Externally validated treatment algorithm acceptably predicts nonoperative treatment success in patients with anterior cruciate ligament rupture

PURPOSE

This study aims to develop and externally validate a treatment algorithm to predict nonoperative treatment success or failure in patients with anterior cruciate ligament (ACL) rupture.

METHODS

Data were used from two completed studies of adult patients with ACL ruptures: the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation study (development cohort) and the KNee osteoArthritis anterior cruciate Ligament Lesion study (validation cohort). The primary outcome variable is nonoperative treatment success or failure. Potential predictor variables were collected, entered into the univariable logistic regression model and then incorporated into the multivariable logistic regression model for constructing the treatment algorithm. Finally, predictive performance and goodness-of-fit were assessed and externally validated by discrimination and calibration measures.

RESULTS

In the univariable logistic regression model, a stable knee measured with the pivot shift test and a posttrauma International Knee Documentation Committee (IKDC) score <50 were predictive of needing an ACL reconstruction. Age >30 years and a body mass index > 30 kg/m2 were predictive for not needing an ACL reconstruction. Age, pretrauma Tegner score, the outcome of the pivot shift test and the posttrauma IKDC score are entered into the treatment algorithm. The predictability of needing an ACL reconstruction after nonoperative treatment (discrimination) is acceptable in both the development and the validation cohort: area under the curve = resp. 0.69 (95% confidence interval [CI]: 0.58-0.81) and 0.68 (95% CI: 0.58-0.78).

CONCLUSION

This study shows that the treatment algorithm can acceptably predict whether an ACL injury patient will have a(n) (un)successful nonoperative treatment (discrimination). Calibration of the treatment algorithm suggests a systematical underestimation of the need for ACL reconstruction. Given the limitations regarding the sample size of this study, larger data sets must be constructed to improve the treatment algorithm further.

LEVEL OF EVIDENCE

Level II.

Post-traumatic and OA-related lesions in the knee at baseline and 2 years after traumatic meniscal injury: Secondary analysis of a randomized controlled trial

OBJECTIVE

To assess the presence of early degenerative changes on Magnetic Resonance Imaging (MRI) 24 months after a traumatic meniscal tear and to compare these changes in patients treated with arthroscopic partial meniscectomy or physical therapy plus optional delayed arthroscopic partial meniscectomy.

DESIGN

We included patients aged 18-45 years with a recent onset, traumatic, MRI verified, isolated meniscal tear without radiographic osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with optional delayed arthroscopic partial meniscectomy. MRIs at baseline and 24 months were scored using the MRI Osteoarthritis Knee Score (MOAKS). We compared baseline MRIs to healthy controls aged 18-40 years. The outcome was the progression of bone marrow lesions (BMLs), cartilage defects and osteophytes after 24 months in patients.

RESULTS

We included 99 patients and 50 controls. At baseline, grade 2 and 3 BMLs were present in 26% of the patients (n = 26), compared to 2% of the controls (n = 1) (between group difference 24% (95% CI 15% to 34%)). In patients, 35% (n = 35) had one or more cartilage defects grade 1 or higher, compared to 2% of controls (n = 1) (between group difference 33% (95% CI 23% to 44%)). At 24 months MRI was available for 40 patients randomized to arthroscopic partial meniscectomy and 41 patients randomized to physical therapy. At 24 months 30% (n = 12) of the patients randomized to arthroscopic partial meniscectomy showed BML worsening, compared to 22% (n = 9) of the patients randomized to physical therapy (between group difference 8% (95% CI -11% to 27%)). Worsening of cartilage defects was present in 40% (n = 16) of the arthroscopic partial meniscectomy group, compared to 22% (n = 9) of the physical therapy group (between group difference 18% (95% CI -2% to 38%)). Of the patients who had no cartilage defect at baseline, 33% of the arthroscopic partial meniscectomy group had a new cartilage defect at follow-up compared to 14% of the physical therapy group. Osteophyte worsening was present in 18% (n = 7) of the arthroscopic partial meniscectomy group and 15% (n = 6) of the physical therapy group (between group difference 3% (95% CI -13% to 19%)).

CONCLUSIONS

Our results might suggest more worsening of BMLs and cartilage defects with arthroscopic partial meniscectomy compared to physical therapy with optional delayed arthroscopic partial meniscectomy at 24-month follow-up in young patients with isolated traumatic meniscal tears without radiographic OA.

Talocrural Arthrodesis Increases Osteoarthritis Severity in Adjacent Joints: A Midterm Computed Tomography Follow-Up Study

BACKGROUND

After talocrural arthrodesis, adjacent joints (subtalar, talonavicular, and calcaneocuboid) are often affected by osteoarthritis (OA)). It is unclear if OA is pre-existing to talocrural arthrodesis, or whether it develops after talocrural arthrodesis. This retrospective study is unique because it is the first study with preoperative and follow-up computed tomography (CT). The aim of this study is to investigate whether OA develops in adjacent joints after talocrural arthrodesis or if OA is already pre-existing. In addition, associations between degree of OA and patient-reported outcomes are investigated.

METHODS

Patients were selected from electronic files, and adjacent joint OA was assessed on preoperative CT and bilateral follow-up CT. Patient-reported outcomes were collected.

RESULTS

Twenty-three patients were included with an average follow-up time of 7 years (SD = 2). In participants without pre-existing OA, OA significantly progressed in all adjacent joints. In participants with pre-existing OA, OA progressed in the subtalar joint. Patient-reported outcomes were not correlated to OA.

CONCLUSIONS

Osteoarthritis in the adjacent joints progresses after talocrural arthrodesis, especially in participants without pre-existing OA. The severity of OA is not related to patient-reported outcomes. Therefore, the clinical impact of the progression of OA seems to be limited.

LEVEL OF EVIDENCE

Level III: retrospective.

Cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in patients aged under 45 years

Aims

The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears.

Methods

We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective.

Results

A total of 100 patients were included: 49 were randomized to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in the arthroscopic partial meniscectomy group had a mean 0.005 QALYs lower quality of life (95% confidence interval -0.13 to 0.14). The cost-utility ratio was €-160,000/QALY from the healthcare perspective and €-223,372/QALY from the societal perspective, indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit.

Conclusion

Arthroscopic partial meniscectomy is arthroscopic partial meniscectomy is unlikely to be cost-effective in treating young patients with isolated traumatic meniscal tears compared to physical therapy as a primary health intervention. Arthroscopic partial meniscectomy leads to a similar quality of life, but higher costs, compared to physical therapy plus optional delayed arthroscopic partial meniscectomy.

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis

BACKGROUND

Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis.

PURPOSE

To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks.

RESULTS

Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures.

CONCLUSION

For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections.

REGISTRATION

NTR7261 (Netherlands Trial Register).

Improved Understanding of the Inflammatory Response in Synovial Fluid and Serum after Traumatic Knee Injury, Excluding Fractures of the Knee: A Systematic Review

BACKGROUND

Traumatic knee injury results in a 4- to 10-fold increased risk of post-traumatic osteoarthritis (PTOA). Currently, there are no successful interventions for preventing PTOA after knee injury. The aim of this study is to identify inflammatory proteins that are increased in serum and synovial fluid after acute knee injury, excluding intra-articular fractures.

METHODS

A literature search was done according to the PRISMA guidelines. Articles reporting about inflammatory proteins after knee injury, except fractures, up to December 8, 2021 were collected. Inclusion criteria were as follows: patients younger than 45 years, no radiographic signs of knee osteoarthritis at baseline, and inflammatory protein measurement within 1 year after trauma. Risk of bias was assessed of the included studies. The level of evidence was determined by the Strength of Recommendation Taxonomy.

RESULTS

Ten studies were included. All included studies used a healthy control group or the contralateral knee as healthy control. Strong evidence for interleukin 6 (IL-6) and limited evidence for CCL4 show elevated concentrations of these proteins in synovial fluid (SF) after acute knee injury; no upregulation in SF for IL-2, IL-10, CCL3, CCL5, CCL11, granulocyte colony-stimulating factor (G-CSF), and granulocyte-macrophage colony-stimulating factor (GM-CSF) was found. Limited evidence was found for no difference in serum concentration of IL-1β, IL-6, IL-10, CCL2, and tumor necrosis factor alpha (TNF-α) after knee injury.

CONCLUSION

Interleukin 6 and CCL4 are elevated in SF after acute knee injury. Included studies failed to demonstrate increased concentration of inflammatory proteins in SF samples taken 6 weeks after trauma. Future research should focus on SF inflammatory protein measurements taken less than 6 weeks after injury.

A transcriptome atlas of leg muscles from healthy human volunteers reveals molecular and cellular signatures associated with muscle location

Skeletal muscles support the stability and mobility of the skeleton but differ in biomechanical properties and physiological functions. The intrinsic factors that regulate muscle-specific characteristics are poorly understood. To study these, we constructed a large atlas of RNA-seq profiles from six leg muscles and two locations from one muscle, using biopsies from 20 healthy young males. We identified differential expression patterns and cellular composition across the seven tissues using three bioinformatics approaches confirmed by large-scale newly developed quantitative immune-histology procedures. With all three procedures, the muscle samples clustered into three groups congruent with their anatomical location. Concomitant with genes marking oxidative metabolism, genes marking fast- or slow-twitch myofibers differed between the three groups. The groups of muscles with higher expression of slow-twitch genes were enriched in endothelial cells and showed higher capillary content. In addition, expression profiles of Homeobox (HOX) transcription factors differed between the three groups and were confirmed by spatial RNA hybridization. We created an open-source graphical interface to explore and visualize the leg muscle atlas (https://tabbassidaloii.shinyapps.io/muscleAtlasShinyApp/). Our study reveals the molecular specialization of human leg muscles, and provides a novel resource to study muscle-specific molecular features, which could be linked with (patho)physiological processes.

Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trial

OBJECTIVE

To assess whether initial non-operative treatment of anterior cruciate ligament (ACL) ruptures with optional delayed ACL reconstruction leads to more meniscal procedures compared with early ACL reconstruction during the 2-year follow-up.

METHODS

We compared the number of meniscal procedures of 167 patients with an ACL rupture, who either received early ACL reconstruction (n=85) or rehabilitation therapy plus optional delayed ACL reconstruction (n=82), participating in the Conservative vs Operative Methods for Patients with ACL Rupture Evaluation trial. Patients were aged 18 to 65 years (mean 31.3, SD 10.5), 60% male sex (n=100). We evaluated the presence and location of meniscal tears by baseline MRI. We analysed and compared how many patients per randomisation group had a meniscal procedure during follow-up in the ACL injured knee, adjusted for sex, body mass index, age group and orthopaedic surgeon.

RESULTS

At baseline, 41% of the entire study population (69/167 patients) had a meniscal tear on MRI. During the 2-year follow-up, 25 patients randomised to early ACL reconstruction (29%, 25/85 patients) had a meniscal procedure, compared with 17 patients randomised to rehabilitation plus optional delayed reconstruction (21%, 17/82 patients) (risk ratio 0.67 with 95% CI 0.40 to 1.12, p=0.12). Of these patients who received early ACL reconstruction (n=82) and patients that received delayed ACL reconstruction (n=41), 5% of the patients had an additional isolated meniscal procedure after ACL reconstruction. In patients who received no ACL reconstruction (n=41), 10% (n=4) had an isolated surgical procedure for a meniscal tear during the 2-year follow-up period.

CONCLUSION

Initial non-surgical treatment of ACL ruptures followed by optional delayed ACL reconstruction does not lead to a higher number of meniscal procedures compared with early ACL reconstruction over a 2-year follow-up period.

TRIAL REGISTRATION NUMBER

NL 2618.

How to assess consolidation after foot and ankle arthrodesis with computed tomography. A systematic review

PURPOSES

Many studies have been performed that investigate consolidation after arthrodesis of foot and ankle joints. Consolidation in foot and ankle joints is best assessed by computed tomography (CT). However, no golden-standard methodology exists for radiological consolidation assessment from CT after ankle and foot arthrodesis. The aim of this review is to present an overview of the radiological methodologies for consolidation assessment, outcomes on reliability and validity and to advise which methodology should be used.

METHOD

Scientific databases were systematically searched. Eligible studies were studies that 1) performed foot or ankle arthrodesis, 2) mentioned radiological or CT follow-up in abstract, 3) performed postoperative CT in > 50% of patients. Two authors selected eligible studies and performed a risk of bias assessment with the COSMIN tool.

RESULTS

Risk of bias assessment showed that most studies (80%) were at high risk of bias due to poor methodology. The most popular method for consolidation assessment is by subjectively categorizing consolidation into consolidation groups, with a substantial reliability score. Another popular method is to calculate the fusion ratio and then apply a fusion threshold, to distinguish between fused and non-fused joints. This method had an excellent reliability score. In most studies a fusion threshold of 50% is used. However, four studies in this review showed that a 30% fusion threshold may by more valid.

CONCLUSION

Based on the results of this review we would advise to calculate fusion threshold and apply a 30% fusion threshold to distinguish fused from non-fused foot and ankle joints.

Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in a young study population: a randomised controlled trial

OBJECTIVE

To compare outcomes from arthroscopic partial meniscectomy versus physical therapy in young patients with traumatic meniscal tears.

METHODS

We conducted a multicentre, open-labelled, randomised controlled trial in patients aged 18-45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomised to arthroscopic partial meniscectomy or standardised physical therapy with an optional delayed arthroscopic partial meniscectomy after 3-month follow-up. The primary outcome was the International Knee Documentation Committee (IKDC) score (best 100, worst 0) at 24 months, which measures patients' perception of symptoms, knee function and ability to participate in sports activities.

RESULTS

Between 2014 and 2018, 100 patients were included (mean age 35.1 (SD 8.1), 76% male, 34 competitive or elite athletes). Forty-nine were randomised to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during the follow-up period. In both groups, improvement in IKDC scores was clinically relevant during follow-up compared with baseline scores. At 24 months mean (95% CI) IKDC scores were 78 (71 to 84) out of 100 points in the arthroscopic partial meniscectomy group and 78 (71 to 84) in the physical therapy group with a between group difference of 0.1 (95% CI -7.6 to 7.7) points out of 100.

CONCLUSIONS

In this trial involving young patients with isolated traumatic meniscal tears, early arthroscopic partial meniscectomy was not superior to a strategy of physical therapy with optional delayed arthroscopic partial meniscectomy at 24-month follow-up.

TRIAL REGISTRATION

https://www.trialregister.nl/trials.

Why, When, and in Which Patients Nonoperative Treatment of Anterior Cruciate Ligament Injury Fails: An Exploratory Analysis of the COMPARE Trial

BACKGROUND

The optimal treatment strategy for patients with an anterior cruciate ligament (ACL) rupture is still under debate. Different determinants of the need for a reconstruction have not been thoroughly investigated before.

PURPOSE

To investigate why, when, and which patients with an ACL rupture who initially started with rehabilitation therapy required reconstructive surgery.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

In the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation (COMPARE) trial, 167 patients with an ACL rupture were randomized to early ACL reconstruction or rehabilitation therapy plus optional delayed ACL reconstruction. We conducted an exploratory analysis of a subgroup of 82 patients from this trial who were randomized to rehabilitation therapy plus optional delayed ACL reconstruction. The reasons for surgery were registered for the patients who underwent a delayed ACL reconstruction. For these patients, we used the International Knee Documentation Committee (IKDC) subjective knee form, Numeric Rating Scale for pain, and instability question from the Lysholm questionnaire before surgery. To determine between-group differences between the nonoperative treatment and delayed ACL reconstruction group, IKDC and pain scores during follow-up were determined using mixed models and adjusted for sex, age, and body mass index.

RESULTS

During the 2-year follow-up of the trial, 41 of the 82 patients received a delayed ACL reconstruction after a median time of 6.4 months after inclusion (interquartile range, 3.9-10.3 months). Most reconstructions occurred between 3 and 6 months after inclusion (n = 17; 41.5%). Ninety percent of the patients (n = 37) reported knee instability concerns as a reason for surgery at the moment of planning surgery. Of these patients, 18 had an IKDC score ≤60, 29 had a pain score of ≥3, and 33 patients had knee instability concerns according to the Lysholm questionnaire before surgery. During follow-up, IKDC scores were lower and pain scores were higher in the delayed reconstruction group compared with the nonoperative treatment group. Patients in the delayed reconstruction group had a significantly younger age (27.4 vs 35.3 years; P = .001) and higher preinjury activity level compared with patients in the nonoperative treatment group.

CONCLUSION

Patients who experienced instability concerns, had pain during activity, and had a low perception of their knee function had unsuccessful nonoperative treatment. Most patients received a delayed ACL reconstruction after 3 to 6 months of rehabilitation therapy. At baseline, patients who required reconstructive surgery had a younger age and higher preinjury activity level compared with patients who did not undergo reconstruction.

Study protocol ROTATE-trial: anterior cruciate ligament rupture, the influence of a treatment algorithm and shared decision making on clinical outcome– a cluster randomized controlled trial

Background

Anterior cruciate ligament (ACL) rupture is a very common knee injury in the sport active population. There is much debate on which treatment (operative or non-operative) is best for the individual patient. In order to give a more personalized recommendation we aim to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture.

Methods

The ROTATE-trial is a multicenter, open-labeled cluster randomized controlled trial with superiority design. Randomization will take place on hospital level (n = 10). Patients must meet all the following criteria: aged 18 year or older, with a complete primary ACL rupture (confirmed by MRI and physical examination) and maximum of 6 weeks of non-operative treatment. Exclusion criteria consists of multi ligament trauma indicated for surgical intervention, presence of another disorder that affects the activity level of the lower limb, pregnancy, and insufficient command of the Dutch language. The intervention to be investigated will be an adjusted treatment decision strategy, including an advice from our treatment algorithm. Patient reported outcomes will be conducted at baseline, 3, 6, 12 and 24 months. Physical examination of the knee at baseline, 12 and 24 months. Primary outcome will be function of the knee measured by the International Knee Documentation Committee (IKDC) questionnaire. Secondary outcomes are, among others, the Tegner activity score, the Knee injury and Osteoarthritis Outcome Score (KOOS) and the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Healthcare use, productivity and satisfaction with ((non-)operative) care are also measured by means of questionnaires. In total 230 patients will be included, resulting in 23 patients per hospital.

Discussion

The ROTATE study aims to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture compared to current used treatment strategy. Using a treatment algorithm might give the much-wanted personalized treatment recommendation.

Trial registration

This study is approved by the Medical Research Ethics Committee of Erasmus Medical Center in Rotterdam and prospectively registered at the Dutch Trial Registry on May 13th, 2020. Registration number: NL8637.

Bone Union Assessment with Computed Tomography (CT) and Statistical Associations with Mechanical or Histological Testing: A Systematic Review of Animal Studies

Objective and accurate assessment of bone union after a fracture, arthrodesis, or osteotomy is relevant for scientific and clinical purposes. Bone union is most accurately imaged with computed tomography (CT), but no consensus exists about objective assessment of bone union from CT images. It is unclear which CT-generated parameters are most suitable for bone union assessment. The aim of this review of animal studies is to find which CT-generated parameters are associated most strongly with actual bone union. Scientific databases were systematically searched. Eligible studies were studies that (1) were animal studies, (2) created a fracture, (3) assessed bone union with CT, (4) performed mechanical or histological testing as measure of actual bone union, and (5) associated CT-generated outcomes to mechanical or histological testing results. Two authors selected eligible studies and performed risk of bias assessment with QUADAS-2 tool. From 2567 studies that were screened, thirteen studies were included. Most common CT parameters that were investigated were bone mineral density, bone volume, and total callus volume. Studies showed conflicting results concerning the associations of these parameters with actual bone union. CT-assessed torsional rigidity (assessed by three studies) and callus density (assessed by two studies) showed best results. The studies investigating these two parameters reported moderate to strong associations with actual bone union. CT-assessed torsional rigidity and callus density seem the most promising parameters to represent actual bone union after a fracture, arthrodesis, or osteotomy.Prospero trial registration number: CRD42020164733.

An Anterior Cruciate Ligament Rupture Increases Levels of Urine N-terminal Cross-linked Telopeptide of Type I Collagen, Urine C-terminal Cross-linked Telopeptide of Type II Collagen, Serum Aggrecan ARGS Neoepitope, and Serum Tumor Necrosis Factor-α

BACKGROUND

An anterior cruciate ligament (ACL) rupture results in an increased risk of developing knee osteoarthritis (OA) at an early age. Before clinical signs become apparent, the OA process has already been initiated. Therefore, it is important to look at the cascade of changes, such as the activity of cytokines and proteases, which might be associated with the later development of OA.

PURPOSE

To compare biomarker levels in patients with a recent ACL rupture with those in controls with a healthy knee and to monitor biomarker levels over 2 years after an ACL rupture.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Patients were enrolled after an ACL tear was identified. Serum and urine samples were collected at the time of enrollment in the study (3-25 weeks after the injury) and then at 14 and 27 months after the injury between January 2009 and November 2010. Reference samples were obtained from participants with healthy knees. The following biomarkers were measured with immunological assays: aggrecan ARGS neoepitope (ARGS-aggrecan), tumor necrosis factor-α (TNF-α), interferon-γ, interleukin (IL)-8, IL-10, IL-13, N-terminal cross-linked telopeptide of type I collagen (NTX-I), and C-terminal cross-linked telopeptide of type II collagen (CTX-II).

RESULTS

Samples were collected from 152 patients with an acute ACL rupture, who had a median age of 25 years (interquartile range [IQR], 21-32 years). There were 62 urine reference samples (median age, 25 years [IQR, 22-36 years]) and 26 serum reference samples (median age, 35 years [IQR, 24-39 years]). At a median of 11 weeks (IQR, 7-17 weeks) after trauma, serum levels of both ARGS-aggrecan and TNF-α were elevated 1.5-fold (P < .001) compared with reference samples and showed a time-dependent decrease during follow-up. Urine NTX-I and CTX-II concentrations were elevated in an early phase after trauma (1.3-fold [P < .001] and 3.7-fold [P < .001], respectively) compared with reference samples, and CTX-II levels remained elevated compared with reference samples at 2-year follow-up. Strong correlations were found between serum ARGS-aggrecan, urinary NTX-I, and urinary CTX-II (r_s = 0.57-0.68).

CONCLUSION

In the first few months after an ACL injury, there was a measurable increase in serum levels of ARGS-aggrecan and TNF-α as well as urine levels of NTX-I and CTX-II. These markers remained high compared with those of controls with healthy knees at 2-year follow-up.

Standardized pain mapping for diagnosing Achilles tendinopathy

OBJECTIVES

To assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy.

DESIGN

Cross-sectional study.

METHODS

Eligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy.

RESULTS

110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78-0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54-0.79).

CONCLUSIONS

There is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.

Facial subcutaneous emphysema due to rectum injury after pelvic fracture

A 35-year old dockworker sustained a pelvic injury when he was caught by a large loading clamshell grab. Primary survey revealed an open book pelvic fracture with soft tissue defects of the left thigh and groin. CT scanning of the thorax and abdomen did not reveal significant additional injuries. Partly due to patient's haemodynamical instability, osteosynthesis of the pelvic fracture was performed immediately after resuscitation, whereby the severely contaminated wound of the thigh was debrided and irrigated. The following days, progressive facial subcutaneous emphysema developed, but patient remained clinically stable. Several specialists were consulted, but did not find a cause. At day 7, a second surgery was planned to treat a pelvic surgical wound infection. Unexpectedly, we found faecal contamination in the pelvic surgical wound. The consulted gastro/intestinal-surgeon performed a laparoscopic colostomy for a rectal laceration. Awareness for bowel injuries with open pelvic fracture should be high, also when subcutaneous emphysema is found remotely.

Effects of eccentric exercises on improving ankle dorsiflexion in soccer players

Purpose

The purpose of this study was to determine the effect of targeted eccentric calf muscle exercises compared to regular training on ankle dorsiflexion in healthy adolescent soccer players with a decreased ankle dorsiflexion.

Methods

Male adolescent players (aged 14–21 years) from two professional soccer clubs were evaluated with the Weight Bearing Dorsiflexion Lunge Test (WBDLT) at baseline and after 12 weeks of this prospective controlled study. One club served as the control group and the other as the intervention group. Players with decreased ankle dorsiflexion (WBDLT) ≤ 10 cm) performed stretching and eccentric calf muscle exercises three times per week next to regular training in the intervention group, and performed only regular training in the control group. Primary outcome was the between-group difference in change in WBDLT between baseline and 12 weeks.

Results

Of 107 eligible players, 47(44 %) had a decreased ankle dorsiflexion. The WBDLT (± standard deviation) increased in the intervention group from 7.1 (± 1.8) to 7.4 (± 2.4) cm (95 % Confidence Interval (CI)[-0.493 to 1.108], p = 0.381) and in the control group from 6.1 (± 2.4) to 8.2 (± 2.9) cm (95 % CI [1.313 to 2.659], p < 0.001). The difference in change of WBDLT between both groups was statistically significant (95 % CI [-2.742 to -0.510], p = 0.005).

Conclusions

Targeted eccentric calf muscle exercises do not increase ankle dorsiflexion in healthy adolescent soccer players. Compared to regular training, eccentric exercises even resulted in a decreased calf muscle flexibility.

Trial registration

This trial was registered retrospectively on the 7th of September 2016 in The Netherlands Trial Register (ID number: 6044).

Predictive Factors for Hamstring Autograft Diameter in Anterior Cruciate Ligament Reconstruction

Multiple studies found hamstring tendon (HT) autograft diameter to be a risk factor for anterior cruciate ligament (ACL) reconstruction failure. This study aimed to determine which preoperative measurements are associated with HT autograft diameter in ACL reconstruction by directly comparing patient characteristics and cross-sectional area (CSA) measurement of the semitendinosus and gracilis tendon on magnetic resonance imaging (MRI). Fifty-three patients with a primary ACL reconstruction with a four-stranded HT autograft were included in this study. Preoperatively we recorded length, weight, thigh circumference, gender, age, preinjury Tegner activity score, and CSA of the semitendinosus and gracilis tendon on MRI. Total CSA on MRI, weight, height, gender, and thigh circumference were all significantly correlated with HT autograft diameter (p < 0.05). A multiple linear regression model with CSA measurement of the HTs on MRI, weight, and height showed the most explained variance of HT autograft diameter (adjusted R ² = 44%). A regression equation was derived for an estimation of the expected intraoperative HT autograft diameter: 1.2508 + 0.0400 × total CSA (mm²) + 0.0100 × weight (kg) + 0.0296 × length (cm). The Bland and Altman analysis indicated a 95% limit of agreement of ± 1.14 mm and an error correlation of r = 0.47. Smaller CSA of the semitendinosus and gracilis tendon on MRI, shorter stature, lower weight, smaller thigh circumference, and female gender are associated with a smaller four-stranded HT autograft diameter in ACL reconstruction. Multiple linear regression analysis indicated that the combination of MRI CSA measurement, weight, and height is the strongest predictor.

Current State of Care for Pediatric ACL Ruptures in the Netherlands: A Survey

The management of anterior cruciate ligament (ACL) injuries in the skeletally immature patient is an area of controversy. The purpose of this survey is to inventory the current state of care for pediatric ACL injuries in the Netherlands. This survey was conveyed by e-mail among all members of the Dutch Arthroscopy Society (Nederlandse Vereniging van Arthroscopie [NVA]) and promoted on the Web site of the NVA. It was developed by the scientific committee of the NVA by a consensus meeting discussing relevant topics in pediatric ACL injuries. All members of the NVA received the survey (n = 540). A total of 158 (29%) members responded to the survey, of which 143 were completed. A total of 126 responses were analyzed after exclusion. The main finding of this survey is that 78% of the respondents tend to treat children with open physes nonoperatively, while 65% tend to treat children with closed physes operatively. The most frequently performed procedure is the transphyseal reconstruction. Many considerations were involved in choosing operative treatment. The postoperative follow-up period varies from less than 1 year (24%) until fully grown (27%). In conclusion, this survey shows that the current state of care for pediatric ACL injuries is variable and a matter of debate in the Netherlands. Although the response rate seems low, this survey provides an overview of the opinions of specialized orthopaedic surgeons in the Netherlands. The results of this survey led to the development of the national registry for pediatric ACL in the Netherlands. The level of evidence for this study is V.

Differences in Knee Shape between ACL Injured and Non-Injured: A Matched Case-Control Study of 168 Patients

OBJECTIVE

Anterior cruciate ligament (ACL) injury prevention programs could be more effective if we could select patients at risk for sustaining an ACL rupture. The purpose of this study is to identify radiographic shape variants of the knee between patients with and patients without an ACL rupture.

METHODS

We compared the lateral and Rosenberg view X-rays of 168 prospectively followed patients with a ruptured ACL to a control group with intact ACLs, matched for gender, after knee trauma. We used statistical shape modeling software to examine knee shape and find differences in shape variants between both groups.

RESULTS

In the Rosenberg view X-rays, we found five shape variants to be significantly different between patients with an ACL rupture and patients with an intact ACL but with knee trauma. Overall, patients who had ruptured their ACL had smaller, flatter intercondylar notches, a lower lateral tibia plateau, a lower medial spike of the eminence, and a smaller tibial eminence compared to control patients.

CONCLUSION

Patients with an ACL rupture have smaller intercondylar notches and smaller tibial eminences in comparison to patients with an intact ACL after knee trauma.

Detection of knee synovitis using non-contrast-enhanced qDESS compared with contrast-enhanced MRI

Background

To assess diagnostic accuracy of quantitative double-echo in steady-state (qDESS) MRI for detecting synovitis in knee osteoarthritis (OA).

Methods

Patients with different degrees of radiographic knee OA were included prospectively. All underwent MRI with both qDESS and contrast-enhanced T1-weighted magnetic resonance imaging (CE-MRI). A linear combination of the two qDESS images can be used to create an image that displays contrast between synovium and the synovial fluid. Synovitis on both qDESS and CE-MRI was assessed semi-quantitatively, using a whole-knee synovitis sum score, indicating no/equivocal, mild, moderate, and severe synovitis. The correlation between sum scores of qDESS and CE-MRI (reference standard) was determined using Spearman’s rank correlation coefficient and intraclass correlation coefficient for absolute agreement. Receiver operating characteristic analysis was performed to assess the diagnostic performance of qDESS for detecting different degrees of synovitis, with CE-MRI as reference standard.

Results

In the 31 patients included, very strong correlation was found between synovitis sum scores on qDESS and CE-MRI (ρ = 0.96, p < 0.001), with high absolute agreement (0.84 (95%CI 0.14–0.95)). Mean sum score (SD) values on qDESS 5.16 (3.75) were lower than on CE-MRI 7.13 (4.66), indicating systematically underestimated synovitis severity on qDESS. For detecting mild synovitis or higher, high sensitivity and specificity were found for qDESS (1.00 (95%CI 0.80–1.00) and 0.909 (0.571–1.00), respectively). For detecting moderate synovitis or higher, sensitivity and specificity were good (0.727 (95%CI 0.393–0.927) and 1.00 (0.800–1.00), respectively).

Conclusion

qDESS MRI is able to, however with an underestimation, detect synovitis in patients with knee OA.

Do we publish what we present? The publication rate of a national arthroscopy society and a review of the literature

The publication rate (PR) of full-text articles after presentation at medical society meetings varies widely. The purpose of this study is (1) to determine the PR of abstracts presented at the Dutch Arthroscopy Society's (NVA) annual meeting from 2006 until 2016, (2) to determine the time between presentation and publication, and (3) to review the known literature on the PR of orthopaedic scientific meetings. We retrospectively reviewed the programs of the NVA annual meetings from 2006 to 2016. All podium presentations reported were included. The search for subsequent journal publication was performed using PubMed, EMBASE, and Google Scholar databases. A systematic literature search was performed in PubMed. All studies regarding the publication rates of orthopaedic scientific meetings were included. From 2006 to 2016 a total of 131 papers were presented at the NVA annual meetings, of which 83 were published as full text articles (63%). The mean time to publication was 16.5 months. The overall PR at orthopaedic scientific meetings ranges from 21% to 71%.

Diagnostic accuracy of grayscale, power Doppler and contrast-enhanced ultrasound compared with contrast-enhanced MRI in the visualization of synovitis in knee osteoarthritis

PURPOSE

To assess the diagnostic accuracy of grayscale (GSUS), power Doppler (PDUS) and contrast-enhanced ultrasound (CEUS) for detecting synovitis in knee osteoarthritis (OA).

METHOD

Patients with different degrees of radiographic knee OA were included prospectively. All underwent GSUS, PDUS, CEUS, and contrast-enhanced magnetic resonance imaging (CE-MRI), on which synovitis was assessed semi-quantitatively. Correlations of synovitis severity on ultrasound based techniques with CE-MRI were determined. Receiver operating characteristic (ROC) analysis was performed to assess diagnostic performance of GSUS, PDUS, and CEUS, for detecting synovitis, using CE-MRI as reference-standard.

RESULTS

In the 31 patients included, synovitis scoring on GSUS and CEUS was significantly correlated (ρ = 0.608, p < 0.001 and ρ = 0.391, p = 0.033) with CE-MRI. For detecting mild synovitis, the area under the curve (AUC) was 0.781 (95 %CI 0.609-0.953) for GSUS, 0.788 (0.622-0.954) for PDUS, and 0.653 (0.452-0.853) for CEUS. Sensitivity and specificity were 0.667 (0.431-0.845) and 0.700 (0.354-0.919) for GSUS, 0.905 (0.682-0.983) and 0.500 (0.201-0.799) for PDUS, and 0.550 (0.320-0.762) and 0.700 (0.354-0.919) for CEUS, respectively. The AUC of GSUS increased to 0.862 (0.735-0.989), 0.823 (0.666-0.979), and 0.885 (0.767-1.000), when combined with PDUS, CEUS, or both, respectively. For detecting moderate synovitis, the AUC of GSUS was higher (0.882 (0.750-1.000)) and no added value of PDUS and CEUS was observed.

CONCLUSIONS

GSUS has limited overall accuracy for detecting synovitis in knee OA. When GSUS is combined with PDUS or CEUS, overall diagnostic performance improves for detecting mild synovitis, but not for moderate synovitis.

Traumatic Meniscal Tears Are Associated With Meniscal Degeneration

BACKGROUND

Meniscal tears are traditionally classified into traumatic versus degenerative tears. Although this classification plays a major role in clinical decision making, no consensus exists on the exact definition of a traumatic or degenerative tear, and the histopathological basis for this classification is unclear.

PURPOSE

To assess the histological degree of meniscal degeneration in patients with a traumatic meniscal tear, as compared with intact meniscal tissue and osteoarthritic meniscal tissue.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Traumatically torn meniscal tissue was collected during arthroscopic partial meniscectomy. As a control group, intact meniscal tissue was used from transfemoral amputations or direct postmortem dissections. Meniscal tissue from osteoarthritic knees was obtained during total knee replacement surgery. Meniscal tissue was processed, stained, and histologically analyzed with the Pauli scoring system (range, 0-18), comprising the subdomains surface integrity, cellularity, collagen organization, and matrix staining. Scoring was performed by 2 independent observers, blinded to condition, region, and patient data of the meniscus.

RESULTS

The traumatic meniscal tear group contained 43 patients (34 men; median age, 29 years; median body mass index [BMI], 24 kg/m²); the intact meniscal tissue group, 8 patients (3 men; median age, 58 years; median BMI, 30 kg/m²); and the osteoarthritic group, 14 patients (4 men; median age, 66 years; median BMI, 28 kg/m²). After adjustment for sex, age, and BMI, patients with a traumatic meniscal tear had a significantly higher histological score than patients with intact meniscal tissue (2.7-point difference; P = .035). Histological score between the traumatic and osteoarthritic groups was not different.

CONCLUSION

Traumatically torn menisci possess a higher degree of degeneration than intact menisci. Our results suggest that patients with a traumatic meniscal tear may already have had a certain degree of meniscal degeneration. These findings potentially challenge the classic view of traumatic versus degenerative meniscal tears.

CLINICAL RELEVANCE

Our findings provide a better understanding of the tissue condition of a torn meniscus. This knowledge may help clinicians decide on choice of treatment and may lead to new perspectives to prevent knee osteoarthritis in patients with a torn meniscus.

[Preventing anterior cruciate ligament injury in children is effective]

An anterior cruciate ligament (ACL) injury in children is a devastating injury. After an ACL injury 1 in 3 children obtain a second injury of the ipsilateral or contralateral ACL. Children who suffer an ACL injury also have a ten times higher risk of osteoarthritis. Preventative training programmes can decrease the risk of acute knee injuries in young sportspeople; however, implementation of these prevention programmes is challenging, so it is important to inform associations, clubs, youth trainers and parents about the added value of these programmes. Children with ACL injuries must receive specialized guidance during rehabilitation, regardless of whether they have been treated conservatively or surgically. Because of the risk of a second ACL injury,we recommend that children should not to return to pivoting sports until at least 12 months after surgery for ACL.