Noyes FR, Barber-Westin SD: Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy 28: 123-130, 2012.
Purpose: To define the incidence of meniscectomy, meniscus repair, and meniscus tears left in situ during anterior cruciate ligament (ACL) reconstruction.
Methods: A systematic search of PubMed and 7 sportsmedicine journal databases was performed to determine the treatment of meniscus tears during ACL reconstruction. Inclusionary criteria were English language, published last 10 years, clinical trials, all evidence levels, and skeletally mature or immature. Exclusionary criteria were revision ACL reconstruction, concomitant ligament reconstruction, and studies with exclusionary or inclusionary criteria regarding meniscus surgery during ACL reconstruction.
Results: Of 634 articles identified, 159 met the inclusionary criteria encompassing 19,531 patients. There were 11,711 meniscus tears that were treated by meniscectomy in 65% (7,621 tears), repair in 26% (3,022 tears), or left in situ in 9% (1,068 tears). Only 19 studies analyzed the treatment of meniscus tears according to the tibiofemoral compartment. These reported medial compartment tears were treated by meniscectomy in 63%, repair in 27%, and left in situ in 9%. Lateral compartment tears were treated by meniscectomy in 71%, repair in 14%, and left in situ in 14%. Only 24 studies identified the type of meniscus repair procedure performed. Thirty-three studies (21%) performed repair more frequently than meniscectomy.
Conclusions: Meniscectomy is performed 2-3 times more frequently than meniscus repair during ACL reconstruction. We were unable to analyze the effect of the location and type of meniscus tear, gender, age, or chronicity of injury on the treatment of meniscus tears. The number of potentially repairable meniscus tears that were treated by resection could not be identified.
Clinical Relevance: This study found that meniscectomy was performed in 65% of meniscus tears. This is concerning as studies have shown that, regardless of knee stability obtained following ACL reconstruction, meniscectomy accelerates degenerative joint changes.
Noyes FR, Barber-Westin SD: Management of meniscus tears that extend into the avascular region. Clin Sports Med. 31: 65-90, 2012.
The value of the menisci for normal function of the knee joint is well documented. Meniscectomy often results in noteworthy damage to the knee joint, including deterioration of articular cartilage surfaces and subchondral bone sclerosis. Early investigations of meniscus repair that focused on simple longitudinal tears located in the periphery or outer one-third region reported high success rates. More recently, studies have documented satisfactory outcome of repair of complex multiplanar tears that extend into the central third avascular region. We prefer an inside-out technique where multiple vertical divergent sutures are placed every 3-5 mm to repair large unstable meniscus tears which extend into the avascular region. An accessory 3-cm posteromedial or posterolateral exposure and popliteal retractor are used to protect the neurovascular structures. This technique has a higher success rate compared to all-inside suture repairs. The rehabilitation program allows immediate knee motion from 0-90º and partial weight-bearing. No squatting or deep flexion activities are permitted for 4-6 months and running, jumping, and cutting are restricted for 6 months. We have conducted a series of studies to determine the outcome of repair of meniscus tears that extend into the central third avascular region. The encouraging results justify the procedure in correctly indicated patients, especially younger active individuals. We consider meniscus repair as important, if not more important, as an ACL reconstruction in regard to long-term knee function. In the future, tissue engineering may increase the success rates of meniscus repair for tears that extend into the avascular region. Cell-based therapy using either meniscal fibrochondrocytes, articular chondrocytes, or mesenchymal stem cells seeded onto scaffolds offers promise, as does the introduction of growth factors into repair sites.
Noyes FR, Heckmann TP, Barber-Westin SD: Meniscus repair and transplantation: A comprehensive update. J. Orthop. Sports Physical Therapy. Sept 4, 2011. Epub ahead of print.
Preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following repair of meniscus tears for both simple longitudinal tears located in the periphery and complex multi-planar tears that extend into the central third avascular region. This operation is usually indicated in active patients who have tibiofemoral joint line pain and are less than 50 years of age. However, not all meniscus tears are repairable, especially if considerable damage has occurred. In select patients, meniscus transplantation may restore partial load-bearing meniscus function, decrease symptoms, and provide chondroprotective effects. The initial postoperative goal after both meniscus repair and transplantation is to prevent excessive weight bearing, as high compressive and shear forces can disrupt healing meniscus repair sites and transplants. Immediate knee motion and muscle strengthening are begun the day following surgery. Variations are built into the rehabilitation protocol according to the type, location, and size of the meniscus repair; if concomitant procedures are performed; and if articular cartilage damage is present. Meniscus repairs located in the periphery heal rapidly, whereas complex multiplanar repairs tend to heal more slowly and require greater caution. We have reported the efficacy of the rehabilitation programs and the results of meniscus repair and transplantation in many studies.
Noyes FR, Barber-Westin SD: ACL injury prevention training in female athletes. A systematic review of injury reduction and results of athletic performance tests. Sports Health 4: 36-46, 2012.
Context: Many anterior cruciate ligament (ACL) injury prevention training programs have been published, but few have assessed the effects of training on both ACL injury rates and athletic performance tests.
Objective: To determine if ACL injury prevention programs have a positive influence on both injury rates and athletic performance tests in female athletes.
Data sources: In August 2011, a search was conducted (1995-August 2011) of PubMed, Science Direct, and CINAHL databases.
Study selection: Selected studies determined the effect of ACL intervention training programs on ACL incidence rates (determined by athlete-exposures) and athletic performance tests such as isokinetic strength, vertical jump height, speed, agility, and dynamic balance. Because no single article contained both of these criteria, investigations were cross-referenced to obtain data on both of these factors from the same training programs.
Data extraction: The authors reviewed the selected studies for cohort population numbers, age, sports, duration of study, program components, duration of training, number of athlete-exposures, ACL injury incidence rates, and results of athletic performance tests.
Results: Initially, 57 studies were identified that described 42 different ACL injury prevention training programs. Of these, 17 studies that investigated 5 programs met the inclusion criteria. Two programs (Sportsmetrics and the Prevent Injury and Enhance Performance [PEP] program) significantly reduced ACL injury rates and improved athletic performance tests. The Sportsmetrics program produced significant increases in lower extremity and abdominal strength, vertical jump height (VJH), estimated maximal aerobic power, speed, and agility. The PEP program significantly improved isokinetic knee flexion strength, but did not improve VJH, speed, or agility. The other 3 programs (Myklebust, the “11” and Knee Ligament Injury Prevention program) did not improve both ACL injury rates and athletic performance tests.
Conclusions: Only the Sportsmetrics and PEP ACL intervention training programs had a positive influence on injury reduction and athletic performance tests.
Barber-Westin SD, Noyes FR: Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy 27: 1697-1705, 2011.
Purpose: Anterior cruciate ligament (ACL) reconstruction is commonly performed in athletes, with the goal of return to sports activities. Unfortunately, this operation may fail and the rates of either reinjuring an ACL-reconstructed knee or sustaining an ACL rupture to the contralateral knee range from 3-49%. One problem that exists is a lack of information and consensus regarding the appropriate criteria for releasing patients to unrestricted sports activities postoperatively. The purpose of this study was to determine the published criteria used to allow athletes to return to unrestricted sports activities following ACL reconstruction.
Methods: A systematic search was performed toidentify the factors investigators used to determine when return to athletics was allowed after primary ACL reconstruction. Inclusionary criteria were English language, published in the last 10 years, clinical trial, all adult, primary ACL reconstruction, original research investigation, and minimum 12 months follow-up.
Results: Of 716 studies identified, 264 met the inclusionary criteria. Of these, 105 (40%) failed to provide any criteria for return to sports following ACL reconstruction. In 84 studies (32%), the amount of time postoperative was the only criteria provided. In 40 (15%) studies, the amount of time along with subjective criteria were given. Only 35 studies (13%) noted objective criteria required for return to athletics. These criteria included muscle strength or thigh circumference (28 studies), general knee examination (15 studies), single-leg hop tests (10 studies), Lachman rating (1 study), and validated questionnaires (1 study).
Conclusions: The results of this systematic review show noteworthy problems and a lack of objective assessment prior to release to unrestricted sports activities. General recommendations are made for quantification of muscle strength, stability, neuromuscular control, and function in patients who desire to return to athletics after ACL reconstruction, realizing the need for continued research in this area.
Barber-Westin SD, Noyes FR: Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Physician Sports Medicine 39: 100-110, 2011.
Objective: To review anterior cruciate ligament (ACL) clinical studies to determine the objective functional criteria used to determine when return to athletics is allowed postoperatively. Secondly, to determine the rates of reinjury to either knee in studies included in this review. Methods: A literature search was conducted with inclusionary criteria of English language, published last 10 years, skeletally mature, primary ACL reconstruction, original research investigation, and minimum 24 months follow-up. Exclusionary criteria were revision ACL reconstructions or dislocated knees; studies that excluded patients with ACL graft failure or reinjuries; and major concomitant procedures. Twenty-one studies met the study criteria. Results: Three objective criteria were used to allow release to sports activities. The most common was lower extremity muscle strength, followed by lower limb symmetry, and knee examination parameters of range of knee motion and effusion. Twelve studies listed 1 criterion for release to sports; 8 studies listed 2 criteria; and 1 study recommended 3 criteria. Failure rates of the ACL reconstructions ranged from 0-3% in 7 studies, from 4-6% in 6 studies, from 7-10% in 4 studies, and from 14-24% in 4 studies. There were no injuries in the contralateral ACL in 14 studies (67%) and in 7 studies, the rates ranged from 2-15%. Conclusions: Our review demonstrates that few objective functional criteria are typically used to determine when patients return to unrestricted activities. Recommendations are made that are clinically feasible for measurement of muscle strength, lower limb symmetry, lower limb neuromuscular control, and ligament function in patients who desire to return to athletics after ACL reconstruction. Future studies are required to determine if the demonstration of normal lower limb function before return to sports is effective in reducing reinjury rates.
Noyes FR, Barber-Westin SD, Smith ST, Campbell T, Garrison TT: A training program to improve neuromuscular and performance indices in female high school basketball players. J Strength Conditioning Research, Jan. 31, 2012. Epub ahead of print.
The purpose of this study was to determine if a sports-specific training program could improve neuromuscular and performance indices in female high school basketball players. We combined components from a published anterior cruciate ligament injury prevention program for jump and strength training with other exercises and drills to improve speed, agility, overall strength, and aerobic conditioning. We hypothesized that this sports-specific training program would lead to significant improvements in neuromuscular and performance indices in high school female basketball players. Fifty-seven female athletes aged 14-17 years participated in the supervised 6-week program, 3 d-wk-1 for approximately 90-120 minutes per session. The program was conducted on the basketball court and weight room facilities in high schools. The athletes underwent a video drop-jump test, multistage fitness test, vertical jump test, and an 18-m sprint test before and upon completion of the training program. All subjects attended at least 14 training sessions. After training, a significant increase was found in the mean estimated VO2max (p < 0.001), with 89% of the athletes improving this score. In the drop-jump video test, significant increases were found in the mean absolute knee separation distance (p < 0.0001) and in the mean normalized knee separation distance (p < 0.0001), indicating a more neutral lower limb alignment on landing. A significant improvement was found in the vertical jump test (p < 0.0001); however, the effect size was small (0.09). No improvement was noted in the sprint test. This program significantly improved lower limb alignment on a drop-jump test and estimated maximal aerobic power and may be implemented pre-season or off-season in high school female basketball players.
Noyes FR, Chen RC, Barber-Westin SD, Potter HG: Greater Than 10-Year Results of Red-White Longitudinal Meniscus Repairs in Patients 20 Years of Age or Younger. Am J Sports Medicine 39: 1008-1017, 2011.
Abstract:
Background: A prospective longitudinal investigation was conducted to determine the long-term outcome of single longitudinal meniscus repairs extending into the central avascular region in patients aged 20 or younger.
Hypothesis/Purpose: The purpose was to determine the long-term success rate and reoperation rate of meniscus repairs extending into the avascular zone.
Study Design: Case series
Methods: Thirty-three meniscus repairs were performed using an inside-out multiple vertical divergent suture technique. A concomitant anterior cruciate ligament reconstruction was done in 18 patients. The mean follow-up was 16.8 years (range, 10.1 to 21.9 years). The long-term success rate was determined in 29 repairs (88%) by the presence of normal or nearly normal parameters from two validated knee rating systems, assessment of magnetic resonance imaging and weight bearing posteroanterior radiographs by independent physicians, and follow-up arthroscopy when required. A 3 Tesla magnetic resonance imaging scanner with cartilage-sensitive pulse sequences was used and T2 mapping was performed. A comparison was made between the short-term (mean, 4 years) and long-term outcomes.
Results: Eighteen (62%) of the meniscus repairs had normal or nearly normal characteristics in all of the parameters assessed. Six repairs (21%) required partial arthroscopic resection, 2 had loss of joint space on radiographs, and 3 that were asymptomatic failed according to magnetic resonance imaging criteria, for a total of 11 documented failures (38%).There was no significant difference in the mean articular cartilage T2 scores in the healed menisci between the involved and contralateral tibiofemoral compartments in the same knee. There were no significant differences between short and long-term evaluations for pain, swelling, jumping, patient knee condition rating, or the overall Cincinnati rating score.
Conclusions: A chondroprotective joint effect was demonstrated in the healed menisci repairs which, in our opinion, warrants the procedure in select patients. The long-term evaluation of the ACL-reconstructed knees with concurrent successful meniscus repairs demonstrated a low rate of radiographic arthritis.
Noyes FR, Barber-Westin SD: Long-Term Assessment of Posterolateral Ligament Femoral-Fibular Reconstruction in Chronic Multi-ligament Unstable Knees. Am J Sports Medicine 39: 497-505, 2011.
Abstract
A prospective longitudinal investigation was conducted to determine the long-term outcome of posterolateral femoral-fibular knee ligament reconstructions in chronic multi-ligament unstable knees.
Hypothesis/Purpose: The purpose of this study was to compare the short-term (mean, 3.5 years) to the long-term (mean, 14 years) results of this operation in regard to restoration of posterolateral knee stability.
Methods: We report on 21 patients who underwent a posterolateral femoral-fibular reconstruction after sustaining multi-ligament ruptures with chronic instability. The results were determined by a comprehensive knee examination, stress radiographs, standing posteroanterior radiographs, knee arthrometer testing, the Cincinnati Knee Rating System, and the International Knee Documentations Committee Rating System.
Results: In the short-term analysis, the posterolateral reconstruction restored normal or nearly normal lateral joint opening and external tibial rotation according to IKDC criteria in 16 of 21 patients (76%), while the other 5 were deemed early failures. Fourteen of these patients were followed 10-19.4 years postoperatively. Retention of normal or nearly normal lateral joint opening and external tibial rotation was found and there were no significant differences between evaluations for symptoms, sports and daily activity functions, overall knee ratings, and knee ligament function. At the long-term follow-up evaluation, 71% had no symptoms with low-impact sports. However, concurrent arthritis affected 14% who had symptoms with sports (but no symptoms with daily activities), and 14% who had symptoms with daily activities.
Conclusions: The long-term success rate of the femoral-fibular procedure in restoring posterolateral stability warrants consideration of this procedure, particularly in acute cases or when operative time is prolonged and a more simplified procedure is indicated.
Noyes FR, Barber-Westin SD, Tutalo Smith S, Campbell T: A Training Program to Improve Neuromuscular Indices in Female High School Volleyball Players. J Strength Conditioning Research 25: 2151-2160, 2011.
Abstract
The purpose of this study was to determine if a sports-specific training program could improve neuromuscular indices in female high school volleyball players. We combined components from a previously published knee ligament injury prevention intervention program for jump and strength training with additional exercises and drills to improve speed, agility, overall strength, and aerobic conditioning. We hypothesized that this sports-specific training program would lead to significant improvements in neuromuscular indices in high school female volleyball players. Thirty-four athletes (age 14.5 years + 1.0) participated in the supervised 6-week program, 3 days a week for approximately 90-120 minutes per session. The program was done on the school’s volleyball court and weight room facilities. The athletes underwent a video drop-jump test, multi-stage fitness test, vertical jump test, and sit-up test before and after training. A significant increase was found in the mean VO2max score (p < 0.001), as 73% of the athletes improved this score. A significant improvement was found in the sit-up test (p = 0.03) and in the vertical jump test (p = 0.05), as 68% of the athletes increased their scores. In the drop-jump video test, significant increases were found in both the mean absolute knee separation distance (p = 0.002) and in the mean normalized knee separation distance (p = 0.04), indicating improved lower limb alignment on landing. No athlete sustained an injury or developed an overuse syndrome during training. This program significantly improved lower limb alignment on a drop-jump test, abdominal strength, estimated maximal aerobic power, and vertical jump height and may be implemented in high school female volleyball programs.
Patients travel great distances to visit Dr. Frank Noyes when they have serious knee injuries, and with good reason. The Indian Hill resident has been named one of the top 25 knee surgeons in the U.S. by Becker’s Hospital Review, a bimonthly publication offering business and legal news relating to hospitals and health systems. Noyes specializes in sports medicine. He received his medical degree from George Washington University, completed his internship and orthopaedic residency at the University of Michigan and started the University of Cincinnati’s sports medicine program after joining the school’s orthopaedic surgery department in 1975. Noyes said he’s devoted much of his medical career to the knees because when he began practicing, there was very little science devoted to the knees. He said knee and ligament problems were much more difficult to treat than they are today. “We didn’t have the basic research or knowledge to deal with that,” Noyes said. Joseph Siebenaler, who traveled from Hawaii to Montgomery to be treated by Noyes, said he went to numerous knee surgeons on various Hawaiian islands who couldn’t help him. He said upon doing research on his issues he found Noyes’s achievements in repairing knee ligaments. Noyes actually invented the surgery Siebenaler needed to recover from his injury, which he’s been dealing with for two years. “Of course, I’m going to go with (Noyes),” he said. Siebenaler said doctors near his home gave his injury a 10 percent chance of recovery. He said after visiting with Noyes for several weeks, his chance of recovery is now 90 percent.
Barber-Westin SD, Hermeto A, Noyes FR: A Six-week Neuromuscular Training Program for Competitive Junior Tennis Players. J Strength Conditioning Research 24: 2372-2382, 2010.
Abstract
This study evaluated the effectiveness of a tennis-specific training program on improving neuromuscular indices in competitive junior players. Tennis is a demanding sport as it requires speed, agility, explosive power, and aerobic conditioning along with the ability to react and anticipate quickly and there are limited studies that evaluate these indices in young players following a multi-week training program. The program designed for this study implemented the essential components of a previously published neuromuscular training program (Sportsmetrics; www.sportsmetrics.net) and also included exercises designed to improve dynamic balance, agility, speed, and strength. Fifteen junior tennis players (10 girls, 5 boys; mean age, 13.0 + 1.5 years) who routinely participated in local tournaments and high school teams participated in the 6-week supervised program. Training was conducted 3 times a week, with sessions lasting 1.5 hours that included a dynamic warm-up, plyometric and jump training, strength training (lower extremity, upper extremity, core), tennis-specific drills, and flexibility. After training, statistically significant improvements and large to moderate effect sizes were found in the single-leg triple crossover hop for both legs (p < .05), the baseline forehand (p = .006) and backhand (p = .0008) tests, the service line (p = .0009) test, the 1-court suicide (p < .0001), the 2-court suicide (p = .02), and the abdominal endurance test (p = .01). Mean improvements between pre-train and post-train test sessions were 15% for the single-leg triple crossover hop, 10-11% for the baseline tests, 18% for the service line test, 21% for the 1-court suicide, 10% for the 2-court suicide, and 76% for the abdominal endurance test. No athlete sustained an injury or developed an overuse syndrome as a result of the training program. The results demonstrate that this program is feasible, low in cost, and appears to be effective in improving the majority of neuromuscular indices tested. We accomplished our goal of developing training and testing procedures that could all be performed on the tennis court.
Noyes FR, Barber-Westin SD: Repair of complex and avascular meniscal tears and meniscal transplantation. J Bone Joint Surg Am 92:1012-1029, 2010.
Summary:
This selected Instructional Course Lecture by the American Academy of Orthopaedic Surgeons reviews Dr. Noyes’ current indications/contraindications, operative techniques, and clinical outcomes of meniscus repair for tears that extend into the avascular region and meniscus transplantation. The article is richly illustrated and contains over 100 references on these topics.
Noyes FR, Barber-Westin SD: Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy 28: 123-130, 2012. Purpose: To define the incidence of meniscectomy, meniscus repair, and meniscus tears left in situ during anterior cruciate ligament (ACL) reconstruction. Methods: A systematic search of PubMed and 7 sportsmedicine journal databases was performed to determine the treatment [...]
Noyes FR, Barber-Westin SD: ACL injury prevention training in female athletes. A systematic review of injury reduction and results of athletic performance tests. Sports Health 4: 36-46, 2012. Context: Many anterior cruciate ligament (ACL) injury prevention training programs have been published, but few have assessed the effects of training on both ACL injury rates and [...]
Barber-Westin SD, Noyes FR: Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy 27: 1697-1705, 2011. Purpose: Anterior cruciate ligament (ACL) reconstruction is commonly performed in athletes, with the goal of return to sports activities. Unfortunately, this operation may fail and the rates of either reinjuring an ACL-reconstructed knee [...]
Noyes FR, Barber-Westin SD, Smith ST, Campbell T, Garrison TT: A training program to improve neuromuscular and performance indices in female high school basketball players. J Strength Conditioning Research, Jan. 31, 2012. Epub ahead of print. The purpose of this study was to determine if a sports-specific training program could improve neuromuscular and performance indices [...]
Noyes FR, Chen RC, Barber-Westin SD, Potter HG: Greater Than 10-Year Results of Red-White Longitudinal Meniscus Repairs in Patients 20 Years of Age or Younger. Am J Sports Medicine 39: 1008-1017, 2011. Abstract: Background: A prospective longitudinal investigation was conducted to determine the long-term outcome of single longitudinal meniscus repairs extending into the central avascular [...]
Noyes FR, Barber-Westin SD: Long-Term Assessment of Posterolateral Ligament Femoral-Fibular Reconstruction in Chronic Multi-ligament Unstable Knees. Am J Sports Medicine 39: 497-505, 2011. Abstract A prospective longitudinal investigation was conducted to determine the long-term outcome of posterolateral femoral-fibular knee ligament reconstructions in chronic multi-ligament unstable knees. Hypothesis/Purpose: The purpose of this study was to compare [...]
Noyes FR, Barber-Westin SD, Tutalo Smith S, Campbell T: A Training Program to Improve Neuromuscular Indices in Female High School Volleyball Players. J Strength Conditioning Research 25: 2151-2160, 2011. Abstract The purpose of this study was to determine if a sports-specific training program could improve neuromuscular indices in female high school volleyball players. We combined [...]
Click Here for Original Story Patients travel great distances to visit Dr. Frank Noyes when they have serious knee injuries, and with good reason. The Indian Hill resident has been named one of the top 25 knee surgeons in the U.S. by Becker’s Hospital Review, a bimonthly publication offering business and legal news relating to [...]
Barber-Westin SD, Hermeto A, Noyes FR: A Six-week Neuromuscular Training Program for Competitive Junior Tennis Players. J Strength Conditioning Research 24: 2372-2382, 2010. Abstract This study evaluated the effectiveness of a tennis-specific training program on improving neuromuscular indices in competitive junior players. Tennis is a demanding sport as it requires speed, agility, explosive power, and [...]
Noyes FR, Barber-Westin SD: Repair of complex and avascular meniscal tears and meniscal transplantation. J Bone Joint Surg Am 92:1012-1029, 2010. Summary: This selected Instructional Course Lecture by the American Academy of Orthopaedic Surgeons reviews Dr. Noyes’ current indications/contraindications, operative techniques, and clinical outcomes of meniscus repair for tears that extend into the avascular region [...]
