[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.

Knee arthrodesis for a congenital luxation with Larsen syndrome

A 31-year-old woman with known Larsen syndrome presented with congenital chronic luxation of her right knee with increasing instability symptoms, which limited her daily activities. We refrained from a constrained knee arthroplasty due to her relatively young age and decided to perform a knee arthrodesis. Knee arthrodesis is a viable lifelong-lasting operative treatment alternative for specific instability-related knee disease. The knee arthrodesis was performed by double plating with an additional fixation of the patella. At 1-yearfollow-up, she was able to walk without limitations and did not experience any pain with complete consolidation of the arthrodesis. At 2-year follow-up, she performed all her daily activities without limitations. Both the Knee injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee subjective knee form (IKDC) improved at 2-year follow-up (KOOS: 61.3; IKDC: 56.3) compared with 1-year follow-up (KOOS: 52; IKDC: 40.2).

Quantitative DCE-MRI demonstrates increased blood perfusion in Hoffa's fat pad signal abnormalities in knee osteoarthritis, but not in patellofemoral pain

OBJECTIVE

Infrapatellar fat pad (IPFP) fat-suppressed T2 (T2FS) hyperintense regions on MRI are an important imaging feature of knee osteoarthritis (OA) and are thought to represent inflammation. These regions are also common in non-OA subjects, and may not always be linked to inflammation. Our aim was to evaluate quantitative blood perfusion parameters, as surrogate measure of inflammation, within T2FS-hyperintense regions in patients with OA, with patellofemoral pain (PFP) (supposed OA precursor), and control subjects.

METHODS

Twenty-two knee OA patients, 35 PFP patients and 43 healthy controls were included and underwent MRI, comprising T2 and DCE-MRI sequences. T2FS-hyperintense IPFP regions were delineated and a reference region was drawn in adjacent IPFP tissue with normal signal intensity. After fitting the extended Tofts pharmacokinetic model, quantitative DCE-MRI perfusion parameters were compared between the two regions within subjects in each subgroup, using a paired Wilcoxon signed-rank test.

RESULTS

T2FS-hyperintense IPFP regions were present in 16 of 22 (73%) OA patients, 13 of 35 (37%) PFP patients, and 14 of 43 (33%) controls. DCE-MRI perfusion parameters were significantly different between regions with and without a T2FS-hyperintense signal in OA patients, demonstrating higher Ktrans compared to normal IFPF tissue (0.039 min-1 versus 0.025 min-1, p = 0.017) and higher Ve (0.157 versus 0.119, p = 0.010). For PFP patients and controls no significant differences were found.

CONCLUSIONS

IPFP T2FS-hyperintense regions are associated with higher perfusion in knee OA patients in contrast to identically appearing regions in PFP patients and controls, pointing towards an inflammatory pathogenesis in OA only.

KEY POINTS

• Morphologically identical appearing T2FS-hyperintense infrapatellar fat pad regions show different perfusion in healthy subjects, subjects with patellofemoral pain, and subjects with knee osteoarthritis. • Elevated DCE-MRI perfusion parameters within T2FS-hyperintense infrapatellar fat pad regions in patients with osteoarthritis suggest an inflammatory pathogenesis in osteoarthritis, but not in patellofemoral pain and healthy subjects.

Four-strand hamstring graft is stiffer than a tripled semitendinosus graft in anterior cruciate ligament reconstruction: a cadaveric study

Purpose

The aim of this study was to compare the biomechanics of a four-strand hamstring graft with a tripled semitendinosus graft, with and without adjustable extra-cortical button fixation, in a cadaveric model.

Methods

Four groups of 10 cadaveric hamstrings were tested: In group A, a tripled semitendinosus graft fixated with two adjustable extra-cortical buttons; in Group B, a four-strand semitendinosus and gracilis graft fixated with an adjustable extra-cortical button and a clamp; in group C, a tripled semitendinosus graft fixated to a steel hook and a clamp; in group D, a four-strand semitendinosus and gracilis graft fixated to a steel hook and a clamp. Each group was submitted to a cyclic loading test (1000 cycles between 50 and 250 Newton at a frequency of 0.5 hertz) and a load-to-failure test. Primary outcomes were ultimate failure load and stiffness. Secondary outcomes were graft elongation and graft diameter.

Results

There was no difference in ultimate failure load among groups. Group B achieved a median stiffness of 171 N/mm (interquartile range [IQR] 139–204) which was significantly higher than Group A (median 103 N/mm (74–119), p < 0.01). Group B showed more cyclic elongation (4.1 mm (3.4–5.7)) compared to group D (2.3 mm (1.9–3.0)), and also lower stiffness was noted (171 N/mm (139–204) vs 265 N/mm (227–305)). There was no difference in graft diameter among groups.

Conclusions

The results of this study indicate that higher stiffness can be achieved using four-strand hamstring tendon grafts compared to tripled semitendinosus grafts when using femoral extra-cortical buttons, despite comparable graft diameters. Thereby, the use of adjustable extra-cortical fixation devices may result in more cyclic elongation and lower stiffness of the graft.

Non-operative treatment of peroneal tendon dislocations: A systematic review

Purpose

This study evaluated the clinical outcome of non-operative treatment of peroneal tendon dislocations.

Methods

A systematic review of literature was performed.

Results

Six studies were included. Redislocation rates differed between treatments: taping ≥ 3 weeks; 18/30 (60%) patients. Plaster cast ≥ 4 weeks; 5/13 (32%) plaster cast ≥ 6 weeks; 1/6 (17%). Strapping or taping treatment indicated a higher rate of pain and instability and a lower rate of ability to return to former activity.

Conclusions

A non-weight bearing cast ≥ 6 weeks was successful in 5/6 patients. A non-weight bearing cast might be a good alternative for surgical intervention.Level of Clinical Evidence: Level IV, systematic review of level IV studies.

Posterior cruciate ligament injury is influenced by intercondylar shape and size of tibial eminence

AIMS

Little is known about the risk factors that predispose to a rupture of the posterior cruciate ligament (PCL). Identifying risk factors is the first step in trying to prevent a rupture of the PCL from occurring. The morphology of the knee in patients who rupture their PCL may differ from that of control patients. The purpose of this study was to identify any variations in bone morphology that are related to a PCL.

PATIENTS AND METHODS

We compared the anteroposterior (AP), lateral, and Rosenberg view radiographs of 94 patients with a ruptured PCL to a control group of 168 patients matched by age, sex, and body mass index (BMI), but with an intact PCL after a knee injury. Statistical shape modelling software was used to assess the shape of the knee and determine any difference in anatomical landmarks.

RESULTS

We found shape variants on the AP and Rosenberg view radiographs to be significantly different between patients who tore their PCL and those with an intact PCL after a knee injury. Overall, patients who ruptured their PCL have smaller intercondylar notches and smaller tibial eminences than control patients.

CONCLUSION

This study shows that differences in the shape of the knee are associated with the presence of a PCL rupture after injury. A smaller and more sharply angled intercondylar notch and a more flattened tibial eminence are related to PCL rupture. This suggests that the morphology of the knee is a risk factor for sustaining a PCL rupture. Cite this article: Bone Joint J 2019;101-B:1058-1062.

Functional polymorphisms within the inflammatory pathway regulate expression of extracellular matrix components in a genetic risk dependent model for anterior cruciate ligament injuries

OBJECTIVES

To investigate the functional effect of genetic polymorphisms of the inflammatory pathway on structural extracellular matrix components (ECM) and the susceptibility to an anterior cruciate ligament (ACL) injury.

DESIGN

Laboratory study, case-control study.

METHODS

Eight healthy participants were genotyped for interleukin (IL)1B rs16944 C>T and IL6 rs1800795 G>C and classified into genetic risk profile groups. Differences in type I collagen (COL1A1), type V collagen (COL5A1), biglycan (BGN) and decorin (DCN) gene expression were measured in fibroblasts either unstimulated or following IL-1β, IL-6 or tumor necrosis factor (TNF)-α treatment. Moreover, a genetic association study was conducted in: (i) a Swedish cohort comprised of 116 asymptomatic controls (CON) and 79 ACL ruptures and (ii) a South African cohort of 100 CONs and 98 ACLs. Participants were genotyped for COL5A1 rs12722 C>T, IL1B rs16944 C>T, IL6 rs1800795 G>C and IL6R rs2228145 G>C.

RESULTS

IL1B high-risk fibroblasts had decreased BGN (p=0.020) and COL5A1 (p=0.012) levels after IL-1β stimulation and expressed less COL5A1 (p=0.042) following TNF-α treatment. Similarly, unstimulated IL6 high-risk fibroblasts had lower COL5A1 (p=0.012) levels than IL6 low-risk fibroblasts. In the genetic association study, the COL5A1-IL1B-IL6 T-C-G (p=0.034, Haplo-score 2.1) and the COL5A1-IL1B-IL6R T-C-A (p=0.044, Haplo-score: 2.0) combinations were associated with an increased susceptibility to ACL injury in the Swedish cohort when only male participants were evaluated.

CONCLUSIONS

This study shows that polymorphisms within genes of the inflammatory pathway modulate the expression of structural and fibril-associated ECM components in a genetic risk depended manner, contributing to an increased susceptibility to ACL injuries.

T2 mapping of the meniscus is a biomarker for early osteoarthritis

Purpose

To evaluate in vivo T₂ mapping as quantitative, imaging-based biomarker for meniscal degeneration in humans, by studying the correlation between T₂ relaxation time and degree of histological degeneration as reference standard.

Methods

In this prospective validation study, 13 menisci from seven patients with radiographic knee osteoarthritis (median age 67 years, three males) were included. Menisci were obtained during total knee replacement surgery. All patients underwent pre-operative magnetic resonance imaging using a 3-T MR scanner which included a T₂ mapping pulse sequence with multiple echoes. Histological analysis of the collected menisci was performed using the Pauli score, involving surface integrity, cellularity, matrix organization, and staining intensity. Mean T₂ relaxation times were calculated in meniscal regions of interest corresponding with the areas scored histologically, using a multi-slice multi-echo postprocessing algorithm. Correlation between T₂ mapping and histology was assessed using a generalized least squares model fit by maximum likelihood.

Results

The mean T₂ relaxation time was 22.4 ± 2.7 ms (range 18.5–27). The median histological score was 10, IQR 7–11 (range 4–13). A strong correlation between T₂ relaxation time and histological score was found (r_s = 0.84, CI 95% 0.64–0.93).

Conclusion

In vivo T₂ mapping of the human meniscus correlates strongly with histological degeneration, suggesting that T₂ mapping enables the detection and quantification of early compositional changes of the meniscus in knee OA.

Key Points

• Prospective histology-based study showed that in vivo T₂mapping of the human meniscus correlates strongly with histological degeneration.

• Meniscal T₂mapping allows detection and quantifying of compositional changes, without need for contrast or special MRI hardware.

• Meniscal T₂mapping provides a biomarker for early OA, potentially allowing early treatment strategies and prevention of OA progression.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06091-1) contains supplementary material, which is available to authorized users.

Is Training Load Associated with Symptoms of Overuse Injury in Dancers? A Prospective Observational Study

Overuse injuries in dance are extremely common and often difficult to treat. High training load and dancing with pain are frequently regarded as risk factors for musculoskeletal injuries in professional dancers. The aims of this study were to assess for: 1. any association between training load (TL) and symptoms of overuse injury in professional dancers, and 2. any difference between the number of "time-loss" injuries and injuries causing significant symptoms not leading to decreased performance time. Twenty-one dancers from a professional contemporary dance company were followed for 7 weeks. They completed the dance-specific Self-Estimated Functional Inability because of Pain (SEFIP) questionnaire on a weekly basis to quantify musculoskeletal pain. Their TL was calculated by multiplying the Ratings of Perceived Exertion scale (RPE Borg CR10) by the daily training time. Associations between TL and SEFIP scores, recorded on a weekly basis, were evaluated using a mixed linear model with repeated measurements. No significant association was found between TL and severity of musculoskeletal pain. However, the TL of the dancers with no symptoms of overuse-injury, SEFIP = 0, was significantly lower compared to the dancers with symptoms, SEFIP > 0; p = 0.02. No time loss because of injury was reported during the study period. There were 251 symptoms of overuse injury reported, and 67% of the recorded time was danced with pain. It is concluded that dancers without musculoskeletal pain had lower TLs. While no time-loss injuries were found, two-third of the participants danced with pain during this 7-week period.

Meniscal extrusion and degeneration during the course of osteoarthritis in the Murine collagenase-induced osteoarthritis model

Meniscal damage is, despite its major role in knee osteoarthritis (OA), often neglected in OA animal models. We evaluated structural meniscal degeneration during the course of OA in the murine collagenase-induced OA (CIOA) model. To investigate this, OA was induced in the knee joints of 33 male C57BL/6 mice by an intra-articular injection of 10U collagenase. The mice were sacrificed after 1, 3, 7, 14, 28, and 56 days, and the knees were harvested and processed for histological analysis. As control, six knees were obtained from 16-week-old mice in which no OA was induced. Meniscal damage, meniscal extrusion, and articular cartilage damage were evaluated on thionin-stained sections. Associations between parameters of interest were evaluated with Spearman rho correlation tests. When compared to non-OA knees, meniscal extrusion was visible from day 1 onwards and meniscal degeneration had a tendency to increase over time. The meniscus damage appeared around the same time as articular cartilage damage (day 14-28) and was statistically significantly more pronounced anterior than posterior, and no differences were seen between medial and lateral menisci. Meniscus and articular cartilage damage were moderately associated in the CIOA knees (ρ = 0.57; 95%CI [0.23-0.78]). Our findings suggest that the CIOA model is a valuable model to study the role of meniscal damage during OA progression and can support the development of future preventative treatment strategies. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2416-2420, 2018.

Satisfactory outcomes following combined unicompartmental knee replacement and anterior cruciate ligament reconstruction

PURPOSE

There exist limited options for treatment of patients with combined medial compartment arthritis and anterior cruciate ligament (ACL) deficiency. Ideal treatment is one that offers lasting relief of symptoms not compromising any future surgery. Unicompartmental knee replacement has shown consistently good results in the relatively young and active population, but there is a high reported incidence of failure up to 20%, if performed in ACL-deficient knees. One of the recognized treatment modality is combined ACL reconstruction and unicompartmental arthroplasty. A systematic review was conducted looking at the demographics, techniques, complications and outcome of combined ACL reconstruction with unicompartmental knee arthroplasty.

METHODS

A systematic literature search within the online Medline, PubMed Database, EMBASE, Web of Science, Cochrane and Google Scholar was carried out until October 2016 to identify relevant articles. A study was defined eligible if it met the following inclusion criteria: the surgical procedure combined unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction; patient's clinical and/or functional outcomes were reported; any complications intra-operatively and post-operatively were reported; and the full-text articles, written in English, German, Italian, Dutch or Spanish, were available. Quality and risk of bias assessments were done using standardized criteria set.

RESULTS

A total of 8 studies met the inclusion criteria encompassing 186 patients who were treated with simultaneous ACL reconstruction and unicompartmental knee arthroplasty. The mean age was 50.5 years (range from 44 to 56) with a mean follow-up of 37.6 months (range from 24 to 60). There was an improvement in mean Oxford Score from 27.5 to 36.8. Complications reported included tibial inlay dislocation (n = 3), conversion to a total knee arthroplasty (n = 1), infection requiring two-stage revision (n = 2), deep-vein thrombosis (n = 1), stiffness requiring manipulation under anaesthesia (n = 1), retropatellar pain requiring arthroscopic adhesiolysis (n = 1).

CONCLUSION

Unicompartmental knee arthroplasty combined with ACL reconstruction can be a valid treatment option for selected patients, with combined medial unicompartmental knee osteoarthritis and ACL deficiency.

LEVEL OF EVIDENCE

Systematic Review of Level IV Studies, Level IV.

High knee loading in male adolescent pre-professional football players: Effects of a targeted training programme

OBJECTIVE

To assess whether targeted neuromuscular exercises can decrease knee loading of adolescent pre-professional footballers with high knee loading as identified with the field-based Drop Vertical Jump Test (DVJT).

DESIGN

Prospective controlled trial, conducted between August and November 2016 at Erasmus Medical Centre, The Netherlands.

METHODS

Pre-professional football players (aged 14-21years) were evaluated at baseline and after 12weeks follow-up with the field-based DVJT. The field-based DVJT is a standardised test in which a player drops from a box and jumps up immediately after landing; knee load is calculated based on five parameters. Players with high knee load (probability≥0.75) from one club performed regular training(control group), and players with high knee load from another other club performed targeted neuromuscular exercises for 12weeks (intervention group). The difference of change in knee load between both groups after 12weeks was the primary outcome measure.

RESULTS

Of 107 eligible players, 75 had a high knee loading. Knee loading decreased in both groups after 12weeks of training, but change in probability of high knee load was not significantly different between both groups (95% Confidence Interval [-0.012-0.082], p=0.139).

CONCLUSION

Targeted neuromuscular exercises had no additional effect in decreasing knee loading of adolescent male pre-professional football players compared to regular training.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register (ID number: 6044).

Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes

BACKGROUND

An anterior cruciate ligament (ACL) rupture has major consequences at midterm follow-up, with an increasing chance of developing an old knee in a young patient. The long-term (≥20 years) effects of the operative and nonoperative treatment of ACL ruptures are still unclear.

PURPOSE

To compare the long-term treatment outcomes of operative versus nonoperative treatment of ACL ruptures in high-level athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Fifty patients with an ACL rupture were eligible for participation, and they were treated either nonoperatively (n = 25) in 1992, consisting of structured rehabilitation and lifestyle adjustments, or operatively (n = 25) between 1994 and 1996 with an arthroscopic transtibial bone-patellar tendon-bone technique. The patients in the nonoperative group were drawn from those who responded well to 3 months of nonoperative treatment, whereas the patients in the operative group were drawn from those who had persistent instability after 3 months of nonoperative treatment. Both groups were pair-matched and assessed at 10- and 20-year follow-up regarding radiological knee osteoarthritis, functional outcomes (Lysholm, International Knee Documentation Committee [IKDC], Tegner, Knee injury and Osteoarthritis Outcome Score), meniscal status, and knee stability (KT-1000 arthrometer, pivot-shift test, Lachman test, 1-legged hop test).

RESULTS

All 50 patients (100%) were included in the current study for follow-up. After 20 years, we found knee osteoarthritis in 80% of the operative group compared with 68% of the nonoperative group ( P = .508). There was no difference between groups regarding functional outcomes and meniscectomy performed. The median IKDC subjective score was 81.6 (interquartile range [IQR], 59.8-89.1) for the operative group and 78.2 (IQR, 61.5-92.0) for the nonoperative group ( P = .679). Regarding the IKDC objective score, 21 patients (84%) in the operative group had a normal or near normal score (A and B) compared with 5 patients (20%) in the nonoperative group ( P < .001). The pivot-shift test finding was negative in 17 patients (68%) versus 3 patients (13%) for the operative and nonoperative groups, respectively ( P < .001), and the Lachman test finding was negative in 12 patients (48%) versus 1 patient (4%), respectively ( P = .002).

CONCLUSION

In this retrospective pair-matched follow-up study, we found that after 20-year follow-up, there was no difference in knee osteoarthritis between operative versus nonoperative treatment when treatment was allocated on the basis of a patient's response to 3 months of nonoperative treatment. Although knee stability was better in the operative group, it did not result in better subjective and objective functional outcomes.

Possibility of quantitative T2-mapping MRI of cartilage near metal in high tibial osteotomy: A human cadaver study

T2-mapping is a widely used quantitative MRI technique in osteoarthritis research. An important challenge for its application in the context of high tibial osteotomy (HTO) is the presence of metallic fixation devices. In this study, we evaluated the possibility of performing T2-mapping after a HTO, by assessing the extent of magnetic susceptibility artifacts and the influence on T2 relaxation times caused by two commonly used fixation devices. T2-mapping with a 3D fast spin-echo sequence at three Tesla was performed on 11 human cadaveric knee joints before and after implantation of a titanium plate and screws (n = 5) or cobalt chrome staples (n = 6). Mean T2 relaxation times were calculated in six cartilage regions, located in the distal and posterior cartilage of femoral condyles and the cartilage of tibial plateaus, both medially and laterally. T2 relaxation times before and after the implantation were compared with paired t-tests and Wilcoxon rank tests. Due to the extent of the magnetic susceptibility artifact, it was not possible to segment the knee cartilage and thus calculate T2 relaxation times in the lateral weight-bearing femoral and tibial cartilage regions only in the cobalt chrome group. In all cartilage regions of the titanium implanted knees and those unaffected by artifacts due to cobalt chrome implants, T2 relaxation times did not significantly differ between the two scans. Our results suggest that accurate T2-mapping after a HTO procedure is possible in all areas after implantation of a titanium fixation device and in most areas after implantation of a cobalt chrome fixation device. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1206-1212, 2018.

Predictive Factors of Hamstring Tendon Regeneration and Functional Recovery After Harvesting: A Prospective Follow-up Study

BACKGROUND

Semitendinosus and gracilis tendons may regenerate after harvesting for ligament reconstruction procedures. However, predictive factors of tendon regeneration and the extent of functional recovery remain unclear.

PURPOSE

To identify predictive factors for hamstring tendon regeneration and to examine the morbidity of nonregenerated hamstring tendons.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Of the 154 patients who were included in a prospective follow-up study, 79 underwent reconstruction of the anterior cruciate ligament entailing the hamstring tendons and met the following inclusion criteria: (1) anterior cruciate ligament rupture diagnosed by physical examination and magnetic resonance imaging (MRI), (2) MRI within 6 months after trauma, (3) age between 18 and 45 years, and (4) 2-year follow-up MRI data available. Hamstring tendon regeneration was assessed as complete if a tendon-like structure could be visualized at the level of the joint line or more cranially. Patient characteristics-such as age, sex, body mass index, alcohol/nicotine use, activity level (Tegner scores), and functional instability (1-legged hop test)-were evaluated preoperatively and at 2 years to determine predictive factors for tendon regeneration or examine functional recovery of hamstring tendon regeneration.

RESULTS

At 2 years' follow-up, 67.1% of the patients showed regeneration of semitendinosus tendons, 81.0% of gracilis tendons, and 59.5% of both tendons. The likelihood of semitendinosus tendon regeneration significantly decreased with aging (odds ratio [OR], 0.92 change per year of age; 95% CI, 0.84-0.99; P = .03) and smoking (OR, 0.20; 95% CI, 0.05-0.77; P = .02). No predictive factor was found for gracilis tendon regeneration. Regeneration of the semitendinosus and gracilis tendons was negatively related with smoking (OR, 0.22; 95% CI, 0.06-0.79; P = .02). Patients without regeneration showed similar postoperative visual analog scale scores during physical activity, similar Tegner scores, and a significant decrease of the upper leg circumference, as compared with their preoperative results. Regardless of the regeneration status, 1-legged hop test results significantly increased at 2-year follow-up.

CONCLUSION

Hamstring tendon regeneration occurs less frequently in older patients and in smokers. However, absence of regenerated tendons does not seem to cause a loss of function.

Can we predict the clinical outcome of arthroscopic partial meniscectomy? A systematic review

NHS-Prospero registration number

42016048592

Objective

In order to make a more evidence-based selection of patients who would benefit the most from arthroscopic partial meniscectomy (APM), knowledge of prognostic factors is essential. We conducted a systematic review of predictors for the clinical outcome following APM.

Design

Systematic review

Data sources

Medline, Embase, Cochrane Central Register, Web of Science, SPORTDiscus, PubMed Publisher, Google Scholar

Inclusion criteria

Report an association between factor(s) and clinical outcome; validated questionnaire; follow-up >1 year.

Exclusion criteria

<20 subjects; anterior cruciate ligament-deficient patients; discoid menisci; meniscus repair, transplantation or implants; total or open meniscectomy.

Methods

One reviewer extracted the data, two reviewers assessed the risk of bias and performed a best-evidence synthesis.

Results

Finally, 32 studies met the inclusion criteria. Moderate evidence was found, that the presence of radiological knee osteoarthritis at baseline and longer duration of symptoms (>1 year) are associated with worse clinical outcome following APM. In addition, resecting >50% of meniscal tissue and leaving a non-intact meniscal rim after meniscectomy are intra-articular predictive factors for worse clinical outcome. Moderate evidence was found that sex, onset of symptoms (acute or chronic), tear type or preoperative sport level are not predictors for clinical outcome. Conflicting evidence was found for the prognostic value of age, perioperative chondral damage, body mass index and leg alignment.

Summary/conclusion

Long duration of symptoms (>1 year), radiological knee osteoarthritis and resecting >50% of meniscus are associated with a worse clinical outcome following APM. These prognostic factors should be considered in clinical decision making for patients with meniscal tears.

Validation of the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale Dutch language version in patients with hindfoot fractures

OBJECTIVES

The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale is among the most used questionnaires for measuring functional recovery after a hindfoot injury. Recently, this instrument was translated and culturally adapted into a Dutch version. In this study, the measurement properties of the Dutch language version (DLV) were investigated in patients with a unilateral hindfoot fracture.

DESIGN

Multicentre, prospective observational study.

SETTING

This multicentre study was conducted in three Dutch hospitals.

PARTICIPANTS

In total, 118 patients with a unilateral hindfoot fracture were included. Three patients were lost to follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were asked to complete the AOFAS-DLV, the Foot Function Index and the Short Form-36 on three occasions. Descriptive statistics (including floor and ceiling effects), reliability (ie, internal consistency), construct validity, reproducibility (ie, test-retest reliability, agreement and smallest detectable change (SDC)) and responsiveness were determined.

RESULTS

Internal consistency was inadequate for the AOFAS-DLV total scale (α=0.585), but adequate for the function subscale (α=0.863). The questionnaire had adequate construct validity (82.4% of predefined hypotheses were confirmed), but inadequate longitudinal validity (70.6%). No floor effects were found, but ceiling effects were present in all AOFAS-DLV (sub)scales, most pronounced from 6 to 24 months after trauma onwards. Responsiveness was only adequate for the pain and alignment subscales, with a SDC of 1.7 points.

CONCLUSIONS

The AOFAS Ankle-Hindfoot Scale DLV has adequate construct validity and is reliable, making it a suitable instrument for cross-sectional studies investigating functional outcome in patients with a hindfoot fracture. The inadequate longitudinal validity and responsiveness, however, hamper the use of the questionnaire in longitudinal studies and for assessing long-term functional outcome.

TRIAL REGISTRATION NUMBER

NTR5613; Post-results.

International patellofemoral osteoarthritis consortium: Consensus statement on the diagnosis, burden, outcome measures, prognosis, risk factors and treatment

OBJECTIVE

To present the current status of knowledge in the field of patellofemoral (PF) osteoarthritis (OA) and formulate a research agenda in order to guide future research on this topic.

DESIGN

A 1-day meeting was organized with the aim to bring together international experts in the field to discuss the current state of knowledge on PF OA. Experts from multiple disciplines were invited based on their scientific publications in the field of PF OA and interest in the subject. Topics discussed include the diagnosis, impact, prognosis, and treatment of PF OA.

METHODS

Following context-setting presentations, an interactive discussion was held in order to achieve consensus on the PF OA topics of interest: (1) diagnosis and definition; (2) burden; (3) outcome measures; (4) prognosis; (5) risk factors, and (6) treatment. Groups of meeting attendees reviewed the literature on these topics and narratively summarized the current state of knowledge, and each group formulated research agenda items relevant to the specific topics of interest. Each consortium member consequently ranked the importance of all items on a 0-10 Numerical Rating Scale (NRS) (10 = extremely important, to 0 = not at all important).

RESULTS

After ranking all formulated items on importance, 6 of the 28 research agenda items formulated received an average of 7.5 points on the NRS. The most highly ranked items covered the fields of treatment, diagnosis, and definition of PF OA.

CONCLUSIONS

We recommend to develop clear clinical criteria for PF OA and to reach consensus on the definition of PF OA by both radiographs and MRI. Additionally, more understanding is necessary to be able to distinguish PF symptoms from those arising from the tibiofemoral joint. More insight is needed on effective treatment strategies for PF OA; specifically, tailoring nonpharmacological treatments to individuals with PF OA, and determining whether isolated PF OA requires different treatment strategies than combined PF and tibiofemoral OA.

The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale; translation and validation of the Dutch language version for ankle fractures

OBJECTIVES

The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale is among the most commonly used instruments for measuring outcome of treatment in patients who sustained a complex ankle or hindfoot injury. It consists of a patient-reported and a physician-reported part. A validated, Dutch version of this instrument is currently not available. The aim of this study was to translate the instrument into Dutch and to determine the measurement properties of the AOFAS Ankle-Hindfoot Scale Dutch language version (DLV) in patients with a unilateral ankle fracture.

SETTING

Multicentre (two Dutch hospitals), prospective observational study.

PARTICIPANTS

In total, 142 patients with a unilateral ankle fracture were included. Ten patients were lost to follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients completed the subjective (patient-reported) part of the AOFAS Ankle-Hindfoot Scale-DLV. A physician or trained physician-assistant completed the physician-reported part. For comparison and evaluation of the measuring characteristics, the Foot Function Index and the Short Form-36 were completed by the patient. Descriptive statistics (including floor and ceiling effects), reliability (ie, internal consistency), construct validity, reproducibility (ie, test-retest reliability, agreement and smallest detectable change) and responsiveness were determined.

RESULTS

The AOFAS-DLV and its subscales showed good internal consistency (Cronbach's α >0.90). Construct validity and longitudinal validity were proven to be adequate (76.5% of predefined hypotheses were confirmed). Floor effects were not present. Ceiling effects were present from 6 months onwards, as expected. Responsiveness was adequate, with a smallest detectable change of 12.0 points.

CONCLUSIONS

The AOFAS-DLV is a reliable, valid and responsive measurement instrument for evaluating functional outcome in patients with a unilateral ankle fracture. This implies that the questionnaire is suitable to compare different treatment modalities within this population or to compare outcome across hospitals.

TRIAL REGISTRATION

The Netherlands Trial Register (NTR5613; 05-jan-2016).

American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score: a study protocol for the translation and validation of the Dutch language version

INTRODUCTION

The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score is among the most commonly used instruments for measuring the outcome of treatment in patients who sustained a complex ankle or hindfoot injury. It combines a clinician-reported and a patient-reported part. A valid Dutch version of this instrument is currently not available. Such a translated and validated instrument would allow objective comparison across hospitals or between patient groups, and with shown validity and reliability it may become a quality of care indicator in future. The main aims of this study are to translate and culturally adapt the AOFAS Ankle-Hindfoot Score questionnaire into Dutch according to international guidelines, and to evaluate the measurement properties of the AOFAS Ankle-Hindfoot Score-Dutch language version (DLV) in patients with a unilateral ankle or hindfoot fracture.

METHODS AND ANALYSIS

The design of the study will be a multicentre prospective observational study (case series) in patients who presented to the emergency department with a unilateral ankle or hindfoot fracture or (fracture) dislocation. A research physician or research assistant will complete the AOFAS Ankle-Hindfoot Score-DLV based on interview for the subjective part and a physical examination for the objective part. In addition, patients will be asked to complete the Foot Function Index (FFI) and the Short Form-36 (SF-36). Descriptive statistics (including floor and ceiling effects), internal consistency, construct validity, reproducibility (ie, test-retest reliability, agreement and smallest detectable change) and responsiveness will be assessed for the AOFAS DLV.

ETHICS AND DISSEMINATION

This study has been exempted by the Medical Research Ethics Committee (MREC) Erasmus MC (Rotterdam, the Netherlands). Each participant will provide written consent to participate and remain anonymised during the study. The results of the study are planned to be published in an international, peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NTR5613. pre-result.

Degenerative Changes in the Knee 2 Years After Anterior Cruciate Ligament Rupture and Related Risk Factors: A Prospective Observational Follow-up Study

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a well-known risk factor for development of knee osteoarthritis. Early identification of those patients at risk and early identification of the process of ACL rupture leading to osteoarthritis may aid in preventing the onset or progression of osteoarthritis.

PURPOSE

To identify early degenerative changes as assessed on magnetic resonance imaging (MRI) after 2-year follow-up in patients with a recent ACL rupture and to evaluate which determinants are related to these changes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Included in this study were 154 adults aged between 18 and 45 years with acute ACL rupture diagnosed by physical examination and MRI, without previous knee trauma or surgery, and without osteoarthritic changes on radiographs. A total of 143 patients completed the 2-year follow-up, and the results in this study apply to these 143 patients. All patients were treated according to the Dutch guideline on ACL injury. Of the 143 patients, 50 patients were treated nonoperatively during the 2-year follow-up period. Main outcome was early degenerative changes assessed on MRI defined as progression of cartilage defects and osteophytes in tibiofemoral and patellofemoral compartments. Patient characteristics, activity level, functional instability, treatment type, and trauma-related variables were evaluated as determinants.

RESULTS

The median time between MRI at baseline and MRI at 2-year follow-up was 25.9 months (interquartile range, 24.7-26.9 months). Progression of cartilage defects in the medial and lateral tibiofemoral compartments was present in 12% and 27% of patients, and progression of osteophytes in tibiofemoral and patellofemoral compartments was present in 10% and 8% of patients, respectively. The following determinants were positively significantly associated with early degenerative changes: male sex (odds ratio [OR], 4.43; 95% CI, 1.43-13.66; P = .010), cartilage defect in the medial tibiofemoral compartment at baseline (OR, 3.66; 95% CI, 1.04-12.95; P = .044), presence of bone marrow lesions in the medial tibiofemoral compartment 1 year after trauma (OR, 5.19; 95% CI, 1.56-17.25; P = .007), joint effusion 1 year after trauma (OR, 4.19; 95% CI, 1.05-16.72; P = .042), and presence of meniscal tears (OR, 6.37; 95% CI, 1.94-20.88; P = .002). When the patients were categorized into 3 treatment groups (nonoperative, reconstruction <6 months after ACL rupture, and reconstruction ≥6 months after ACL rupture), there was no significant relationship between the treatment options and the development of early degenerative changes.

CONCLUSION

Two years after ACL rupture, early degenerative changes were assessed on MRI. Concomitant medial cartilage defect and meniscal injury, male sex, persistent bone marrow lesions in the medial tibiofemoral compartment, and joint effusion are risk factors for degenerative changes.

Effects of Pulsed Electromagnetic Fields on Return to Sports After Arthroscopic Debridement and Microfracture of Osteochondral Talar Defects: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

BACKGROUND

Osteochondral defects (OCDs) of the talus usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracture. Various possibilities have been suggested to improve the recovery process after debridement and microfracture. A potential solution to obtain this goal is the application of pulsed electromagnetic fields (PEMFs), which stimulate the repair process of bone and cartilage.

HYPOTHESIS

The use of PEMFs after arthroscopic debridement and microfracture of an OCD of the talus leads to earlier resumption of sports and an increased number of patients that resume sports.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 68 patients were randomized to receive either PEMFs (n = 36) or placebo (n = 32) after arthroscopic treatment of an OCD of the talus. The primary outcomes (ie, the number of patients who resumed sports and time to resumption of sports) were analyzed with Kaplan-Meier curves as well as Mann-Whitney U, chi-square, and log-rank tests. Secondary functional outcomes were assessed with questionnaires (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot and Ankle Outcome Score, EuroQol, and numeric rating scales for pain and satisfaction) at multiple time points up to 1-year follow-up. To assess bone repair, computed tomography scans were obtained at 2 weeks and 1 year postoperatively.

RESULTS

Almost all outcome measures improved significantly in both groups. The percentage of sport resumption (PEMF, 79%; placebo, 80%; P = .95) and median time to sport resumption (PEMF, 17 weeks; placebo, 16 weeks; P = .69) did not differ significantly between the treatment groups. Likewise, there were no significant between-group differences with regard to the secondary functional outcomes and the computed tomography results.

CONCLUSION

PEMF does not lead to a higher percentage of patients who resume sports or to earlier resumption of sports after arthroscopic debridement and microfracture of talar OCDs. Furthermore, no differences were found in bone repair between groups.

REGISTRATION

Netherlands Trial Register NTR1636.