Impaired voluntary quadriceps force control following anterior cruciate ligament reconstruction: relationship with knee function

Purpose

Impairments in quadriceps force control and altered quadriceps and hamstring muscle activation strategies have been observed following anterior cruciate ligament reconstruction; however, the functional implications of these impairments are unclear. This study examined the cross-sectional associations between quadriceps force control, quadriceps activation, hamstring coactivation and clinically assessed knee function following anterior cruciate ligament reconstruction with a hamstring graft.

Methods

Sixty-six patients (18 ± 3 months following surgery) and 41 uninjured individuals participated. Quadriceps force control was assessed using an isometric knee extension task. Participants cyclically increased and decreased quadriceps force at slow speeds between 5 and 30 % maximum voluntary isometric contraction matching a moving target displayed on a screen. Quadriceps activation and hamstring coactivation were assessed concurrently using surface electromyography. Knee function was assessed with the Cincinnati Knee Rating Scale and three single-leg hop tests.

Results

The reconstructed group completed the task with 48 % greater root-mean-square error (RMSE), indicating significantly worse quadriceps force control (p < 0.001). In a multivariable model adjusted for sex, greater RMSE and greater lateral hamstring coactivation were significantly associated with worse knee function that is greater odds of scoring <85 % on one or more knee functional assessment.

Conclusions

Less-accurate quadriceps force output and greater hamstring coactivation are associated with worse knee joint function following anterior cruciate ligament reconstruction and may contribute to irregular knee joint loading and the onset or progression of knee osteoarthritis. Impairments in quadriceps force control and altered muscle activation strategies may be modifiable through neuromuscular training, and this is an area for future research.

Level of evidence

Case–control study, Level III.

     

Antibiotic-loaded bone cement reduces risk of infections in primary total knee arthroplasty? A systematic review

Purpose

Antibiotic-loaded bone cement has been widely used for the treatment of infected knee replacement, but its routine use in primary TKA remains controversial. The aim of this systematic review was to analyze the literature about the antimicrobial efficacy and safety of antibiotic-loaded bone cement for its prophylactic use in primary TKA.

Methods

A detailed and systematic search of the Pubmed, Medline, Cochrane Reviews and Google Scholar databases had been performed using the keyword “total knee arthroplasty” “total knee replacement” “total knee prosthesis” and “antibiotic-loaded bone cement” with no limit regarding the year of publication. We used modified Coleman scoring methodology (mCMS) to identify scientifically sound articles in a reproducible format. The review was limited to the English-language articles.

Results

Six articles met inclusion criteria. In total, 6318 arthroplasties were included in our study. 3217 of these arthroplasties received antibiotic-loaded bone cement and 3101 arthroplasties served as the control. There was no statistical difference between the two groups in terms of the incidence of deep or superficial surgical site infection. The average mCMS score was 67.6, indicating good methodological quality in the included studies.

Conclusions

Present review did not reveal any significant difference in terms of rate of deep or superficial surgical site infection in patients receiving antibiotic-loaded bone cement compared with the control (plain bone cement) during primary TKA. The clinical relevance of this study was that the use of antibiotic-loaded bone cement did not significantly reduce the risk of infection in primary TKA.

Level of evidence

III.

     

Restoring tibiofemoral alignment during ACL reconstruction results in better knee biomechanics

Purpose

Anterior cruciate ligament (ACL) reconstruction (ACLR) aims to restore normal knee joint function, stability and biomechanics and in the long term avoid joint degeneration. The purpose of this study is to present the anatomic single bundle (SB) ACLR that emphasizes intraoperative correction of tibiofemoral subluxation that occurs after ACL injury. It was hypothesized that this technique leads to optimal outcomes and better restoration of pathological tibiofemoral joint movement that results from ACL deficiency (ACLD).

Methods

Thirteen men with unilateral ACLD were prospectively evaluated before and at a mean follow-up of 14.9 (SD?=?1.8) months after anatomic SB ACLR with bone patellar tendon bone autograft. The anatomic ACLR replicated the native ACL attachment site anatomy and graft orientation. Emphasis was placed on intraoperative correction of tibiofemoral subluxation by reducing anterior tibial translation (ATT) and internal tibial rotation. Function was measured with IKDC, Lysholm and the Tegner activity scale, ATT was measured with the KT-1000 arthrometer and tibial rotation (TR) kinematics were measured with 3Dmotion analysis during a high-demand pivoting task.

Results

The results showed significantly higher TR of the ACL-deficient knee when compared to the intact knee prior to surgery (12.2° ± 3.7° and 10.7° ± 2.6° respectively, P?=?0.014). Postoperatively, the ACLR knee showed significantly lower TR as compared to the ACL-deficient knee (9.6°±3.1°, P?=?0.001) but no difference as compared to the control knee (n.s.). All functional scores were significantly improved and ATT was restored within normal values (P?<?0.001).

Conclusions

Intraoperative correction of tibiofemoral subluxation that results after ACL injury is an important step during anatomic SB ACLR. The intraoperative correction of tibiofemoral subluxation along with the replication of native ACL anatomy results in restoration of rotational kinematics of ACLD patients to normal levels that are comparable to the control knee. These results indicate that the reestablishment of tibiofemoral alignment during ACLR may be an important step that facilitates normal knee kinematics postoperatively.

Level of evidence

Level II, prospective cohort study.

     

Ablation protocols and ancillary procedures in tumor ablation therapy: consensus from Japanese experts

Purpose

A panel of Japanese experts on tumor ablation therapy gathered to reach a general consensus on topics surrounding ablation therapy.

Materials and methods

Questionnaires relating to ablation protocols for radiofrequency ablation (RFA) and cryoablation, as well as ancillary procedures required for safe and secure ablation therapy, were sent to seven institutions. Experts from these institutions discussed each topic based on the evidence and the questionnaire data, and a consensus was reached at an annual meeting of the Japan Image-guided Ablation Group in Maebashi, Japan, in October 2015.

Results

A consensus was reached on each of six topics, including “management of antiplatelet and anticoagulation drug therapy”; “pain control in the perioperative period”; “arterial embolization combined with ablation therapy”; “protection of non-target organs”; “RFA and cryoablation protocols”; and “ablative margins.”

Conclusions

The consensus achieved here will serve as the framework for tumor ablation therapies in Japan.

     

The timing of surgical treatment of knee dislocations: a systematic review

Purpose

Traumatic knee dislocations (KDs) are unusual yet limb-threatening injuries; the timing of surgical intervention is still debated. A systematic review was performed to determine the optimal timing of surgery with respect to injury pattern.

Methods

A comprehensive search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials was performed for studies published between 1 January 1974 and 20 April 2014 on the surgical management of “knee dislocation” and “multiligament knee injuries”. Surgical timing was classified as acute, chronic, or staged. A systematic review was performed for patients with KD-III according to Schenck’s classification using individual patient data.

Results

Twelve studies including 150 patients (153 knees) with KDs fulfilled the study requirements. Sixty-nine cases with KD-IIIM and 84 cases with KD-IIIL were identified. Excellent or good results were demonstrated in 79.1 % (34 cases) of cases managed with staged treatment versus 58.4 % (45 cases) of cases undergoing acute surgery (p = 0.02), and versus 45.5 % (15 cases) of cases undergoing chronic surgery (p = 0.002). No statistically significant difference was found in the percentage of excellent or good results between the acute and chronic surgery groups (n.s.), or between the KD-IIIM and KD-IIIL groups (n.s.).

Conclusion

Staged treatment yields the best clinical results for patients with KD-III. No statistically significant difference was shown in the clinical results between acute surgery and chronic surgery groups.

Level of evidence

IV.

     

Deficits in functional performance and gait one year after total knee arthroplasty despite improved self-reported function

Purpose

The current literature lacks sufficient information about improvements in gait patterns and function after total knee arthroplasty (TKA) and whether patients return to full function. This study evaluated change in gait, performance-based function, and self-reported function 1 year after TKA in patients with symptomatic knee osteoarthritis and how these aspects interrelate.

Methods

A total of 28 patients (64 % female) with knee osteoarthritis, with a mean age of 66 (±7) years, and 25 age- and gender-matched controls participated in this prospective cohort study. Three-dimensional gait analysis generated comprehensive measures of kinematic and kinetic gait deviations, respectively. Participants completed the Five Times Sit-to-Stand (5STS) test, and the self-reported questionnaire Knee Injury and Osteoarthritis Outcome Score (KOOS), at baseline prior to surgery and 1 year after TKA.

Results

Kinetic gait deviations of both the operated and non-operated limb persisted in patients with knee osteoarthritis at 1 year after surgery, while kinematic gait patterns were comparable to controls. Performance on the 5STS and KOOS scores in patients with knee osteoarthritis improved significantly 1 year after surgery (effect size 0.5–1.5), but did not reach the level of controls. Ten patients with knee osteoarthritis (36 %) exceeded the minimally detectable change on the 5STS.

Conclusion

Measures of overall gait patterns and the 5STS revealed improvements in function 1 year after TKA, but were not restored to the level of healthy controls. Based on change in 5STS performance, we identified patients with substantial improvements in gait patterns. Self-reported measures of function could not detect differences between patients improving in 5STS performance and those who did not. These findings highlight the use of the 5STS in clinical practice since improvement on this test seems to follow the reduction in gait pattern deviations.

Level of evidence

II.

     

Anterior cruciate ligament deficiency reduces walking economy in “copers” and “non-copers”

Purpose

Patients with ACL injury requiring surgical treatment (non-copers) demonstrate altered neuromuscular control and gait pattern compared with those returning to their pre-injury activities without surgery (copers). Pathological gait pattern may increase the energy cost of walking. We compared the energy cost of flat, uphill, and downhill walking between ACL-deficient and healthy individuals and between “copers” and “non-copers”.

Methods

Nineteen young males with unilateral ACL injury were allocated into “copers” and “non-copers” according to their ability to return to pre-injury activity without ACL reconstruction. Lysholm and IKDC scales were recorded, and a control group (n = 10) matched for physical characteristics and activity levels was included. All participants performed 8-min walking tasks at 0, +10, and ?10 % gradients. Energy cost was assessed by measurement of oxygen consumption (VO₂). HR and ventilation (VE), respiratory exchange ratio (RER), and VE/VO₂ were also measured.

Results

VO₂ and HR were higher in ACL-deficient patients than in controls during walking at 0, +10, and ?10 % gradients (p < 0.01–0.05). There were no differences between “copers” and “non-copers” in VO₂ and HR for any gradient. No differences were observed in VE, RER, and VE/VO₂ among the three groups.

Conclusions

The walking economy of level, uphill, and downhill walking is reduced in ACL-deficient patients. Despite the improved functional and clinical outcome of “copers”, their walking economy appears similar to that of “non-copers” but impaired compared with healthy individuals. The higher energy demand and effort during locomotion in “copers” and “non-copers” has clinical implications for designing safer rehabilitation programmes. The increased energy cost in “copers” may be another parameter to consider when deciding on the most appropriate therapeutic intervention (operative and non-operative), particularly for athletes.

Level of evidence

II.

     

Gait adaptations following multiple-ligament knee reconstruction occur with altered knee kinematics during level walking

Purpose

The biomechanical behaviour of the knee following multiple-ligament reconstruction (MLKR) may play a role in the pathogenesis of post-traumatic osteoarthritis. The aim of this study was to compare three-dimensional knee kinematics and gait characteristics of MLKR patients to healthy controls during level walking.

Methods

Three-dimensional optoelectronic motion capture during overground walking was performed on 16 patients with MLKR and a group of healthy controls matched individually to each patient for age, gender, height and weight. Three-dimensional knee angles were extracted from the weight acceptance and propulsion sub-phases of gait. Statistical analysis was performed using group-aggregated data, as well as for each patient–control pair using a single-case approach.

Results

Although group analysis detected few differences, single-case analysis revealed significant differences for a proportion of patients for all dependent variables during weight acceptance and propulsion sub-phases of stance. These kinematic differences occurred in the context of reduced gait velocity, step length and cadence, as well as increased time spent in double support.

Conclusion

Patients with MLKR display abnormalities in knee kinematics during gait at an average of 4.5 years after surgery. The pattern of kinematic abnormalities appears individual specific and may not be related to differences in spatiotemporal gait characteristics. The current findings describe detailed functional outcomes of MLKR reconstruction at average medium-term follow-up that provide improved prognostic information for clinicians to counsel patients with these types of injuries.

     

Changes in gait pattern and early functional results after ACL repair are comparable to those of ACL reconstruction

Purpose

Dynamic intraligamentary stabilization (DIS) has been introduced as a new technique to repair the torn anterior cruciate ligament (ACL) and to restore knee joint kinematics after an acute ACL tear. Aim of the present study was to compare the early post-operative activity, restoration of gait pattern and functional results after DIS in comparison with primary ACL reconstruction (ACLR) for acute ACL tears. It was hypothesized that functional results, post-operative activity and changes in gait pattern after DIS are comparable to those after ACLR.

Methods

Sixty patients with acute ACL tears were included in this study and underwent either DIS or ACLR with an anatomic semitendinosus autograft in a randomized manner. Patients were equipped with an accelerometric step counter for the first 6 weeks after surgery in order to monitor their early post-operative activity. 3D gait analysis was performed at 6 weeks and 6 months after surgery. Temporal-spatial, kinematic and kinetic parameters were extracted and averaged for each subject. Functional results were recorded at 6 weeks, 6 months and 12 months after surgery using the Tegner activity scale, International Knee Documentation Committee score and Lysholm score.

Results

Patients who underwent DIS showed an increased early post-operative activity with significant differences at week 2 and 3 (p = 0.0241 and 0.0220). No significant differences between groups were found for knee kinematic and kinetic parameters or the functional scores at any time of the follow-up. Furthermore, the difference in anterior tibial translation was not significantly different between the two groups (n.s.).

Conclusion

Early functional results and changes in gait pattern after DIS are comparable to those of primary ACLR. Therefore, ACL repair may be an alternative to ACLR in this cohort of patients.

Level of evidence

I.

     

Similar clinical outcomes following collagen or polyurethane meniscal scaffold implantation: a systematic review

Purpose

The purpose of this systematic review is to evaluate the current literature in an effort to assess specific clinical outcomes following meniscal scaffold implantation using the two available scaffolds: Collagen Meniscal Implant (CMI) and the Actifit polyurethane meniscal scaffold.

Methods

A systematic review was performed by searching PubMed, Embase, and Cochrane Library to find studies evaluating clinical outcomes of patients undergoing meniscal scaffold implantation. Search terms used were “meniscus”, “meniscal”, “scaffold”, and “implant”. Studies were evaluated based on scaffold type, treatment failure rates, patient-reported outcome scores, concomitant procedures, and radiological findings. Radiological findings were recorded using the Genovese scale to assess morphology and signal intensity and the Yulish score to assess articular cartilage.

Results

Nineteen studies (1 level I, 1 level II, 17 level IV evidence) were identified that met inclusion criteria, including a total of 658 patients (347 Actifit, 311 CMI). The overall average follow-up was 45 months. Treatment failure occurred in 9.9% of patients receiving the Actifit scaffold at a mean follow-up of 40 months and 6.7% of patients receiving CMI at a mean follow-up of 44 months (n.s.). However, the rate of failure ranged from 0 to 31.8% amongst the included studies with a variable definition of failure. Additionally, overlapping patients and presence of concomitant surgeries such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO) may have a significant influence on these results. Outcomes for the Visual Analog Scale (VAS) for pain, Lysholm knee score, and Tegner activity score improved from preoperatively to latest follow-up in both groups, while the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores improved from preoperatively to latest follow-up for Actifit scaffold patients. Overall, patients receiving CMI scaffolds had higher grades for Genovese morphology and signal intensity when compared to Actifit scaffold patients.

Conclusion

Patients undergoing meniscal scaffold implantation with either CMI or Actifit scaffold can both be expected to experience improvement in clinical outcomes when used in association with concomitant procedures such as ACLR and HTO.

Level of evidence

IV, systematic review.

     

Landing mechanics during single hop for distance in females following anterior cruciate ligament reconstruction compared to healthy controls

Purpose

To determine possible differences in single-hop kinematics and kinetics in females with anterior cruciate ligament reconstruction compared to healthy controls. A second purpose was to make comparisons between the healthy and reconstructed limbs.

Methods

Subjects were grouped based on surgical status (33 ACLR patients and 31 healthy controls). 3D motion capture synchronized with force plates was used to capture the landing phase of three successful trials of single hop for distance during a single data collection session. Peak values during the loading phase were analysed. Subjects additionally completed three successful trials of the triple hop for distance Tegner activity scale and International Knee Document Committee 2000 (IKDC).

Results

Controls demonstrated greater peak knee flexion and greater internal knee extension moment and hip extension moment than ACLR subjects. Within the ACLR group, the healthy limb exhibited greater peak knee flexion, hip flexion, hip extension moment, single hop and triple hops for distance and normalized quadriceps strength.

Conclusion

Patients who undergo anterior cruciate ligament reconstruction land in a more extended posture when compared to healthy controls and compared to their healthy limb.

Level of evidence

III.

     

Diagnostic accuracy of bone scintigraphy in the assessment of cardiac transthyretin-related amyloidosis: a bivariate meta-analysis

Purpose

Cardiac transthyretin-related amyloidosis (ATTR) is a progressive and fatal cardiomyopathy. The diagnosis of this disease is frequently delayed or missed due to the limited specificity of echocardiography. An increasing amount of data in the literature demonstrate the ability of bone scintigraphy with bone-seeking radiopharmaceuticals to detect myocardial amyloid deposits, in particular in patients with ATTR. Therefore we performed a systematic review and bivariate meta-analysis of the diagnostic accuracy of bone scintigraphy in patients with suspected cardiac ATTR.

Methods

A comprehensive computer literature search of studies published up to 30 November 2017 on the role of bone scintigraphy in patients with ATTR was performed using the following search algorithm: (a) “amyloid” OR “amyloidosis” AND (b) “TTR” OR “ATTR” OR “transthyretin” AND (c) “scintigraphy” OR “scan” OR “SPECT” OR “SPET” OR “bone” OR “skeletal” OR “skeleton” OR “PYP” OR “DPD” OR “HMDP” OR “MDP” OR “HDP”. Pooled sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR?) and diagnostic odds ratio (DOR) of bone scintigraphy were calculated.

Results

The meta-analysis of six selected studies on bone scintigraphy in cardiac ATTR including 529 patients provided the following results: sensitivity 92.2% (95% CI 89–95%), specificity 95.4% (95% CI 77–99%), LR+ 7.02 (95% CI 3.42–14.4), LR? 0.09 (95% CI 0.06–0.14), and DOR 81.6 (95% CI 44–153). Mild heterogeneity was found among the selected studies.

Conclusion

Our evidence-based data demonstrate that bone scintigraphy using technetium-labelled radiotracers provides very high diagnostic accuracy in the non-invasive assessment of cardiac ATTR.

     

Dynamic and static tibial translation in patients with anterior cruciate ligament deficiency initially treated with a structured rehabilitation protocol

Purpose

To compare dynamic and static tibial translation, in patients with anterior cruciate ligament deficiency, at 2- to 5-year follow-up, with the tibial translation after 4 months of rehabilitation initiated early after the injury. Secondarily, to compare tibial translation in the injured knee and non-injured knee and explore correlations between dynamic and static tibial translation.

Methods

Twelve patients with ACL rupture were assessed at 3–8 weeks after ACL injury, after 4 months of structured rehabilitation, and 2–5 years after ACL injury. Sagittal tibial translation was measured during the Lachman test (static translation) and during gait (dynamic translation) using a CA-4000 electrogoniometer.

Results

Static tibial translation was increased bilateral 2–5 years after ACL injury, whereas the dynamic tibial translation was unchanged. Tibial translation was greater in the injured knee compared with the non-injured knee (Lachman test 134 N 9.1 ± 1.0 vs. 7.0 ± 1.7 mm, P = 0.001, gait 5.6 ± 2.1 vs. 4.7 ± 1.8 mm, P = 0.011). There were no correlations between dynamic and static tibial translation.

Conclusion

Dynamic tibial translation was unchanged in spite of increased static tibial translation in the ACL-deficient knee at 2- to 5-year follow-up compared to directly after rehabilitation. Dynamic tibial translation did not correlate with the static tibial translation. A more normal gait kinematics may be maintained from completion of a rehabilitation programme to mid-term follow-up in patients with ACL deficiency treated with rehabilitation only.

Level of evidence

IV.

     

Knee kinetics and kinematics: What are the effects of TKA malconfigurations?

Purpose

Total knee arthroplasty (TKA) is a very successful surgical procedure. However, implant failures and patient dissatisfaction still persist. Sometimes surgeons are not able to understand and explain these negative performances because the patient’s medical images “look good”, but the patient “feels bad”. Apart from radiograph imaging and clinical outcome scores, conventionally used follow-up methods are mainly based on the analysis of knee kinematics. However, even if kinematics remains close to the “normal” range of motion, the patient may still complain about pain and functional limitations. To provide more insight into this paradox, a better quantitative understanding of TKA mechanics must be developed. For this purpose, improved techniques for clinical follow-up, combining kinetics and kinematics analysis, should be introduced to help surgeons to assess and understand TKA performance.

Methods

An analysis on four TKA designs was performed, and the changes in kinematics and in kinetics induced by several implant configurations (simulating implant malalignment and different knee anatomy) were compared. More specifically, analysed tibio-femoral and patello-femoral contact forces and tibio-femoral kinematics were analysed during a squat task up to 120°.

Results

The results from this study show that contact forces (with changes up to 67 %) are more heavily affected by malconfigurations than kinematics, for which maximum deviations are of the order of 5 mm or 5°, similar to the simulated surgical errors. The results present a similar trend for the different designs.

Conclusions

The results confirm the hypothesis that kinematics is not the only and also not the most relevant parameter to predict or explain knee function after TKA. In the future, techniques to analyse knee kinetics should be integrated in the clinical follow-up.

     

A review of split-bolus single-pass CT in the assessment of trauma patients

Purpose

The purpose of this study was to review and compare the image quality and radiation dose of split-bolus single-pass computed tomography(CT) in the assessment of trauma patients in comparison to standard multi-phase CT techniques.

Methods

An online electronic database was searched using the MESH terms “split-bolus,” “dual phase,” and “single pass.” Inclusion criteria required the research article to compare a split contrast bolus protocol in a single-pass scan in the assessment of trauma patients. Studies using split-bolus CT technique in non-traumatic injury assessment were excluded. Six articles met the inclusion criteria.

Conclusions

Parenchymal and vascular image qualities, as well as subjective image quality assessments, were equal or superior in comparison to non-split-bolus multi-phase trauma CT protocols. Split-bolus single-pass CT decreased radiation exposure in all studies. Further research is required to determine the superior split-bolus protocol and the specificity and sensitivity of detecting blunt cerebrovascular injury screening, splenic parenchymal vascular lesions, and characterization of pelvic vascular extravasation.

     

Anterolateral ligament anatomy: a comparative anatomical study

Purpose

Some anatomical studies have indicated that the anterolateral ligament (ALL) of the knee is distinct ligamentous structure in humans. The purpose of this study is to compare the lateral anatomy of the knee among human and various animal specimens.

Methods

Fifty-eight fresh-frozen knee specimens, from 24 different animal species, were used for this anatomical study. The same researchers dissected all the specimens in this study, and dissections were performed in a careful and standardized manner.

Results

An ALL was not found in any of the 58 knees dissected. Another interesting finding in this study is that some primate species (the prosimians: the red and black and white lemurs) have two LCLs.

Conclusion

The clinical relevance of this study is the lack of isolation of the ALL as a unique structure in animal species. Therefore, precaution is recommended before assessing the need for surgery to reconstruct the ALL as a singular ligament.

     

Outcome measures in clinical ACL studies: an analysis of highly cited level I trials

Purpose

Clinical research in the area of anterior cruciate ligament (ACL) injury has shown substantial growth during the last decade. This was accompanied by the establishment of a wide range of outcome measures used to address the demands of clinical studies. The aim of this study was to evaluate outcome measures reported by highly cited level I trials in ACL research and identify factors influencing citation metrics.

Methods

The database of the Institute for Scientific Information (ISI) was utilized to screen journals under the subject categories “Orthopaedics”, “Sports Sciences”, “Radiology” and “General medicine” for the 50 most cited level I ACL trials based on predefined inclusion criteria. Metadata, citation metrics and outcome measures were extracted for each article. Frequencies of reported outcome measures were calculated, and a multiple linear regression model applied to identify factors influencing citation metrics.

Results

Two independent outcome measures demonstrated an influence on acquisition of citations including: 1—report of the pivot-shift test and 2—inclusion of the Knee Injury and Osteoarthritis Outcome (KOOS) score. Furthermore, highly cited ACL trials frequently reported KT-1000 measures of anterior translation, range of motion (ROM), graft failure, Lysholm, Tegner and subjective International Knee Documentation (IKDC) scores.

Conclusion

This analysis reflects on the outcome measures utilized in highly cited level I trials impacting the field of ACL research. It also identifies factors likely to influence acquisition of citations. This is of both clinical and academic relevance when choosing appropriate measures for post-operative outcome evaluation after ACL surgery.

Level of evidence

I.

     

A new technique in double-bundle anterior cruciate ligament reconstruction with implant-free tibial fixation

Purpose

This case-series outcome study presents a surgical technique for anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with 4-tunnel using two interference screws. There was a 2-year minimum follow-up.

Methods

From January to December 2009, an ACL 4-tunnel, anatomic, double-bundle reconstruction was performed on 27 patients. Double-strand hamstring tendon grafts were used in each femoral tunnel as well as two interference screws. Tibial fixation was insured through manual tension, by tying non-absorbable sutures on the bone bridge between the two tunnels at 20° of knee flexion. Clinical assessments included the International Knee Documentation Committee (IKDC) and Lysholm knee scores, range of motion (ROM), pivot-shift test, single-leg hop, and quadriceps-hamstrings strength tests using a hand-held dynamometer. Anterior knee laxity was also assessed using a rolimeter. A single examiner performed all testing pre-operatively at 6 months and during the 2-year follow-up.

Results

All patients were assessed during the 2-year follow-up. At that time, 92 % of the patients presented normal anterior laxity (average, 1.3 ± 0.5 mm) and rotational knee stability. No statistical side-to-side difference was found for ROM, muscle strength, single-leg hop, and function (n.s.). All patients presented a normal knee function according to the IKDC and the Lysholm score. In addition, no infection, graft failure, or pain were observed at the harvesting site.

Conclusion

The study shows that satisfactory results in relation to knee laxity, function, and strength can be achieved with the implant-free tibial fixation in the ACL double-bundle reconstruction with two interference screws.

Level of evidence

Therapeutic case series, Level IV.

     

Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence

Purpose

The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non-operative treatment may not be as important as rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization. The purpose of this meta-analysis of randomized controlled trials (RCTs) was to compare functional rehabilitation to immobilization in the treatment of ATR.

Method

This meta-analysis was conducted using the databases: PubMed, EMBASE, Rehabilitation and Sports Medicine Source, AMED, CINAHL, Cochrane Library and PEDro using the search terms: “Achilles tendon,” “rupture,” “mobilization” and “immobilization”. Seven RCTs involving 427 participants were eligible for inclusion, with a total of 211 participants treated with functional rehabilitation and 216 treated with immobilization.

Results

Re-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction were examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes.

Conclusion

Functional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. A trend toward earlier return to work and sport, and increased patient satisfaction was found when functional rehabilitation was used. The present literature is of low-to-average quality, and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings.

Level of evidence

II.

     

No differences between fixed- and mobile-bearing total knee arthroplasty

Purpose

For years, numerous studies have been performed to determine whether mobile-bearing total knee arthroplasty (MB-TKA) or fixed-bearing total knee arthroplasty (FB-TKA) is the preferential design in total knee arthroplasty. Reviews and meta-analyses on this subject have focused on a relatively small number of randomised controlled trials, possibly missing important results of smaller studies. The goal of this review was to provide a comprehensive overview of all literature comparing MB-TKA and FB-TKA in the treatment of osteoarthritis of the knee.

Methods

An extensive literature search was performed in the PubMed database. All studies that compared MB-TKA with FB-TKA and looked at one of four theorised advantages (insert wear, signs of loosening, survival rate of the prosthesis and clinical outcome) were included.

Results

The initial search yielded 258 articles, of which 127 were included after the first screening. The included studies consisted of 9 meta-analyses, 3 systematic reviews, 48 RCT’s, 44 comparative studies, 10 reviews and 13 studies that examined patients who received bilateral TKA (one MB-TKA and one FB-TKA). Combining the results of all studies showed that almost all studies found no difference between MB-TKA and FB-TKA.

Conclusions

Even when examining all different types of studies on MB-TKA and FB-TKA, the results of this review showed no difference in insert wear, risk of loosening, survivorship or clinical outcome. In daily practice, the choice between MB-TKA and FB-TKA should be based on the experience and judgment of the surgeon, since no clear differences are observed in the scientific literature.

Level of evidence

III.