PTG Reinjury Rates The Shelbourne Knee Center study included primary (n = 2,439) and revision (n = 324) ACL reconstruction patients. Researchers collected data
Benefits of Contralateral PTG Over Hamstring Graft3
on injury to either knee at followup appointments and through annual subjective questionnaires, including the International Knee Documentation Committee Subjective Survey and the Cincinnati Knee Rating Scale survey. Researchers collected more data on patients who had a reinjury and confirmed the injury by physician physical examination or patient report and medical records. Results showed that primary ACL reconstruction patients with PTS >10° had a statistically significantly higher rate of graft tear (9.7%) than patients with PTS <9° (4.8%). There was no increase in the contralateral tear rate. “If the tibial slope is a big problem, the opposite knee should have a higher rate of tear too. It doesn’t,” says Dr. Shelbourne. For patients who had revision surgery, PTS was not a statistically significant predictor of recurrent ACL graft tear. Overall, rates of injury to the graft or contralateral knee for both primary and revision ACL surgeries were low. “Higher PTS and reinjury in competitive athletes is primarily a hamstring graft problem,” says Dr. Shelbourne. “It’s well known now that we shouldn’t use a hamstring graft in this population.”
Osteotomy Isn’t a Solution As surgeons look for ways to decrease reinjury after revision ACL reconstruction, some consider osteotomy. This invasive and risky procedure, however, is unnecessary: The Shelbourne Knee Center study showed that overall reinjury rates are relatively low and a higher PTS was not associated with recurrent ACL graft tear. “We don’t have any data that shows osteotomy decreases graft failure after the second time,” says
•U nrestricted rehabilitation •E arlier return to sports •B est chance for two normal knees
Results of Reinjury with Contralateral PTG1 Primary ACL reconstruction: • PTS >10° 9.7% graft tear rate • PTS <9° 4.8% graft tear rate • Contralateral tear rate no increase Revision ACL reconstruction: No significant association between PTS and subsequent tears
Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. “Osteotomy makes the knees asymmetric, which causes problems. We wouldn’t do it.” REFERENCES 1. Shelbourne KD, Benner RW, Jones JA, Gray T. Posterior Tibial Slope in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft: Analysis of Subsequent ACL Graft Tear or Contralateral ACL Tear. Am J Sports Med. 2021 Mar;49(3):620-625. doi: 10.1177/0363546520982241. Epub 2021 Feb 1. PMID: 33523723. 2. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament-reconstructed patient. Am J Sports Med. 2013 Dec;41(12):2800-4. doi: 10.1177/0363546513503288. Epub 2013 Sep 13. PMID: 24036571. 3. Shelbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med. 2000;28:651-8.
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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, Rodney Benner, MD, and K. Donald Shelbourne, MD, founder of Shelbourne Knee Center.
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 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 n K. Donald Shelbourne, MD n Rodney Benner, MD CLINICAL TEAM n Jean Fouts, RN, BSN n Lee Linenberg n Emily Guy, 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 Sarah Eaton, PT, DPT, ATC, LAT n 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