Influence of axial limb rotation on radiographic lower limb alignment: a systematic review

Introduction The influence of limb malrotation on long-leg radiographs (LLR) is frequently discussed in literature. This systematic review aimed to describe the influence of limb rotation on alignment measurements alone and in combination with knee flexion, and determine its clinical impact. Materials and methods A literature search was conducted in June 2021 using the databases MEDLINE, Cochrane, Web of Science (Clarivate Analytics), and Embase. The search term ((radiograph OR X-ray) AND (position OR rotation) AND limb alignment) was used. Database query, record screening, and study inclusion and exclusion were performed by two reviewers independently. Experimental studies (using either specimens or synthetic bones) or clinical studies (prospective or retrospective using radiographs of patients) analyzing the influence of limb rotation on anatomic and mechanical limb alignment measurements were included. Characteristics and results of the included studies were summarized, simplified, and grouped for comparison to answer the research question. Studies were compared descriptively, and no meta-analysis was performed. Results A total of 22 studies were included showing large heterogeneity, comprising studies with cadavers, patients, and synthetic bones. Most studies (7 out of 8) reported that external rotation (ER) causes less apparent valgus and leads to more varus and internal rotation (IR) causes more valgus and leads to less varus. However, there is no consensus on the extent of rotation influencing alignment measures. Studies reported about an average change of > 2° (n = 4) and < 2° (n = 4) hip-knee-ankle angle (HKA) between 15°IR and 15°ER. There is a consensus that the impact of rotation on mechanical alignment is higher if additional sagittal knee angulation, such as knee flexion, is present. All five studies analyzing the influence of rotation combined with knee flexion (5°–15°) showed an HKA change of > 2° between 15°IR and 15°ER. Conclusion Malrotation is frequently present on LLR, possibly influencing the measured alignment especially in knees with extension deficit. Surgeons must consider this when measuring and treating deformities (high tibial osteotomy or total knee arthroplasties), and analyzing surgical outcomes. Especially in patients with osteoarthritis with knee extension deficits or postoperative swelling, the effect of malrotation is significantly greater.

Clinical results after very early, early and late arthroscopic arthrolysis of the knee

Purpose Impaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early (< 3 months), early (3 to 6 months), and late (> 6 months) arthroscopic arthrolysis of the knee. Methods With a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ < 90° of flexion) were included between 2013 and 2018 in the retrospective study, while eight patients were lost to follow-up. A total of 115 patients were examined with a minimum follow-up of two years. Twenty percent (n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early (< 3 months, mean 1.8 months) arthroscopic arthrolysis, and 37 had early (3 to 6 months, mean 4.3 months) and 41 late (> 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery. Results The average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p < 0.001). In the group of very early (< 3 months) arthroscopic arthrolysis 76% (n = 28) of the patients had a normal ROM (extension/flexion 0/140°), in the group of early (3–6 months) arthrolysis 68% (n = 25) of the patients and in the group of late arthrolysis 41.5% (n = 17) of the patients showed a normal ROM after surgery (p = 0.005). The total ROM after arthrolysis was also significantly increased in the group of very early and early arthrolysis (136.5° and 135.3° vs. 123.7°, p < 0.001). A post-operative flexion deficit occurred significantly less in the group of very early and early arthroscopic arthrolysis compared to the late arthroscopic arthrolysis (3.9° and 4.2° vs. 16.6°, p < 0.001). Patients treated with very early (< 3 months) and early (3 to 6 months) showed a significantly increased post-operative Tegner score of 4.8 ± 1 and 4.7 ± 1.1 compared to 3.8 ± 1.1 in the group of late arthroscopic arthrolysis (> 6 months, p < 0.001). Conclusions An arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).

Prognostic Factors for Patient-Reported Outcomes at 32 to 37 Years After Surgical or Nonsurgical Management of Anterior Cruciate Ligament Injury

Background: Knowledge to inform the identification of individuals with a poor long-term prognosis after anterior cruciate ligament (ACL) injury is limited. Identifying prognostic factors for long-term outcomes after ACL injury may inform targeted interventions to improve outcomes for those with a poor long-term prognosis. Purpose: To determine whether ACL treatment (early augmented or nonaugmented ACL repair plus rehabilitation, rehabilitation alone, or rehabilitation plus delayed ACL reconstruction [ACLR]) and 4-year measures (quadriceps and hamstrings strength, single-leg hop, knee laxity, flexion and extension deficit, self-reported knee function, activity level) are prognostic factors for patient-reported outcomes at 32 to 37 years after acute ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 251 patients aged 15 to 40 years with acute ACL rupture between 1980 and 1985 were allocated to early ACL repair (augmented or nonaugmented) plus rehabilitation or to rehabilitation alone, based on birth year. One hundred ninety of 234 completed 32- to 37-year follow-up questionnaires (response rate, 81%); 18 people were excluded, resulting in 172 patients available for analysis (mean age, 59 ± 6 years; 28% female). Potential prognostic factors assessed 4 years after ACL injury were ACL treatment (early ACL repair, rehabilitation alone, or delayed ACLR), isokinetic quadriceps and hamstrings strength, single-leg hop performance, knee flexion and extension deficit, knee laxity, Tegner activity scale, and Lysholm score. Outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and the Anterior Cruciate Ligament Quality of Life (ACL-QOL) measure. Linear regression adjusted for age, sex, baseline meniscal injury, and contralateral ACL injury was used to assess potential prognostic factors for 32- to 37-year outcomes. Multiple imputation accounted for missing data. Results: A fair/poor Lysholm score (vs excellent/good) at 4 years was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −12 [95% confidence interval (CI), −19 to −4]), KOOS Symptoms (−15 [95% CI, −23 to −7]), KOOS Sport and Recreation (−19 [95% CI, −31 to −8]), and ACL QOL (−9 [95% CI, −18 to −1]) scores. A 4-year single-leg hop limb symmetry index <90% was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −9 [95% CI, −17 to −1]) and ACL QOL (−13 [95% CI, −22 to −3]) scores at long-term follow-up. A lower activity level, delayed ACLR, and increased knee laxity were prognostic factors in the crude analysis. Rehabilitation alone versus early repair, quadriceps and hamstring strength, and flexion and extension deficit were not related to 32- to 37-year outcomes. Conclusion: Reduced self-reported knee function and single-leg hop performance 4 years after ACL injury were prognostic factors for worse 32- to 37-year outcomes. Estimates exceeded clinically important thresholds, highlighting the importance of assessing these constructs when managing individuals with ACL injuries. Registration: NCT03182647 ( ClinicalTrials.gov identifier).

The significance of post-operative bracing in preventing knee arthrofibrosis after ACL reconstruction

High-energy injuries of the knee joint can cause ligament damage which may have complications in 4-6% of all cases in the form of movement limitation and arthrofibrosis (5,9,14). There are several intra- and extraarticular factors that could be closely connected with formation of arthrofibrosis. One of the most important factors is the utilization of a knee brace as the means of immobilization during the post-operative period (7,8). There are various opinions on the matter of using a knee brace after an ACL reconstruction surgery. For instance, 85% of members of the American Orthopedic Society for Sports Medicine (AOSSM) support and utilize this method (6). Despite the fact that movement limitations in the affected joint are rare after the aforementioned surgical procedure, the issue of preventing and eliminating knee extension deficit during the post-operative period is still relevant. The following research is based on the evaluation of the findings in 22 patients with extension deficits 2 weeks after arthroscopic ACL reconstruction surgery and it studies the effectiveness of knee brace in eliminating extension limitation during a 3-week rehabilitation period. The results of the abovementioned research showed that utilization of knee brace in the rehabilitation process during 3 weeks is significantly effective method (P<0.008) for eliminating knee extension deficit in a way that the negative influence on the function of the quadriceps muscle of the affected limb stays negligible.

SEX, PATELLAR TENDON GRAFT, AND EARLY MOTION DEFICITS PREDICT ARTHROFIBROSIS AFTER PEDIATRIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Background: Arthrofibrosis remains a concerning early complication after anterior cruciate ligament reconstruction (ACLR) in children and adolescents. Previous studies suggest that those receiving patellar tendon (PT) autograft may be at higher risk than hamstrings tendon (HT), but there is little data regarding this complication in patients receiving quadriceps tendon (QT) autograft. Purpose: The purpose of this study is to identify risk factors for arthrofibrosis following pediatric ACLR with attention to graft type. Methods: The medical records of patients that underwent primary ACLR at a single tertiary children’s hospital were reviewed for this retrospective cohort study. Those with multiligament reconstructions, lateral extra-articular tenodesis procedures, or a modified MacIntosh reconstruction were excluded. Arthrofibrosis was defined as a deficit of 10 degrees of extension and/or 20 degrees of flexion at 3 months after ACLR. Demographic data, intra-operative findings and techniques, and post-operative motion and complications were recorded. Univariate analysis was followed by purposeful entry logistic regression to control for confounding factors. Results: A total of 378 patients were included in the analysis, of which there were 180 PT, 103 HT, and 95 QT grafts. The mean age was 15.9±1.7 years and 188 (49.7%) were female. In univariate analysis, the rate of arthrofibrosis was 1.9% for HT, 6.3% for QT, and 10.0% for PT (p=0.04). Females developed arthrofibrosis more frequently than males (10.6% vs. 3.2%, p=0.004). Additionally, those that ultimately experienced this complication had lower median flexion at 6 weeks after ACLR (88 vs. 110 degrees, p<0.001). After controlling for covariates in a multivariate model, PT graft raised the odds of arthrofibrosis 6.2 times compared to HT (95% CI 1.4-27.6, p=0.02), but there were no significant differences between QT and other graft types. Females were at 4.2 times higher odds than males (95% CI 1.6-10.8; p=0.003). Patients that were unable to attain 90 degrees of flexion 6 weeks after ACLR had 14.7 times higher odds of eventually developing arthrofibrosis (95% CI 5.4-39.8; p<0.001). Finally, those with an extension deficit of ≥5 degrees 6 weeks after ACLR had 4.7 times higher odds of experiencing this complication (95% CI 1.8-12.2, p=0.001). Conclusion: After adjusting for multiple covariates, PT autograft, female sex, and motion deficits at 6 weeks after ACLR (<90 degrees of flexion or extension deficit ≥5 degrees) were predictive of arthrofibrosis in children and adolescents. Quadriceps tendon autograft did not increase the risk of this complication.

Hand function and cost effectiveness after collagenase injection versus aponeurectomy for Dupuytren’s contracture: results of the CeCORD-J study

BackgroundThis study compared hand function and the cost effectiveness of treatment between collagenase Clostridium histolyticum (CCH) injection and limited fasciectomy for patients with Dupuytren’s contracture (DC).Materials and MethodsThe CeCORD-J study is a prospective, multicenter, non-randomized controlled, observational study of two parallel groups. Participants were DC patients with multiple affected fingers, including flexion contracture of the proximal interphalangeal (PIP) joint. The primary outcome was the Hand10 score, as a patient-reported outcome measure. We set secondary outcomes of EQ-5D-5L score, degree of extension deficit, and direct cost. Propensity score adjustment was used to balance differences in patient characteristics between groups.ResultsParticipants comprised 52 patients in the Collagenase group and 26 patients in the Surgery group. Hand10 score was significantly better in the Collagenase group at 1 and 2 weeks. EQ-5D-5L score was significantly higher in the Collagenase group at 8 weeks. Mean direct cost was 248,000 yen higher in the Surgery group than in the Collagenase group. Extension deficit angle of the PIP joint was significantly larger in the Collagenase group at 26 weeks.ConclusionsCCH injection provides better short-term hand function and cost effectiveness than surgery.UMIN-CTR (UMIN000029826)

Arthroscopic Repair in Tibial Spine Avulsion Fractures Using Polyethylene Terephthalate Suture: Good to Excellent Results in Pediatric Patients

Background: The objective of the arthroscopic treatment in tibial spine avulsion fractures (TSAF) is to achieve firm reduction and strong internal fixation while still having the patient undergo a minimally invasive procedure. Material and methods: The study was performed on 12 young patients with avulsion fracture of the anterior tibial spine. All 12 patients had type 3 Modified Meyers and McKeever fractures. The injury mechanism was direct anterior to posterior trauma in full leg length hyperextension with sport trauma reported in all cases. The physical examination revealed decreased range of motion, extension deficit, and pain during walking. Radiology, MRI, and CT pathologic findings described complete fracture of the anterior tibial spine with no clear signs of callus formation at the time of examination. All patients underwent arthroscopic suture surgical treatment. The Tegner, the Lysholm, and the International Knee Documentation Committee (IKDC) scores were used to evaluate subjective outcomes at three and six months after the surgery. Radiographs were used to assess callus formation and healing status of the fracture. Results: The mean IKDC score was 33.4 ± 23.3 (p = 0.032) preoperatively and 84.2 ± 14.3 at final follow-up (p = 0.0032, CI = 95%). The mean Tegner score improved from 3.8 ± 1.1 pre-operatively to 6.7 ± 2.2 at six months follow-up (p = 0.0231, CI = 95%). The Lysholm score differed significantly at baseline compared to final follow-up (53.7 ± 17.3 vs. 87.7 ± 9.9; p = 0.0066, CI = 95%). In all cases (n = 12), the radiographs taken after six months revealed the healing of the fracture in the anatomic position without secondary displacement. No functional knee instability was detected at the end of the study. Conclusions: The study provides preliminary promising results regarding fracture healing, knee stability, and functional subjective scores. Patient selection was a major factor of success prediction for this technique.

Hand function 5 years after treatment with collagenase Clostridium histolyticum injection for Dupuytren’s disease

The aim of this study was to report hand function, disability and satisfaction and patients’ perception of functionally troublesome contractures 5 years after injection with collagenase Clostridium histolyticum and hand therapy for Dupuytren's disease. Data from 79 patients were collected before and at 3, 12 and 60 months after treatment. Hand function was significantly improved, and 70% achieved a functional range of motion in the treated hand. QuickDASH scores and range of motion were best at 3 months follow-up. At 60 months, mean total extension deficit was 48°, which was 57% of the deficit before treatment. Thirty-seven patients (47%) had developed recurrent contractures in treated finger(s) meeting the criteria for new treatment. The threshold for functionally troublesome contractures was found to be 30°–60° in the finger joints. Treatment was experienced as painful, but few hand function problems occurred. Most patients would choose this treatment method again. Level of evidence: IV

Comparison of Hand Therapy with or without Splinting Postfasciectomy for Dupuytren’s Contracture: Systematic Review and Meta-Analysis

This study aimed to compare the outcomes of hand therapy alone versus additional splinting post fasciectomy for Dupuytren’s contracture patients. A systematic review and meta-analysis were conducted, and a search was performed identifying all relevant studies comparing the two groups. Primary outcome measures included Total active flexion and extension (TAF and TAE) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Secondary outcome measures included pain intensity, grip strength, and global perceived effect and patients’ satisfaction. A random effects model was used for the analysis. Four RCTs were identified enrolling 295 patients. There were no significant differences between hand therapy and splintage groups in terms of all outcomes (both primary and secondary). Splintage offers no added functional benefit to hand therapy alone for post fasciectomy patients with Dupuytren’s contracture, however, orthotic regimes may still be applied on an intention to treat basis in those patients who develop an extension deficit postoperatively.

Comparison between Flexor Carpi Radialis and Flexor Carpi Ulnaris Tendon Transfer for Fingers’ Extension in High Radial Nerve Palsy

The hand grip is severely impaired following high radial nerve palsy due to loss of extension of the wrist, metacarpo- phalangeal joint of fingers and thumb. If radial nerve does not show neural recovery following conservative or surgical repair during the optimum time, tendon transfer is considered the standard treatment. To evaluate and compare the clinical outcome between flexor carpi radialis and flexor carpiulnaris tendon transfer for fingers’ extension in high radial nerve palsy. This randomized controlled trial study was carried out in the Department of Orthopedic Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka over a period of two years from January 2013 to December 2014. A total of 30 patients with high radial nerve palsy were recruited, 15 patients were gone through Flexor Carpi Radialis tendon transfer procedure (FCR group) and the rest 15 patients were gone through Flexor Carpi Ulnaris tendon transfer procedure(FCU group). The patients were followed up for 12 weeks after surgical intervention. Out of all patients, 86.7% male were encountered in each group. The mean age was found 31.07±9.14 years in FCR group and 33.60±10.79 years in FCU group. Humerus fracture was remained a major cause of radial nerve palsy in both FCR and FCU groups (26.7% vs. 33.3%). In final follow-up at 12th week, no extension deficit was observed at MCP joint (93.3% vs. 80.0%, p>0.05).The end result of surgical intervention was found satisfactory equally in both the groups (86.7%). In case of high radial nerve palsy, both FCR and FCU tendon transfer procedures are effective forfingers’ extension at MCP joint. Bangladesh Med J. 2019 Sep; 48 (3): 9-15