OBJECTIVE: This study analyzed survival of the amputee patients, wound healing, and ambulation after knee disarticulation (KD).
METHODS: Between July 1989 and October 2015, 153 KDs in 138 patients were performed at Nij Smellinghe Hospital, Drachten. Data were retrieved from hospital medical records. Wound healing was analyzed using nonparametric tests. Ambulation was recorded according to the Special Interest Group Amputation Medicine Workgroup Amputation and Prosthetics mobility scale.
RESULTS: Survival at 1, 6, and 12 months was 86%, 65%, and 55%, respectively. Wounds healed in 91% of patients. Wounds healed primarily in 57% of residual limbs, and healing was delayed in 33%. A transfemoral amputation (TFA) was performed in 10%. Patients with sagittal flaps had significantly poorer primary wound healing and delayed wound healing more often than patients with a dorsal-myocutaneous (dorsomyocutaneous) flap (P < .027). In total, 62% of patients were provided with a prosthesis. Preoperatively, 71% of the patients had intention to ambulate with prosthesis, of which 91% received prosthesis. Of these, 35% walked without the help of others. KD amputee patients who underwent a reamputation at the transfemoral level were significantly less ambulant than amputee patients who did not (P < .021).
CONCLUSIONS: If feasible, the dorsomyocutaneous flap technique seems to be the treatment of choice in KD. Because the wound complication rate of the group with a dorsomyocutaneous flap and the percentage of amputee patients who received prosthesis after KD fell within the same range as TFA amputee patients, KD may be an appropriate alternative when surgeons consider a TFA.
Cardiovascular Diseases (1) Peripheral Arterial Disease (1), more mentions
... a different likelihood of subsequent meniscal surgery in the ACL-reconstructedknee or in the normal contralateral knee and (2) to compare ... risk factors associated with subsequent meniscal surgery in the ACL-reconstructedknee and contralateral knee AbstractText: Cohort study; Level of evidence, 3 ... the relative risk of subsequent meniscal surgery in the ACL-reconstructedknee was higher compared with the contralateral knee.
BACKGROUND: Although knees that have undergone anterior cruciate ligament reconstruction (ACLR) often exhibit normal laxity on clinical examination, abnormal kinematic patterns have been observed when the joint is dynamically loaded during whole body activity. This study investigated whether abnormal knee kinematics arise with loading under isolated dynamic movements.
HYPOTHESIS: Tibiofemoral and patellofemoral kinematics of ACLR knees will be similar to those of the contralateral uninjured control knee during passive flexion-extension, with bilateral differences emerging when an inertial load is applied.
STUDY DESIGN: Controlled laboratory study.
METHODS: The bilateral knees of 18 subjects who had undergone unilateral ACLR within the past 4 years were imaged by use of magnetic resonance imaging (MRI). Their knees were cyclically (0.5 Hz) flexed passively. Subjects then actively flexed and extended their knees against an inertial load that induced stretch-shortening quadriceps contractions, as seen during the load acceptance phase of gait. A dynamic, volumetric, MRI sequence was used to track tibiofemoral and patellofemoral kinematics through 6 degrees of freedom. A repeated-measures analysis of variance was used to compare secondary tibiofemoral and patellofemoral kinematics between ACLR and healthy contralateral knees during the passive and active extension phases of the cyclic motion.
RESULTS: Relative to the passive motion, inertial loading induced significant shifts in anterior and superior tibial translation, internal tibial rotation, and all patellofemoral degrees of freedom. As hypothesized, tibiofemoral and patellofemoral kinematics were bilaterally symmetric during the passive condition. However, inertial loading induced bilateral differences, with the ACLR knees exhibiting a significant shift toward external tibial rotation. A trend toward greater medial and anterior tibial translation was seen in the ACLR knees.
CONCLUSION: This study demonstrates that abnormal knee kinematic patterns in ACLR knees emerge during a simple, active knee flexion-extension task that can be performed in an MRI scanner.
CLINICAL RELEVANCE: It is hypothesized that abnormal knee kinematics may alter cartilage loading patterns and thereby contribute to increased risk for osteoarthritis. Recent advances in quantitative MRI can be used to detect early cartilage degeneration in ACLR knees. This study demonstrates the feasibility of identifying abnormal ACLR kinematics by use of dynamic MRI, supporting the combined use of dynamic and quantitative MRI to investigate the proposed link between knee motion, cartilage contact, and early biomarkers of cartilage degeneration.
Muscular and Skeletal Diseases (1) Osteoarthritis (1), more mentions
BACKGROUND: The optimal graft choice of anterior cruciate ligament (ACL) reconstruction remains controversial.
PURPOSE: To compare the outcomes, especially the long-term cumulative failure rate, of ACL reconstruction using either synthetics with remnant preservation or hamstring autografts (4-strand semitendinosus and gracilis tendons).
STUDY DESIGN: Cohort study; Level of evidence, 2.
METHODS: A total of 133 patients who underwent ACL reconstruction (synthetics: n = 43; hamstring autografts: n = 90) between July 2004 and December 2007 were included. Questionnaires (Tegner activity scale, Lysholm knee scale, and International Knee Documentation Committee [IKDC] subjective form) were completed preoperatively and at 6 months, 1 year, 5 years, and 10 years postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was additionally applied at 10 years' follow-up. The physical examination was based on the 2000 IKDC form. The manual maximum side-to-side difference (KT-1000 arthrometer), single-hop test, thigh muscle atrophy, and joint degeneration (Kellgren and Lawrence classification) were evaluated. The Kaplan-Meier curve and log-rank test (Mantel-Cox, 95% CI) were used to compare graft survivorship.
RESULTS: Ten years postoperatively, 111 patients were available, with 38 (88.4%) patients (mean age, 27.6 ± 9.3 years; 28 men) with synthetics and 73 (81.1%) patients (mean age, 28.6 ± 8.8 years; 64 men) with hamstring autografts. Among them, 104 patients (synthetics: n = 35 [81.4%]; hamstring autografts: n = 69 [76.7%]) completed subjective evaluations, and 89 patients (synthetics: n = 30 [69.8%]; hamstring autografts: n = 59 [65.6%]) completed objective evaluations. For hamstring autografts and synthetics, the cumulative failure rates were 8.2% and 7.9%, respectively, and the log-rank test demonstrated no significant difference between the 2 Kaplan-Meier survival curves ( P = .910). At 6 months postoperatively, for hamstring autografts and synthetics, the mean Lysholm score was 83.0 ± 7.8 and 88.1 ± 7.5, respectively ( P < .001); the mean IKDC score was 83.8 ± 7.8 and 86.9 ± 4.5, respectively ( P = .036); and the mean Tegner score was 3.7 ± 1.1 and 5.0 ± 1.5, respectively ( P < .001). At 1 year postoperatively, the mean Tegner score was 5.5 ± 1.9 and 6.5 ± 2.0, respectively ( P = .011). No statistically significant difference was observed on other subjective evaluation findings, physical examination findings (overall IKDC grade A: 45.8% of hamstring autografts, 50.0% of synthetics), side-to-side difference (1.5 ± 1.5 mm for synthetics, 2.4 ± 2.1 mm for hamstring autografts), single-hop test findings (grade A: 84.7% of hamstring autografts, 93.3% of synthetics), grade A/B thigh muscle atrophy (88.1% of hamstring autografts, 93.3% of synthetics), ipsilateral radiographic osteoarthritis (55.9% of hamstring autografts, 50.0% of synthetics), and graft survivorship.
CONCLUSION: In this prospective cohort study, primary ACL reconstruction using either synthetics with remnant preservation or hamstring autografts showed satisfactory outcomes, especially the long-term cumulative failure rate, at 10 years postoperatively. Patient-reported outcomes suggested that symptom relief and restoration of function might occur earlier in those with synthetics.
Muscular and Skeletal Diseases (2) Osteoarthritis (2), Atrophy (2), more mentions
This study aimed to investigate activation characteristics of the biceps femoris long head (BFlh) and semitendinosus (ST) muscles during the acceleration and maximum-speed phases of sprinting. Lower-extremity kinematics and electromyographic (EMG) activities of the BFlh and ST muscles were examined during the acceleration sprint and maximum-speed sprint in 13 male sprinters during an overground sprinting. Differences in hamstring activation during each divided phases and in the hip and knee joint angles and torques at each time point of the sprinting gait cycle were determined between two sprints. During the early stance of the acceleration sprint, the hip extension torque was significantly greater than during the maximum-speed sprint, and the relative EMG activation of the BFlh muscle was significantly higher than that of the ST muscle. During the late stance and terminal mid-swing of maximum-speed sprint, the knee was more extended and a higher knee flexion moment was observed compared to the acceleration sprint, and the ST muscle showed higher activation than that of the BFlh. These results indicate that the functional demands of the medial and lateral hamstring muscles differ between two different sprint performances.
OBJECTIVE: The purpose of this study was to compare the diagnostic utility of oblique sagittal and oblique coronal 3D volume isotropic turbo spin-echo acquisition (VISTA) images with that of 2D fast spin-echo (FSE) T2-weighted images in the diagnosis of selective bundle tears of the anterior cruciate ligament (ACL).
MATERIALS AND METHODS: This retrospective study included 56 patients who underwent 2D FSE and 3D VISTA 3-T MRI of the knee before arthroscopic procedures. Images obtained with the two sequences were interpreted by two musculoskeletal radiologists independently, and the results were analyzed with the surgical diagnosis as the reference.
RESULTS: Among the 56 patients with suspected ACL injury, the arthroscopic records revealed 14 cases (25%) of complete tear, four cases (7%) of selective posterolateral bundle tear, and three cases (5%) of selective anteromedial bundle tear. The contrast-to-noise ratio between the ACL and joint fluid for 3D VISTA was 1.97 times as high as that for 2D FSE (p < 0.001). The entire width evaluation and margin sharpness scores for 2D FSE were significantly higher than those for 3D VISTA for both readers (p < 0.05). No significant differences were found in sensitivity, specificity, or accuracy of 2D FSE and 3D VISTA in the diagnosis of selective ACL tears (p > 0.05).
CONCLUSION: The diagnostic utility of oblique sagittal and oblique coronal 3D VISTA sequences was similar to that of 2D FSE sequences in the MRI diagnosis of selective bundle tear of the ACL, but the image quality of 3D VISTA was inferior to that of 2D FSE.
OBJECTIVE: This article reviews the normal anatomy of the extensor tendons of the wrist as well as the clinical presentation and MRI appearances of common tendon abnormalities, such as tears, tenosynovitis, intersection syndromes, and associated or predisposing osseous findings. Treatment options are also discussed.
CONCLUSION: We review the anatomy and normal MRI appearance of the clinically important dorsal extensor tendons of the wrist, in addition to the spectrum of abnormalities associated with these tendons.
OBJECTIVE: To systematically review the literature for studies investigating knee osteoarthritis (OA) phenotypes to examine what OA characteristics are relevant for phenotyping.
METHODS: A comprehensive search was performed in Medline, EMBASE, Web of Sciences, CINAHL, and Scopus databases from inception to September 2016. Inclusion was limited to observational studies of individuals with symptomatic knee OA that identified phenotypes based on any OA characteristics and assessed their association with clinically important outcomes. A descriptive synthesis of the data was performed.
RESULTS: Of the 2777 citations retrieved, 34 studies were included. Clinical phenotypes were investigated most frequently, followed by laboratory, imaging and aetiologic phenotypes. Eight studies defined subgroups based on outcome trajectories (pain, function and radiographic progression trajectories). Most studies used a single patient or disease characteristic to identify patients subgroups while five included characteristics from multiple domains. We found evidence from multiple studies suggesting that pain sensitization, psychological distress, radiographic severity, body mass index (BMI), muscle strength, inflammation and comorbidities are associated with clinically distinct phenotypes. Gender, obesity and other metabolic abnormalities, the pattern of cartilage damage, and inflammation may be implicated in delineating distinct structural phenotypes. Only a few studies investigated the external validity of the phenotypes or their prospective validity using longitudinal outcomes.
CONCLUSIONS: There is marked heterogeneity in the data selected by the studies investigating knee OA phenotypes. We identified the phenotypic characteristics that can be considered for a comprehensive phenotype classification in future studies. A framework for the investigation of phenotypes could be useful for future studies.
PROTOCOL REGISTRATION: PROSPERO CRD42016036220.
Muscular and Skeletal Diseases (3), Anti-Obesity and Weight Loss (2) Knee Osteoarthritis (2), Obesity (1), Osteoarthritis (1), more mentions
OBJECTIVES: To examine the effect of knee targeted exercises compared to knee targeted exercises combined with foot targeted exercises and foot orthoses in patients with patellofemoral pain.
DESIGN: Forty adult individuals (28 women, 12 men) diagnosed with patellofemoral pain and screened for excessive calcaneal eversion were randomized to knee targeted exercises or knee targeted exercises combined with foot targeted exercise and orthoses.
METHODS: The knee targeted exercises were prescribed during three supervised consultations. Individuals were instructed to perform the exercises 3 times per week during a 12-week period. The foot targeted exercises were prescribed for 2 times per week for 12 weeks with one session per week being supervised by a physiotherapist. The primary outcome was the subscale "pain" in the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 4 months.
RESULTS: Individuals randomized to knee targeted exercises combined with foot targeted exercises and foot orthoses had 8.9 points (95%CI: 0.4; 17.4) - NNT=3 (2-16) larger improvement in KOOS pain at the primary endpoint.
CONCLUSIONS: The addition of foot targeted exercises and foot orthoses for 12 weeks was more effective than knee targeted exercises alone in individuals with patellofemoral pain. The effect was apparent after 4 months, but not significantly different after 12 months.
Muscular and Skeletal Diseases (1) Osteoarthritis (1), more mentions
In a randomized, double-blinded, placebo controlled trial, we investigated the postoperative analgesic effect of a single intra-articular injection of 40 mg methylprednisolone acetate (MP) administered one week prior to total knee arthroplasty (TKA). Forty-eight patients with high pain osteoarthritis (≥ 5 NRS during walk) and sensitization (pressure pain threshold < 250 kPa), aged 50 to 80 years and scheduled for primary unilateral TKA under spinal anaesthesia were included. The primary outcome was the proportion of patient with moderate/severe pain during a 5 meter walk test 24 hours postoperatively. Secondary outcomes included pain at 48 hours, during the first 14 days, sensitization (quantitative sensory testing with pressure pain threshold and wind up from temporal summation) and inflammatory changes (systemic CRP, intra-articular IL-6). No difference in proportion of patients with moderate/severe pain was found between MP/placebo groups at 24 hours (67% and 74%, χ(2)=0.2, p=0.63, odds ratio 0.7, 95% CI 0.2 to 2.8) or at 48 hours (57% and 68%, χ(2)=0.5, p=0.46, odds ratio 0.6 95% CI 0.2 to 2.3), and no difference between groups in postoperative sensitization was found (p > 0.4) despite reduced preoperative intra-articular inflammation (IL-6) in the MP group vs. placebo (median change in IL6: -70 pg/mL [IQR -466 to 0] vs. +32 pg/ml [IQR -26 to 75], p= 0.029). Alternative central or peripheral analgesic interventions in this high-risk group are required.
Muscular and Skeletal Diseases (3) Osteoarthritis (2), Knee Osteoarthritis (1), more mentions
PURPOSE: Female athletes are at greater risk of non-contact ACL injury. Three-dimensional kinematic analyses have shown that at-risk female athletes have a greater knee valgus angle during drop jumping. The purpose of this study was to evaluate the relationship between knee valgus angle and non-contact ACL injury in young female athletes using coronal-plane two-dimensional (2D) kinematic analyses of single-leg landing.
METHODS: Two hundred ninety-one female high school athletes newly enrolled in basketball and handball clubs were assessed. Dynamic knee valgus was analysed during single-leg drop jumps using 2D coronal images at hallux-ground contact and at maximal knee valgus. All subjects were followed up for 3 years for ACL injury. Twenty-eight (9.6%) of 291 athletes had ACL rupture, including 27 non-contact ACL injuries. The injured group of 27 knees with non-contact ACL injury was compared with a control group of 27 randomly selected uninjured knees. The relationship between initial 2D movement analysis results and subsequent ACL injury was investigated.
RESULTS: Dynamic knee valgus was significantly greater in the injured group compared to the control group at hallux-ground contact (2.1 ± 2.4 vs. 0.4 ± 2.2 cm, P = 0.006) and at maximal knee valgus (8.3 ± 4.3 vs. 5.1 ± 4.1 cm, P = 0.007).
CONCLUSION: The results of this study confirm that dynamic knee valgus is a potential risk factor for non-contact ACL injury in female high school athletes. Fully understanding the risk factors that increase dynamic knee valgus will help in designing more appropriate training and interventional strategies to prevent injuries in at-risk athletes.
LEVEL OF EVIDENCE: Prognostic studies, Level II.
A recent trial demonstrated that patients with knee osteoarthritis treated with a sodium hyaluronate and corticosteroid combination (Cingal) experienced greater pain reductions compared with those treated with sodium hyaluronate alone (Monovisc) or saline up to 3 weeks postinjection. In this study, injections were administered by 1 of 3 approaches; however, there is currently no consensus on which, if any, of these techniques produce a more favorable outcome. To provide additional insight on this topic, the results of the previous trial were reanalyzed to determine whether (1) the effect of Cingal was significant within each injection technique and (2) pain reductions were similar between injection techniques across all treatment groups. Greater pain reductions with Cingal up to 3 weeks were only significant in the anteromedial subgroup. Across all therapies, both the anteromedial and anterolateral techniques demonstrated significantly greater pain reductions than the lateral midpatellar approach at 18 and 26 weeks.
Muscular and Skeletal Diseases (3) Knee Osteoarthritis (2), Osteoarthritis (1), more mentions
BACKGROUND: There are few published studies with very long-term follow-up of combined intra- and extra-articular anterior cruciate ligament (ACL) reconstruction.
PURPOSE: To analyze clinical and radiographic outcomes of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with autologous hamstrings at minimum 20-year follow-up.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: Of 60 originally eligible patients who underwent over-the-top ACL reconstruction with double-stranded hamstring tendon (leaving intact graft tibial insertions) and extra-articular lateral plasty (performed with the remnant part of tendons), 52 were prospectively evaluated at a minimum 20-year follow-up (mean follow-up, 24 years; 41 men, 11 women; mean age at time of surgery, 25.5 ± 7.6 years). Twenty-nine patients were available for prospective evaluations: clinical (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC]), instrumented (KT-2000), and radiographic (standard, long-standing, and Merchant views). Subjective KOOS (Knee injury and Osteoarthritis Outcome Score) and objective inertial sensor pivot-shift analysis (KiRA) were carried out at final follow-up. Twenty-three patients were investigated by phone interview for subjective Tegner score and documented complications, rerupture, or revision surgery.
RESULTS: At final follow-up, mean Lysholm score was 85.7 ± 14.6; median Tegner score, 4 (range, 3-5); sport activity resumption, 86.2%; and objective IKDC score, good or excellent in 86% of patients (31%, A; 55%, B). Only 3 of 26 patients (12%) had >5-mm manual maximum KT-2000 side-to-side difference. KiRA system documented positive pivot-shift (>0.9-m/s(2) tibial acceleration side-to-side difference) in these 3 of 26 patients (12%). Statistically significant changes were as follows: decrease in Tegner score from 7 (range, 6-8) at 5-year follow-up to 4 (range, 3-5) at 10 years ( P < .0001) and decrease in Lysholm score from 96.1 ± 7.3 at 10-year follow-up to 85.7 ± 14.6 at 20 years ( P = .0003). Radiographic evaluation demonstrated significant difference of medial joint space between injured and healthy knees in patients with concomitant medial meniscectomy (n = 8, 3.2 ± 0.6 vs 5.0 ± 1.8 mm, P = .0114). No significant differences were reported regarding lateral or patellofemoral joint space. One patient (2%) experienced rerupture, with 3 of 52 (5.8%) having a contralateral ACL injury (excluded from KT-2000 and radiographic evaluations). Overall, 4 of 29 clinical failures (objective IKDC, KT-2000) and 1 rerupture among 52 patients were registered at final follow-up.
CONCLUSION: Studied surgical technique demonstrated good results in laxity control at 20-year minimum follow-up. The lateral extra-articular plasty associated with ACL reconstruction did not generate lateral knee or patellofemoral osteoarthritis. The factor increasing osteoarthritis was meniscectomy.
Muscular and Skeletal Diseases (3) Osteoarthritis (3), more mentions
Many published reports consider blockade of the femoral nerve distribution the best available analgesic treatment after anterior cruciate ligament reconstruction. However, some argue that an alternative approach of infiltrating local anaesthetic into the surgical site has similar efficacy. The objectives of this meta-analysis were to compare the analgesic and functional outcomes of both treatments following anterior ligament reconstruction. The primary outcomes were pain scores at rest (analogue scale, 0-10) in the early (0-2 postoperative hours), intermediate (3-12 hours) and late postoperative periods (13-24 hours). Secondary outcomes included range of motion, quadriceps muscle strength and complication rates (neurological problems, cardiovascular events, falls and knee infections). Eleven trials, including 628 patients, were identified. Pain scores in the early, intermediate and late postoperative periods were significantly lower in patients who received a femoral nerve block, with mean differences (95%CI) of 1.6 (0.2-2.9), p = 0.02; 1.2 (0.4-1.5), p = 0.002; and 0.7 (0.1-1.4), p = 0.03 respectively. The quality of evidence for our primary outcomes was moderate to high. Regarding functional outcomes, only one trial reported a similar range of motion between groups at 48 postoperative hours. No trial sought to record complications. In conclusion, femoral nerve block provides superior postoperative analgesia after anterior cruciate ligament reconstruction to local infiltration analgesia. The impact of improved analgesia on function remains unclear due to the lack of reporting of functional outcomes in the existing literature.
... examine whether the peak knee flexion moment (KFM), knee flexion angle (KFA), and vertical ground-reaction force (vGRF) during gait are associated with prospective changes in medial tibiofemoral cartilage T1ρ and T2 in ACL-reconstructedknees and to compare these gait characteristics between patients undergoing ACLR and healthy control participants.
Muscular and Skeletal Diseases (1) Osteoarthritis (1), more mentions
The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension.In combined anterolateral procedure plus intra-articular ACL reconstruction, the knee flexion angle is important when fixing the graft. A modified Lemaire procedure restored intact knee laxities when fixation was performed at 0°, 30°, or 60° of flexion.
OBJECTIVE: Little is known about the extent to which physical activity (PA) changes following total knee or hip joint replacement relative to pain, physical function and quality of life. Our objective was to conduct a systematic review and meta-analysis on changes in PA relative to pain, quality of life and physical function after total knee or hip joint replacement.
METHODS: We searched PubMed (Medline), Embase and Cinahl, for peer-reviewed, English-language cohort studies measuring PA with an accelerometer from pre-surgery to post-surgery. Random-effects models were used to produce standardized mean differences (SMDs) for PA, quality of life, pain, and physical function outcomes. Heterogeneity was measured with I(2) .
RESULTS: Seven studies (336 participants) met eligibility criteria. No significant increase in PA was found at 6-months (SMD 0.14; 95% CI -0.05 to 0.34; I(2) =0%) and a small-moderate significant effect was found for increasing PA at 12-months (SMD 0.43; 95% CI 0.22 to 0.64; I(2) =0%). Large improvements at 6-months in physical function (SMD 0.97; 95% CI 0.12 to 1.82; I(2) =92.3%), pain (SMD -1.47; 95% CI -2.28 to -0.65; I(2) =91.6%), and quality of life (SMD 1.02; 95% CI 0.30 to 1.74; I(2) =83.2%) were found.
CONCLUSIONS: Physical activity did not change at 6-months and a small-moderate improvement was found at 12-months post-surgery, despite large improvements in quality of life, pain, and physical function. Reasons for the lack of increased PA are unknown but may be behavioral in nature as sedentary lifestyle is difficult to change. Changing sedentary behavior should be a future focus among this subgroup. This article is protected by copyright. All rights reserved.