Correlation among Knee Muscle Strength and Self-Reported Outcomes Score, Anterior Tibial Displacement, and Time Post-Injury in Non-Coper Anterior Cruciate Ligament Deficient Patients: A Cross-Sectional Study

Little attention has been paid to knee muscle strength after ACL rupture and its effect on prognostic outcomes and treatment decisions. We studied hamstrings (H) and quadriceps (Q) strength correlation with a patient-reported outcome measures score (International Knee Documentation Committee, IKDC), anterior tibial translation (ATT), and time post-injury in 194 anterior cruciate ligament deficient patients (ACLD) who required surgery after a failed rehabilitation program (non-copers). The correlation between knee muscle strength and ATT was also studied in 53 non-injured controls. ACLD patients showed decreased knee muscle strength of both the injured and non-injured limbs. The median (interquartile range) values of the H/Q ratio were 0.61 (0.52–0.81) for patients’ injured side and 0.65 (0.57–0.8) for the non-injured side (p = 0.010). The median H/Q ratio for the controls was 0.52 (0.45–0.66) on both knees (p < 0.001, compared with the non-injured side of patients). The H/Q, ATT, and time post-injury were not significantly correlated with the IKDC score. ATT was significantly correlated with the H/Q of the injured and non-injured knees of patients, but not in the knees of the controls. Quadriceps strength and H/Q ratio were significantly correlated with ATT for both limbs of the patients. IKDC score correlated significantly with the quadriceps and hamstrings strengths of the injured limb but not with the H/Q ratio, ATT or time passed after injury.

A prospective evaluation of strength and endurance of ankle dorsiflexors-plantar flexors after conservative management of lateral malleolar fractures

Objectives: This study aims to evaluate patients with conservatively treated stable lateral malleolar fractures with isokinetic tests. Patients and methods: Between January 2016 and November 2017, a total of 24 patients (12 males, 12 females; mean age 40.8±15.0 years; range, 18 to 68 years) with an isolated stable lateral malleolar fracture treated conservatively with the circular cast were included in this prospective study. Calf circumferences, ankle range of motion (ROM), pain levels, and functional outcomes were recorded. The muscle strengths and endurance of the injured side were compared with the non-injured side. All patients were evaluated by isokinetic test after removal of the cast, and three and six months after the rehabilitation period. Results: The ROM was found to be lower after removal of the plaster cast, compared to the contralateral ankle. During cast removal, we also found that both dorsiflexor and plantar flexor muscle strength decreased by 25.6% and 44.7%, respectively, and decreased to 10.3% and 3.6% at three months post-rehabilitation. At the end of six months, no statistically significant difference was found between the two sides. In the dorsiflexion-plantar flexion endurance values, 37.8% and 54.1% deficit were detected before the rehabilitation protocol, respectively (p<0.05). At three months, these values decreased to 6.1% and 13.6%, respectively and the endurances of the injured sides surpassed the non-injured sides (p<0.05) at six months. Conclusion: Conservative management of stable isolated lateral malleolar fractures with circular cast causes atrophy and decreases strength-endurance of the calf muscles due to immobilization. These changes are expected to diminish over time and functional outcomes are excellent with a good rehabilitation program.

Gait biomechanics in patients with intra-articular tibial plateau fractures – gait analysis at three months compared with age- and gender-matched healthy subjects

Introduction Tibial plateau fractures involve the knee joint, one of the most weight-bearing joints in the body. Studies have shown that gait asymmetries exist several years after injury. Instrumental gait analysis, generating both kinematic and kinetic data from patients with tibial plateau fractures, is uncommon. Aim To examine walking ability and knee range of motion in patients suffering intra-articular tibial plateau fractures. Method Twenty participants, eight males and 12 females, aged 44 years (range 26–60), with unilateral isolated tibial plateau fractures, were examined 12 weeks (range 7–20) after injury. The investigation consisted of passive range of motion (ROM) using a goniometer, six-minute walking test (6 MW), pain estimation using the visual analogue scale (VAS), the “Knee injury and Osteoarthritis Outcome Score” (KOOS) self-assessment questionnaire and instrumental 3-dimensional gait analysis (3DGA). 3DGA included spatiotemporal variables (speed, relative stance time, step length), kinematic variables (knee flexion, knee extension, ankle dorsiflexion) and kinetic variables (generating knee power (extension) and ankle power (plantarflexion)). A skin marker model with twenty reflective markers was used. Non-parametric tests were used for comparisons of the injured leg, the uninjured leg and a reference group. Result The participants walked more slowly compared with healthy references (p < 0.001). Stance time and step length was shorter for the injured side compared with the uninjured side (p < 0.014). Step length was shorter compared with the reference group (p = 0.001). The maximum knee extension in the single stance phase was worse in the injured side compared with the uninjured side and the reference group (p < 0.001) respectively. The maximum ankle dorsiflexion during stance phase was higher in the injured leg compared with the uninjured side and the reference group (p < 0.012). Maximum generated power in the knee was lower in the injured side compared with the uninjured side and the reference group (p < 0.001 respectively). The same was true of maximum power generated in the ankle (p < 0.023). The median KOOS value was lower in the study group (p < 0.001). ROM showed decreased flexion and extension in the knee joint and decreased dorsiflexion in the ankle joint compared with the uninjured side (p < 0.006). The average distance in the six-minute walking test was shorter in the study group (p < 0.001). Conclusion Patients who have sustained tibial plateau fractures generally display a limitation in their walking pattern 3 months after injury. These limitations are mainly related to the inability to extend the knee.

Clinical outcomes of arthroscopic and navigation-assisted two tunnel technique for coracoclavicular ligament augmentation of acute acromioclavicular joint dislocations

Background The purpose of this study was to present a navigated image-free augmentation technique for the acromioclavicular joint (ACJ) and coracoclavicular (CC) ligaments and to report the clinical and radiological outcomes. Methods From 2013 to 2018, 35 eligible patients were treated with our navigated image-free ACJ- and CC-augmentation technique. The average follow-up was 3 years. Follow-up evaluations included the Constant-Murley Score, subjective shoulder value, Taft score, and the acromioclavicular joint instability (ACJI) score. The patients’ quality of life was assessed using the EuroQol-5D (EQ-5D) questionnaire. In addition, in accordance with the instability criteria, radiographs were evaluated before surgery, after surgery, and during follow-up. Results Overall, 25 patients (71%) suffered an acute type V disruption, 5 (14%) had a type IV disruption, and 5 (14%) had an acute Rockwood type IIIb injury. The mean Constant-Murley Score was 90 (range: 56–100; p = 0.53) on the injured side, and the mean subjective shoulder value was 92% (range: 80–100%). The mean Taft and ACJI scores were 10 (range: 4–12) and 86 (range: 34–100), respectively and the mean EQ-5D was 86 (range: 2–100). The mean CC difference of the injured side was 4 mm (range: 1.9–9.1 mm) at follow-up, which was not significantly different than that of the healthy side (p = 0.06). No fractures in the area of the clavicle or the coracoid were reported. Conclusions The arthroscopic- and navigation-assisted treatment of high-grade ACJ injuries in an anatomical double-tunnel configuration yields similar clinical and radiological outcomes as the conventional technique using an aiming device. Precise positioning of the navigation system prevents multiple drillings, which avoids fractures.

Treatment of Acute Acromioclavicular Joint Dislocations Type III and Type V by Rockwood Classification Using a Dynamic Stabilization System under Arthroscopic Control with and without Suture of the Ligaments of the Acromioclavicular Joint

Summary. Acute acromioclavicular (AC) joint dislocation is still a challenging task for orthopedic surgeons. Objective: to compare the clinical and radiological results of treatment of patients with acute dislocation of the acromial end of the clavicle who were treated with a dynamic stabilization system with and without suture of acromioclavicular ligaments under arthroscopic control. Materials and Methods. A retrospective analysis of the treatment of 44 patients with acute AC joint dislocations type III and type V by Rockwood classification was performed. The patients were divided into 2 groups: group I – 18 patients (40.9%) who underwent stabilization of the dislocation and fixation of the acromial end of the clavicle using a dynamic stabilization system and suture of the ligaments of the acromioclavicular joint under arthroscopic control; group II – 26 patients (59.1%) who underwent stabilization of the dislocation and fixation of the acromial end of the clavicle using a dynamic stabilization system without suture of the ligaments of the acromioclavicular joint under arthroscopic control. There were 40 male (90.9%) and 4 female (9.1%) patients aged 18–58 years (mean age 32.9±10.1 years). The mean time from injury to surgical treatment was 8.3±3.2 days (from 3 to 17 days). Clinical observation was carried out at an average time of 20.1±3.9 months after surgery (from 12 to 28 months). Clinical outcomes were assessed using the Oxford Shoulder scale, the Constant-Murley scale, and the Acromioclavicular Joint Instability Scoring System. Results. The mean Oxford Shoulder score at the final follow-up on the injured side was 45.8±1.3 points and 46.2±1.3 points (p=0.422) in groups I and II, respectively. The mean Constant-Murley score at the final follow-up on the injured side was 94.6±2.4 points and 91.7±4.2 points (p=0.0134) in groups I and II, respectively. The mean score on the Acromioclavicular Joint Instability Scoring System at the final follow-up on the injured side was 83.8±7.1 points and 78.1±11.8 points (p=0.075) in groups I and II, respectively. No significant complications were observed in both groups. Conclusions. The combination of the arthroscopically assisted technique of reconstruction of the acromioclavicular ligaments using high-strength sutures and fixation of the coracoclavicular ligaments using a dynamic stabilization system provides good long-term clinical results.

Mechanosensitive TRPV4 Channel-Induced Extracellular ATP Accumulation at the Acupoint Mediates Acupuncture Analgesia of Ankle Arthritis in Rats

(1) Background: Acupuncture (AP) is a safe and effective analgesic therapy. Understanding how fine needles trigger biological signals can help us optimize needling manipulation to improve its efficiency. Adenosine accumulation in treated acupoints is a vital related event. Here, we hypothesized that extracellular ATP (eATP) mobilization preceded adenosine accumulation, which involved local activation of mechanosensitive channels, especially TRPV4 protein. (2) Methods: AP was applied at the injured-side Zusanli acupoint (ST36) of acute ankle arthritis rats. Pain thresholds were assessed in injured-side hindpaws. eATP in microdialysate from the acupoints was determined by luminescence assay. (3) Results: AP analgesic effect was significantly suppressed by pre-injection of GdCl3 or ruthenium red in ST36, the wide-spectrum inhibitors of mechanosensitive channels, or by HC067047, a specific antagonist of TRPV4 channels. Microdialysate determination revealed a needling-induced transient eATP accumulation that was significantly decreased by pre-injection of HC067047. Additionally, preventing eATP hydrolysis by pre-injection of ARL67156, a non-specific inhibitor of ecto-ATPases, led to the increase in eATP levels and the abolishment of AP analgesic effect. (4) Conclusions: These observations indicate that needling-induced transient accumulation of eATP, due to the activation of mechanosensitive TRPV4 channels and the activities of ecto-ATPases, is involved in the trigger mechanism of AP analgesia.

Casting in finger trap traction without reduction versus closed reduction and percutaneous pin fixation of dorsally displaced, over-riding distal metaphyseal radius fractures in children under 11 years old: a study protocol of a randomised controlled trial

IntroductionDistal radius is the most common site of fracture in children, comprising 23%–31% of all paediatric fractures. Approximately one-fifth of these fractures are displaced. Completely displaced distal metaphyseal radius fractures in children have traditionally been treated with closed reduction. Recent evidence suggests that correcting the shortening in over-riding distal metaphyseal radius fractures is not necessary in prepubertal children. To date, no published randomised controlled trial (RCT) has compared treatment of these fractures in children by casting the fracture in bayonet position to reduction and pin fixation.Methods and analysisWe will conduct an RCT to compare the outcomes of casting the fracture in bayonet position in children under 11 years of age to reduction and percutaneous pin fixation. 60 patients will be randomly assigned to casting or surgery groups. We have two primary outcomes. The first is ratio (injured side/non-injured side) in the total active forearm rotation and the second is ratio (injured side/non-injured side) in total active range of motion of the wrist in the flexion–extension plane at 6 months. The secondary outcomes will include axial radiographic alignment, passive extension of the wrists, grip strength and length of forearms and hands, patient-reported outcome QuickDASH and pain questionnaire PedsQL. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort. Patients not eligible for randomisation will be asked to participate in a non-eligible cohort. These cohorts are included to enhance the external validity of the results of the RCT. Our null hypothesis is that the results of the primary outcome measures in the casting group are non-inferior to surgery group.Ethics and disseminationThe institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings through peer-reviewed publications.Trial registration numberNCT04323410.ProtocolV.1.1, 29 September 2020.

Clinical efficacy of treating the first metacarpal base fracture by closed reduction and percutaneous parallel K-wire interlocking fixation

Objective: To explore the clinical efficacy of treating a first metacarpal base fracture by closed reduction and percutaneous parallel K-wire interlocking fixation between the first and second metacarpals.Methods: Twenty patients treated by the above technique from October 2015 to December 2018 at our institution were retrospectively reviewed. The patients’ average age was 36 years (range, 16–61 years). Eleven patients were extra-articular fractures and nine were intra-articular fractures. The mean follow-up period was 12 months (range, 10–18 months). At the final follow-up, the functional recovery of the injured hand was assessed and compared with that of the uninjured hand.Results: All patients recovered well with no complications. In the extra-articular fracture group, the mean hand grip strength, pinch strength, and Kapandji score were 43.4 ± 7.0 kg, 9.1 ± 1.4 kg, and 9.5 ± 0.7 on the injured side and 41.7 ±6.8 kg, 8.7 ± 0.8 kg, and 9.7 ± 0.5 on the uninjured side, respectively, with no significant differences. In the intra-articular fracture group, the above indexes were 43.0 ± 6.5 kg, 9.0 ± 1.1 kg, and 9.3 ± 0.7 on the injured side and 42.1 ± 6.6 kg, 8.6 ± 1.1 kg, and 9.7 ± 0.5 on the uninjured side, respectively, also with no significant differences. The abduction and flexion-extension arc of the thumb on the injured hand were lower than those on the uninjured hand in both the extra-articular and intra-articular fracture groups, but the patients felt clinically well with respect to daily activities and strength.Conclusion: The percutaneous parallel K-wire and the interlocking fixation technique is simple, effective, and economic for first metacarpal base fractures.

Open reduction and internal fixation for displaced Salter-Harris type II fractures of the distal tibia: a retrospective study of sixty-five cases in children

Background The treatment for displaced Salter-Harris II (S-H II) distal tibia fractures remains controversial. The purpose of this study was to review S-H II distal tibia fractures and evaluate the rate of premature physeal closure (PPC) treated by open reduction and internal fixation (ORIF). Methods We reviewed the charts and radiographs of S-H II fractures of the distal tibia with displacement > 3 mm between 2012 and 2019 treated by ORIF. Patients were followed up for a minimum of 6 months. CT scans of injured side or contralateral ankle radiograph were obtained if there was any evidence of PPC. Any angular deformity or shortening of the involved leg was documented. Multivariable logistic regression was performed to identify risk factors for the occurrence of PPC. Results A total of 65 patients with a mean age of 11.8 years were included in this study. The mean initial displacement was 8.0 mm. All patients but one were treated within 7 days after injury and the mean interval was 3.7 days. Supination-external rotation injuries occurred in 50 patients, pronation-eversion external rotation in 13, and supination-plantar flexion in two. The residual gap was less than 1 mm in all patients following ORIF and all fractures healed within 4–6 weeks. Superficial skin infection developed in one patient. Ten patients complained of the cosmetic scar. The rate of PPC was 29.2% and two patients with PPC developed a varus deformity of the ankle. Patients with associated fibular fracture had 7 times greater odds of developing PPC. Age, gender, injured side, mechanism of injury, amount of initial displacement, interval from injury to surgery, or energy of injury did not significantly affect the rate of PPC. Conclusions ORIF was an effective choice of treatment for S-H II distal tibia fractures with displacement > 3 mm to obtain a satisfactory reduction. PPC is a common complication following ORIF. The presence of concomitant fibula fracture was associated with PPC.

Neuromechanical activation of triceps surae muscle remains altered at 3.5 years following open surgical repair of acute Achilles tendon rupture

Purpose To assess whether the neuromuscular activation pattern following Achilles tendon rupture and repair may contributes to the observable functional deficits in this severe and increasingly frequent injury. Methods In this study, the neuromuscular activation using surface EMG of n = 52 patients was assessed during a battery of functional performance tasks to assess potential alterations of muscular activation and recruitment. We analyzed the injured leg vs. the contralateral healthy leg at a mean of 3.5 years following open surgical repair. The testing battery included isokinetic strength testing, bipedal and single-legged heel-rise testing as well as gait analysis. Results During isokinetic testing, we observed a higher activation integral for all triceps surae muscles of the injured side during active dorsiflexion, e.g., eccentric loading on the injured leg, while concentric plantarflexion showed no significant difference. Dynamic heel-rise testing showed a higher activation in concentric and eccentric loading for all posterior muscles on the injured side (not significant); while static heel-rise for 10 sec. revealed a significantly higher activation. Further analysis of frequency of fast Fourier-transformed EMG revealed a significantly higher median frequency in the injured leg. Gait analysis revealed a higher pre-activation of the tibialis anterior before ground contact, while medial and lateral gastrocnemius muscles of the injured leg showed a significantly higher activation during push-off phase. Conclusions The results of this study provide evidence on the neuromuscular changes 3.5 years following open surgical Achilles tendon repair. These complex neuromuscular changes are manifested to produce the maximum force output whilst protecting the previously injured tendon. The observed alterations may be related to an increased recruitment of type II muscle fibers which could make the muscles prone to fatigue. Level of evidence III.