Young Females Exhibit Decreased Coronal Plane Postural Stability Compared to Young Males

Background

Female athletes are at significantly higher risk of noncontact ACL injury than males, particularly in pivoting sports such as soccer and basketball. Sex-based differences in proprioception and core stability may contribute to this elevated risk.

Questions/Purpose

This study evaluates a novel method of assessing dynamic stability to test the hypothesis that healthy adolescent controls have sex-based differences in postural stability.

Methods

Seventy-nine male and 72 female subjects completed three rounds of dynamic postural stability testing. During the assessment, subjects attempted to stabilize their torso and upper body in response to random movements of the platform. The total time a subject lasted on the platform and dynamic motion analysis (DMA) score, a summation of motion in five planes throughout testing, was calculated for each subject. The average score for each subject was included in the analysis.

Results

Males lasted longer on the platform (98?±?14 s) than females (94?±?13 s) (p?=?0.04). Coronal plane and rotation stability differed significantly between genders (323?±?126 vs. 365?±?128, p?=?0.04) and (318?±?82 vs. 403?±?153, p?=?0.0002), respectively. No statistically significant difference was seen in the other planes of motion.

Conclusions

Females have less dynamic postural stability than their male counterparts in the coronal plane based on a novel assessment tool. This finding may contribute to better understanding of sex-based differences in rates of injury such as noncontact ACL tears.

     

Effects on proprioception by Kinesio taping of the knee after anterior cruciate ligament rupture

Introduction

The use of Kinesio tape (KT) to improve proprioception is a matter of considerable debate. In comparison, the rupture of the anterior cruciate ligament is a sufficiently well-investigated injury with a proven compromise of proprioception. The objective of the present study was to assess a supportive effect on proprioception after KT application, taking the anterior cruciate ligament (ACL) rupture as an example.

Materials and methods

Forty-eight patients who had suffered an ACL rupture, confirmed clinically and by magnetic resonance imaging, and who were treated conservatively or were awaiting surgery were included in this study. In all patients, a gait analysis was performed on the affected leg before and after KT application. In addition, the IKDC score, the Lysholm score, stability using the Rolimeter, and the angle reproduction test were determined.

Results

Thirty-nine men and nine women who had had an ACL rupture for at least 3 weeks were included in the study. Significant improvements were achieved on the affected knee joint for the gait analysis parameters touchdown and unrolling, cadence, stability and stance phase as well as an extension of the hip joint. The Lysholm score improved from 79.3 to 85.8 (p?<?0.001) and the IKDC score from 60.2 to 71.3 points (p?<?0.001). Significant improvements were achieved in the Rolimeter and angle reproduction test.

Conclusions

The use of KT has a positive effect on proprioception in patients with an anterior cruciate ligament rupture. Therefore, the application may improve gait pattern as well as the subjective function of the affected knee joint.

     

ACL Damage and Deficiency is Associated with More Severe Preoperative Deformity,Lower Range of Motion at the Time of TKA

Background

ACL status varies in the arthritic knee during TKA.

Questions/Purposes

The purpose of this study was to examine clinical features and intraoperative findings associated with stages of ACL degeneration.

Methods

Coronal deformity, ROM, intra-articular degenerative patterns, and ligament releases were assessed for 1656 knees during TKA. Common patterns of deformity and severity of degenerative change were assessed as a function of the severity of ACL deficiency.

Results

Of the 1656 knees assessed, 27% had a normal ACL, 55% exhibited damage, and 18% exhibited complete absence of the ACL. Increased coronal deformity and lower preoperative ROM was associated with ACL deficiency. Increased chondral and meniscal damage and more extensive osteophyte formation were also found. More extensive ligament releases were required in ACL-deficient knees.

Conclusions

The status of the ACL is predictive of the need for increased surgical deformity correction. A better understanding of ACL status is an important consideration during in choosing TKA as opposed to unicompartmental arthroplasty. The status of the ACL should be considered in planning for implant choice in TKA.

     

Retrospective comparative study shows no significant difference in postural stability between cruciate-retaining (CR) and cruciate-substituting (PS) total knee implant systems

Purpose

Modified postural stability after retaining the posterior cruciate ligament (PCL) in total knee arthroplasty is still discussed controversially. The objective of this study was to evaluate whether a PCL-retaining implant design should be preferred over a PCL-substituting implant design regarding postural stability in one-leg stance and clinical outcome.

Methods

Forty patients underwent total knee arthroplasty, 20 of them with a cruciate-retaining (CR) and 20 of them with a cruciate-substituting (PS) implant system. Postural stability was analysed 6 months postoperatively in one-leg stance using the Biodex Balance System. In addition, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score were completed.

Results

This study shows that there is no significant difference in postural stability between CR and PS) implant systems with PS implants showing better results in WOMAC score.

Conclusions

In case it is necessary to use a PS implant, no negative influence on postural stability is to be expected compared to a CR implant.

     

Operative Behandlung der ulnaren Seitenbandläsion am Daumengrundgelenk

Objective

Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.

Indications

Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.

Contraindications

Abrasions, wound-healing disturbance, skin disease, osteoarthritis.

Surgical technique

Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.

Postoperative treatment

Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.

Results

Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.

     

Quantitative correlation of mechanoreceptors in tibial remnant of ruptured human anterior cruciate ligament with duration of injury and its significance: an immunohistochemistry-based observational study

Background

Proprioception is a specialized sensory modality encompassing the movement of the joint and its position in space. Reconstruction of the anterior cruciate ligament (ACL) does not always yield expected outcome, suggesting that successful reconstruction depends on not only the ultimate strength of the graft but also recovery of proprioception. Treatment delay is a significant concern in developing countries, e.g., in Asia. Thus, presence of mechanoreceptors is one of the factors having paramount importance for successful outcome. We conducted this study to identify mechanoreceptors via immunohistochemical staining and correlate their presence with duration of injury.

Materials and methods

A total of 38 injured native ACL stumps were harvested from patients undergoing ACL reconstruction and stained with neurofilament protein stain to detect functional mechanoreceptors.

Results

Of the specimens, 44.7% stained positive for monoclonal antibody. No association was found between duration of injury and presence of mechanoreceptors (p = 0.897). No correlation was seen between age and side.

Conclusions

No correlation was found between duration of injury and presence of viable mechanoreceptors, hence it is beneficial to preserve the native ACL stump irrespective of the time interval between injury and surgery.

Level of Evidence

III.

     

Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players

Purpose

The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players.

Methods

Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker–Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing.

Results

At a mean follow-up of 72.6?±?8.1 months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100 %). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture.

Discussion

The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain.

Conclusions

The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity.

     

Hamstring tendon autograft versus fresh-frozen tibialis posterior allograft in primary arthroscopic anterior cruciate ligament reconstruction: a retrospective cohort study with three to six years follow-up

Introduction

Selection of various grafts for anterior cruciate ligament (ACL) reconstructions have been employed in order to improve on stability and function of the knee. This study aimed to compare stability and function of the knee after ACL arthroscopic reconstruction by single-loop tibialis posterior (TP) allograft and four-strand hamstring tendon (HT) autograft.

Materials and methods

The retrospective cohort study included 104 patients in the TP group matched with 118 patients in the HT group in terms of demographic characteristics, associated meniscus injury, subjective and objective knee characteristics. All patients were followed up for at least three years with regards to mentioned criteria and time of return to former activities.

Results

The mean (range) age of TP (88 males and 16 females) and HT (99 males and 19 females) groups was 34.4 (19–48) and 36.9 (20–51) years, respectively. Median (range) follow-up durations were 55 (37–71) and 56 (36–72) months, respectively. No significant differences were observed post-operatively, regarding subjective and objective evaluations. Additionally, time duration for return to former activity was similar in both groups. Post-operative paresthesia and numbness of medial aspect of the calf were observed for two months in eight patients of the HT group which persisted to the final visit in one case. No similar symptom was seen in the TP group.

Conclusion

In arthroscopic ACL reconstruction, fresh frozen doubled TP allograft compared to HT autograft was equally effective in restoring function and stability of knee, permitting return to former activities.

Level of evidence

Retrospective comparative, Level III

     

Mechanisms and situations of anterior cruciate ligament injuries in professional male soccer players: a YouTube-based video analysis

Background

Soccer is considered the most popular sport in the world concerning both audience and athlete participation, and the incidence of ACL injury in this sport is high. The understanding of injury situations and mechanisms could be useful as substratum for preventive actions.

Purpose

To conduct a video analysis evaluating the situations and mechanisms of ACL injury in a homogeneous population of professional male soccer players, through a search entirely performed on the YouTube.com Web site focusing on the most recent years.

Methods

A video analysis was conducted obtaining videos of ACL injury in professional male soccer players from the Web site YouTube. Details regarding injured players, events and situations were obtained. The mechanism of injury was defined on the basis of the action, duel type, contact or non-contact injury, and on the hip, knee and foot position.

Results

Thirty-four videos were analyzed, mostly from the 2014–2015 season. Injuries occurred mostly in the first 9 min of the match (26%), in the penalty area (32%) or near the side-lines (44%), and in non-rainy conditions (97%). Non-contact injuries occurred in 44% of cases, while indirect injuries occurred in 65%, mostly during pressing, dribbling or tackling. The most recurrent mechanism was with an abducted and flexed hip, with knee at first degrees of flexion and under valgus stress.

Conclusions

Through a YouTube-based video analysis, it was possible to delineate recurrent temporal, spatial and mechanical characteristics of ACL injury in male professional soccer players.

Level of evidence

Level IV, case series.

     

Macroscopic evaluation of the anterior cruciate ligament in osteoarthritic patients undergoing total knee arthroplasty

Background

Sacrifice of the anterior cruciate ligament (ACL) is currently common practice during total knee arthroplasty (TKA). However, patients who receive an ACL-retaining TKA maintain more normal knee kinematic patterns than those without an ACL. Additionally, satisfactory survival and function more than 20 years after bicruciate-retaining TKA has recently been reported. The purpose of this study was to compare the percentage of knees with a visually intact ACL prior to TKA surgery with previously reported values.

Methods

A total of 247 knees (216 consecutive patients) that underwent TKA were retrospectively evaluated. The preoperative diagnosis for all patients was primary OA. The macroscopic appearance of the ACL at the time of surgery was retrospectively assessed using routinely recorded digital photographs and classified as normal, moderately damaged (fissured), or completely ruptured. Both normal and moderately damaged ACLs were defined as intact.

Results

Ninety-four percent (233/247) of the knees had an intact ACL (normal or moderately damaged). This value is higher than that found in previous reports.

Conclusions

Our results show more candidates for bicruciate ligament-retaining TKA surgery than reported previously. This suggests that improved techniques for bicruciate-retaining TKA would be clinically useful and could benefit a large number of patients.

     

Combined posterolateral corner and acute anterior cruciate ligament injuries in an adolescent cohort: a magnetic resonance imaging analysis

Purpose

Failure of a reconstructed anterior cruciate ligament (ACL) has significant morbidity in the paediatric and adolescent patient population. Untreated concomitant posterolateral corner (PLC) injury is an identified cause of failed ACL reconstruction; however, the injury pattern has yet to be defined for the paediatric population.

Methods

Magnetic resonance imaging (MRI) studies of the knee performed between 1 January 2009 and 1 January 2013 were retrospectively reviewed. Imaging reports indicating an intra-substance injury of the ACL were reviewed, and all associated injured structures were recorded. Injury patterns were categorised by age, gender, physis status and associated injuries. Logistic regression and chi-square analyses compared ACL disruptions with and without concomitant PLC injuries.

Results

One hundred and twenty-eight patients (74 boys and 54 girls, average age 15.27 years) sustained an ACL disruption. Concomitant injury to the PLC was seen in 13.3 % of injuries. Associated PLC injuries were significantly associated with lateral meniscus injury and Segond fractures. Lateral meniscus injury was predictive of PLC injury (p?=?0.05) upon logistic regression analysis.

Conclusion

Concomitant PLC injuries were found in 13.3 % of all ACL disruptions on MRI analysis. Lateral meniscus injuries associated with an ACL disruption were predictive of concomitant PLC injury. Combined injury of the ACL and lateral meniscus should prompt close scrutiny to PLC structures.

     

Can the gracilis replace the anterior cruciate ligament in the knee? A biomechanical study

Purpose

The purpose of this study was to determine whether a four-strand gracilis-only construct possesses the biomechanical properties needed to act as an anterior cruciate ligament (ACL) reconstruction graft.

Methods

This was a pilot study with 32 cadaver specimens. The biomechanical properties of three types of grafts were determined using validated tensile testing methods: patellar tendon (BTB), both hamstring tendons together (GST4) and gracilis alone (G4).

Results

The maximum load at failure of the G4 was 416.4 N (±187.7). The GST4 and BTB had a maximum load at failure of 473.5 N (±176.9) and 413.3 N (±120.4), respectively. The three groups had similar mean maximum load and stiffness values. The patellar tendon had significantly less elongation at failure than the other two graft types.

Conclusions

The biomechanical properties of a four-strand gracilis construct are comparable to the ones of standard grafts. This type of graft would be useful in the reconstruction of the anteromedial bundle in patients with partial ACL ruptures.

     

Patient-based decision for resuming activity after ACL reconstruction: a single-centre experience

Purpose

The purpose of the study was to report the functional outcome following anterior cruciate ligament (ACL) reconstruction in patients who decide when to resume work and normal sporting activity post-operatively. The hypothesis tested was that patient-based decision to return to work and sport was possible without compromising functional outcome and increased the rate of repeat rupture in comparison with the existing literature.

Methods

This was a monocentric, retrospective study. Seventy-two patients requiring primary ACL reconstruction were included. All patients were followed up for a mean period of 4.3 years. Return to work and to sporting activity was allowed based on patient’s decision. No restriction was suggested by the physician. Delays to return to work and sports and occurrence of graft failure were documented.

Results

Sixty-six patients (92 %) returned to any sporting activity. The mean delay was 4.1 months for running, 6.1 months for pivoting sports, and 6.6 months for contact sports. Return to competitive sport was possible in 82 % of patients after a mean delay of 7.1 months. Return to work was possible for 96 % of patients after a mean delay of 2.3 months. Index Tegner score normalized in 71 % of patients. Four repeat ruptures (6 %) were observed, all of them following a significant knee injury.

Conclusions

Patient-based decision to return to work and sport was possible without compromising functional outcome. The post-operative restrictions implemented by orthopaedic surgeons following ACL reconstructions may be relaxed and more patient based.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.

     

Präklinische Routine? Ein besonderer Fall von akutem Koronarsyndrom

Background

Acute coronary syndrome (ACS) is a prevalent condition. ACS is usually caused by a rupture of plaques in coronary arteries with consecutive thrombosis. However, extracardiac causes exist, which may induce myocardial ischemia as a consequence of mismatch of cardiac oxygen supply and demand.

Case report

The following case report describes a patient suffering from ACS and cardiogenic shock due to anemia.

Conclusion

Primary hypovolemic shock can be misdiagnosed as cardiogenic shock.

     

Prospective analysis using a patient-based health-related scale shows lower functional scores after posterior cruciate ligament reconstructions as compared with anterior cruciate ligament reconstructions of the knee

Purpose

This study evaluated the treatment outcome of posterior cruciate ligament (PCL) reconstruction using the Medical Outcome Study 36-item Short-Form Health Survey (SF-36), a patient-based quality of life (QOL) questionnaire comparing it with anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent reconstruction at our center for PCL (n?=?24) or ACL (n?=?197) injury were studied. The patients were evaluated using SF-36, visual analogue scale (VAS) for knee pain, Lysholm scale, posterior or anterior tibial translation and range of motion (ROM) before surgery until 24 months after surgery. Results were compared.

Results

In the ACL group, all evaluation methods showed significant improvement after surgery. In the PCL group, however, improvement was observed in only three of eight subscales of the SF-36, Lysholm score and posterior tibial translation after surgery. In intergroup comparison, the PCL group showed inferior performance in three subscales of the SF-36, Lysholm score and ROM for flexion compared with the ACL group.

Conclusions

The surgical outcome of PCL reconstruction was inferior to that of ACL reconstruction both in patient-based and conventional doctor-based assessments. An improved surgical technique for PCL is required.

     

Arthroskopisch unterstützte ulnare Refixierung des TFCC mit Schraubanker

Objective

The goal of this operation technique is a stable refixation of the triangular fibrocartilage complex (TFCC) to the fovea ulnaris. The stability of the distal radio-ulnar joint (DRUJ) should be re-established. The patients pain and the feeling of instability should be reduced.

Indications

Lesions of the foveal component of the TFCC resulting in DRUJ instability. Combined lesions of both components of the TFCC. Complete detachment of the TFCC from the ulna either without fracture of the styloid process of the ulna or with fracture (floating styloid).

Contraindications

Severe lacerations of the TFCC and clinically relevant arthrosis of the DRUJ. Severely osteoporotic bone.

Surgical technique

Following diagnostic arthroscopy and performance of stability control of the TFCC with a palpation hook, reduction of the DRUJ with supination position of the wrist. Bone anchor fixation through the direct foveal portal (DF). Under arthroscopic control through the 3/4 portal, the suture from the DF portal is placed through the TFCC. Pull out and tie the strands through the 6 U portal.

Postoperative management

Restriction of rotation of the forearm in a Munster cast or special cast brace for 6 weeks. Self-controlled exercise of the wrist after 6 weeks. Physiotherapy and strength building 8 weeks postoperatively.

Results

Clinical studies of this technique showed a significant amelioration of pain perception, improved range of motion and DASH score in all patients after anchor fixation. The results are comparable to other techniques. All patients returned to work after the operation. Accordingly, using this technique a very good stabilization of the DRUJ with low complications can be achieved.

     

Long-term outcome of anterior cruciate ligament tear without reconstruction: a longitudinal prospective study

Purpose

To analyse subjective and objective long-term outcomes of patients with anterior cruciate ligament (ACL)-deficient knees and limited demands regarding sportive activities. This subgroup of patients might be well-treated without ligament reconstruction.

Methods

We included 303 patients with unilateral tears of the ACL and conservative treatment into a prospective study. Mean age at injury was 33.8 (min. 18, max. 66) years. Follow-up was 27.1 (min. 21.3, max. 31.5) years. Follow-up examinations were conducted 12 and 27 years after injury. At the last follow-up we analysed 50 patients completely. To evaluate clinical and radiological outcomes we used the Lysholm score, Tegner activity scale, visual analogue scale for pain (VAS-pain), KOOS and Sherman score.

Results

Subjective outcome (Lysholm score and VAS-pain scale) improved between the 12th and 27th year after anterior cruciate ligament tear. At the same time activity level (Tegner activity scale) decreased. Also, arthritis (Sherman score) worsened over time. Twenty-seven years after injury, 90 % of the patients rated their ACL-deficient knee as normal or almost normal; 10 % of the patients rated it as abnormal. The findings of this study show that there is a subgroup of patients with ACL tears who are well treated with physiotherapy alone, not reconstructing the ligament. Also, other authors found this correlation between activity level reduction and better subjective outcome.

Conclusions

Conservative treatment of an ACL tear is a good treatment option for patients with limited demands regarding activity. Patient age, sportive activities and foremost subjective instability symptoms in daily life should be considered when deciding for or against ACL reconstruction.

     

Retro-odontoid synovial cyst resected via an anterolateral approach without fusion

Purpose

Retro-odontoid synovial cysts are rare and attributable to degenerative changes in the atlantoaxial joints. An anterolateral approach facilitates access to lesions located anterior to the craniocervical junction without harming the atlantoaxial joints, and can also treat small lesions in the ventral mid-portion of the craniocervical junction without compression of spinal cord.

Methods

We present herein the case of a 70-year-old man with a retro-odontoid synovial cyst. A ventral midsection mass was present at the level of the atlantoaxial joint. The compressed anterior medulla led to neurological deficits. Slight atlantoaxial instability was radiologically present. An intradural cyst resection without fusion was performed via the anterolateral approach. The diagnosis of a synovial cyst was histologically confirmed.

Results

The patient was followed up for 3 years and exhibited improvements in the neurological deficits. There were no recurrence and postoperative deterioration of atlantoaxial instability.

Conclusions

The anterolateral approach for the retro-odontoid synovial cyst had little effect on C1–2 instability and yielded neurological improvements.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.