Validity and reliability of using photography for measuring knee range of motion: a methodological study

Reliability and validity of a method to measure trunk rotation angle from images using a camera and posture mirror

This study aimed to measure trunk rotation angle representations from images using a single camera combined with a posture mirror and to examine its reliability and validity. We applied a trunk rotation angle model using a tripod and markers simulating trunk rotation. We compared two methods of trunk rotation angle measurement: the conventional method from the superior aspect using a manual goniometer and a novel measurement method using images from a digital camera and a posture mirror. Measurement error was calculated as the average absolute error between the angle measured by the goniometer and that calculated from the camera and mirror image. The intraclass correlation coefficient (ICC 1, 1) and ICC (2, 1) were calculated as the intra-rater reliability and agreement between the measurement angles of the two methods, respectively. Systematic errors of the angles measured by the two methods were examined by a Bland‒Altman analysis. The mean (SD) of the mean absolute error was 1.17° (0.71°). ICC (1, 1) was 0.978, and ICC (2, 1) was 0.991. The Bland‒Altman analysis showed no systematic errors. The results suggest the validity and accuracy of our novel method to measure the angle of trunk rotation, which does not require high-cost equipment or a special environment.

Hoffa's fat pad resection during total knee arthroplasty does not affect functioning and gait: a double-blind randomized clinical trial

INTRODUCTION

Hoffa's fat pad is considered a source of anterior knee pain and may limit prosthetic knee function. Resection of Hoffa's fat pad in total knee arthroplasty (TKA), however, is controversial, and little is known about the functional outcomes including gait quality. This double-blind randomized controlled trial (i) compared functional recovery between TKAs where Hoffa was resected or preserved, and (ii) compared recovery of self-reported function with objective (gait-related) outcomes.

MATERIALS AND METHODS

Eighty-five patients (age 66.4 ± 8.0 years, 47% women) scheduled to undergo TKA for primary osteoarthritis were randomly assigned to either fat pad resection or preservation. Subjective measures of functioning were assessed at baseline, 6 weeks, 3 months, and 12 months postoperatively and included the Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala, and visual analog scale (VAS) for pain. Objective measures of functioning were assessed at baseline, 3 months, and 12 months postoperatively and included instrumented range-of-motion and gait analysis. Longitudinal analyses (generalized estimating equations) were used to compare recovery between groups, and chi-square tests compared attainment of minimal clinical important difference (MCID) and patient acceptable symptom state (PASS). Finally, correlation analyses explored associations between subjective and objective recovery in function.

RESULTS

Resection patients showed poorer improvement in KOOS quality of life in the first 6 weeks (B=-10.02, 95% confidence interval (CI) [-18.91, -1.12], p = .027), but stronger improvement in knee extension after 3 months (B = 3.02, 95%CI [0.45, 5.60], p = .021) compared to preservation patients. Regarding MCID or PASS, no differences were noted between groups at 3 and 12 months (all p > .05). Subjective function substantially improved in the first 3 months, while objective outcomes improved only between 3 and 12 months. Moderate to strong correlations were identified between changes in knee flexion and gait with Kujala and KOOS in the resection but not in the preservation group.

CONCLUSIONS

Similar functional outcomes were achieved after TKA with or without resection of Hoffa's fat pad. Hence, removing the fat pad to promote surgical exposure will not affect functional outcomes including gait quality. Functional recovery of objective outcomes was not always consistent with subjective recovery, suggesting that both self-reported as well as objective, gait-related outcomes may provide meaningful information on functional recovery following TKA.

TRIAL REGISTRATION

This clinical trial was prospectively registered under the Netherlands Trial Registry (# NL3638). This registry has recently been replaced by the Dutch Trial Registry where this study can be accessed via https://onderzoekmetmensen.nl/en/trial/20994 .

Thompson Versus Judet Techniques for Quadricepsplasty: A Systematic Review and Meta-analysis of Outcomes and Complications

Background

Quadricepsplasty has been used for over half a century to improve range of motion (ROM) in knees with severe arthrofibrosis. Various surgical techniques for quadricepsplasty exist, including Judet and Thompson, as well as novel minimally invasive approaches. The goal of this review was to compare outcomes between quadricepsplasty techniques for knee contractures.

Methods

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Available databases were queried for all articles on quadricepsplasty. Outcomes included postoperative ROM, outcome scores, and complication rates. Secondarily, we summarized rehabilitation protocols and descriptions of all modified and novel techniques.

Results

Thirty-three articles comprising 797 patients were included in final analysis. Thirty-five percent of patients underwent Thompson quadricepsplasty, 36% underwent Judet, and 29% underwent other techniques. After Judet and Thompson quadricepsplasty, patients achieved a mean postoperative active flexion of 92.7° and 106.4°, respectively (p < 0.01). Complication rates after Judet and Thompson were 17% and 24%, respectively. Wound infection was the most frequently recorded complication after Judet, whereas extension lag predominated for Thompson.

Conclusion

Both the Thompson and Judet quadricepsplasty techniques offer successful treatment options to restore functional knee ROM. Although the Thompson technique resulted in greater postoperative knee flexion compared with the Judet, the difference may be attributable to differences in preoperative flexion and time from injury to quadricepsplasty. Overall, the difference in flexion gained between the 2 techniques is comparable and clinically negligible.

Level of Evidence

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Improving Medical Photography in a Level 1 Trauma Center by Implementing a Specialized Smartphone-Based App in Comparison to the Usage of Digital Cameras: Prospective Panel Study

BACKGROUND

Medical photography plays a pivotal role in modern health care, serving multiple purposes ranging from patient care to medical documentation and education. Specifically, it aids in wound management, surgical planning, and medical training. While digital cameras have traditionally been used, smartphones equipped with specialized apps present an intriguing alternative. Smartphones offer several advantages, including increased usability and efficiency and the capability to uphold medicolegal standards more effectively and consistently.

OBJECTIVE

This study aims to assess whether implementing a specialized smartphone app could lead to more frequent and efficient use of medical photography.

METHODS

We carried out this study as a comprehensive single-center panel investigation at a level 1 trauma center, encompassing various settings including the emergency department, operating theaters, and surgical wards, over a 6-month period from June to November 2020. Using weekly questionnaires, health care providers were asked about their experiences and preferences with using both digital cameras and smartphones equipped with a specialized medical photography app. Parameters such as the frequency of use, time taken for image upload, and general usability were assessed.

RESULTS

A total of 65 questionnaires were assessed for digital camera use and 68 for smartphone use. Usage increased significantly by 5.4 (SD 1.9) times per week (95% CI 1.7-9.2; P=.005) when the smartphone was used. The time it took to upload pictures to the clinical picture and archiving system was significantly shorter for the app (mean 1.8, SD 1.2 min) than for the camera (mean 14.9, SD 24.0 h; P<.001). Smartphone usage also outperformed the digital camera in terms of technical failure (4.4% vs 9.7%; P=.04) and for the technical process of archiving (P<.001) pictures to the picture archiving and communication system (PACS) and display images (P<.001) from it. No difference was found in regard to the photographer's intent (P=.31) or reasoning (P=.94) behind the pictures. Additionally, the study highlighted that potential concerns regarding data security and patient confidentiality were also better addressed through the smartphone app, given its encryption capabilities and password protection.

CONCLUSIONS

Specialized smartphone apps provide a secure, rapid, and user-friendly platform for medical photography, showing significant advantages over traditional digital cameras. This study supports the notion that these apps not only have the potential to improve patient care, particularly in the realm of wound management, but also offer substantial medicolegal and economic benefits. Future research should focus on additional aspects such as patient comfort and preference, image resolution, and the quality of photographs, as well as seek to corroborate these findings through a larger sample size.

Reliability and validity of pose estimation algorithm for measurement of knee range of motion after total knee arthroplasty

We aimed to assess the reliability and validity of OpenPose, a posture estimation algorithm, for measurement of knee range of motion after total knee arthroplasty (TKA), in comparison to radiography and goniometry. In this prospective observational study, we analyzed 35 primary TKAs (24 patients) for knee osteoarthritis. We measured the knee angles in flexion and extension using OpenPose, radiography, and goniometry. We assessed the test-retest reliability of each method using intraclass correlation coefficient (1,1). We evaluated the ability to estimate other measurement values from the OpenPose value using linear regression analysis. We used intraclass correlation coefficients (2,1) and Bland-Altman analyses to evaluate the agreement and error between radiography and the other measurements. OpenPose had excellent test-retest reliability (intraclass correlation coefficient (1,1) = 1.000). The R² of all regression models indicated large correlations (0.747 to 0.927). In the flexion position, the intraclass correlation coefficients (2,1) of OpenPose indicated excellent agreement (0.953) with radiography. In the extension position, the intraclass correlation coefficients (2,1) indicated good agreement of OpenPose and radiography (0.815) and moderate agreement of goniometry with radiography (0.593). OpenPose had no systematic error in the flexion position, and a 2.3° fixed error in the extension position, compared to radiography. OpenPose is a reliable and valid tool for measuring flexion and extension positions after TKA. It has better accuracy than goniometry, especially in the extension position. Accurate measurement values can be obtained with low error, high reproducibility, and no contact, independent of the examiner's skills.

Development of a Manual Measurement Device for Measuring Hallux Valgus Angle in Patients with Hallux Valgus

Background: Hallux valgus (HV) is one of the most common forefoot deformities, and its prevalence increases with age. HV has been associated with poor foot function, difficulty in fitting footwear and poor health-related quality of life. The aims of this study were to design and develop an easy-to-use measurement device for measuring hallux valgus angle (HVA) in patients with HV and to assess the measurement reliability of the newly designed measurement device. Methods: A manual measurement device for measuring HVA was designed and developed to test on patients with HV. Two measuring methods, i.e., test–retest and intra-observer measurements, were used to evaluate the repeatability and reliability of the newly designed measurement device. In the test–retest measurements, a total of 42 feet from 26 patients with HV were repeatedly measured by the same researcher using the manual measurement device every 3 weeks over a period of 12 months. The measurement reliability of the newly designed measurement device was analysed based on the collected HVA data. In the intra-observer measurements, a total of 22 feet from the same group of HV patients were measured by the same researcher using the manual measurement device and by a consultant using X-ray measurement for comparison. The intraclass correlation coefficient (ICC) was used to determine the correlation of measurements between the manual measurement device and X-ray measurement. Results: The mean of the difference between the two repeat measurements of HVA using the newly designed manual device was 0.62°, and the average of ICC was 0.995, which indicates excellent reliability. The ICC between X-ray and the average of twice-repeated manual measurements was 0.868, with 95% CI (0.649, 0.947) (p = 0.000). When the relationship in HVA between X-ray measurement and manual measurement using the new device was regressed as a linear relationship, the regression equation was y = 1.13x − 4.76 (R² = 0.70). Conclusions: The newly designed measurement device is easy to use, with low-cost and excellent reliability for HVA measurement, with the potential for use in clinical practice.

Robotic-assisted surgery and kinematic alignment in total knee arthroplasty (RASKAL study): a protocol of a national registry-nested, multicentre, 2×2 factorial randomised trial assessing clinical, intraoperative, functional, radiographic and survivorship outcomes

INTRODUCTION

Robot-assisted surgery (RAS) and kinematic alignment (KA) are being increasingly adopted to improve patient outcomes in total knee arthroplasty (TKA). There is uncertainty around the individual or combined effect of these concepts compared with computer-assisted surgery (CAS) and mechanical alignment (MA), respectively. This study aims to assess the effectiveness of RAS, KA or both to improve clinical outcomes, functional measures, radiographic precision and prosthetic survivorship when compared with current gold standards of surgical care.

METHODS AND ANALYSIS

A national registry-nested, multicentre, double-blinded, 2×2 factorial, randomised trial will be undertaken with 300 patients undergoing primary unilateral TKA performed by 15 surgeons. The primary outcome will be the between-group differences in postoperative change over 2 years in the mean Knee injury and Osteoarthritis Outcome Score (KOOS-12), comparing first, RAS to CAS as its control, and second, KA to MA as its control. Secondary outcomes will include other knee-specific and general health patient-reported outcome measures (PROMs), intraoperative pressure loads as a measure of soft tissue balance, 6-month postoperative functional outcomes, radiological precision using CT imaging, complications and long-term prosthetic survivorship. The contribution of each patient's unique coronal plane alignment of the knee phenotype to primary and secondary PROMs will be investigated. OMERACT-OARSI criteria and Patient Acceptable Symptom State outcome score thresholds for the KOOS-12 and Oxford Knee Score will be used in secondary analyses. Primary intention-to-treat and secondary per-protocol analyses will be performed. Statistical analysis will include a generalised linear mixed model for repeated measures for continuous KOOS-12 scores. Kaplan-Meier estimates with adjusted HRs of implant survivorship will be calculated.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Sydney Local Health District-Royal Prince Alfred Hospital (Approval X20-0494 and 2020/ETH02896 10.24/DEC20). Results will be submitted for publication in a peer-reviewed journal and presented in national, state and international meetings.

TRIAL REGISTRATION NUMBER

ACTRN12621000205831.

The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder

PURPOSE

This proof of concept study examined the effectiveness of serial casting (SC) and ankle foot orthoses (AFOs) in children with autism spectrum disorder (Ch-ASD) who toe walk (TW). Data collected determined effects of SC, followed by AFO intervention on ankle dorsiflexion (A-DF) passive range of motion and kinematics, and parent-reported functional outcomes for children with autism spectrum disorder who TW and have limited A-DF passive range of motion.

SUMMARY OF KEY POINTS

The 5 participants increased passive range of motion with SC, except for 1 participant's left ankle. Two of 4 participants had near typical A-DF kinematic patterns following SC. The 5 participants improved A-DF during walking following 6 months of AFO use.

CONCLUSIONS

Serial casting increased A-DF ROM and kinematics during walking. Consistent AFO use for walking training improved function and reduced toe walking. Serial casting followed by AFOs is a potential intervention for children with autism spectrum disorder who TW.

The effect of immediate post-operative knee range of motion photographs on post-operative range of motion after total knee arthroplasty : An assessor-blinded randomized controlled clinical trial in sixty patients

PURPOSE

We attempted to determine the effect of immediate post-operative knee range of motion (ROM) photographs on improving ROM after total knee arthroplasty (TKA).

METHODS

Sixty patients, scheduled for unilateral primary TKA, were randomized into two groups. The photo group (n = 30) were immediately shown post-TKA knee ROM photographs as motivation for rehabilitation. The non-photo group (n = 30) received identical post-operative pain control and rehabilitation programs. Post-operative knee ROM and Knee Society Scores (KSS) at day three, six weeks, three months, six months, one year, and two years were evaluated. Outcome assessors were blinded to the groups during the study.

RESULTS

Patients in the photo group had better knee flexion on day three (99.9° ± 15.3°, 95% confidence interval (CI) 94.1-105.7° vs. 92.3° ± 11.4°, 95% CI 87.9-96.8°; p = 0.038) and at six weeks (120.9° ± 13.4°, 95% CI 115.7-126.0° vs. 112.5° ± 13.6°, 95% CI 107.2-117.8°; p = 0.023); however, there were no differences in range of flexion beyond six weeks post-operatively. Knee extension did not significantly differ throughout. Clinical KSS was significantly higher in the photo group at six weeks (90.7° ± 6.2° vs. 86.6° ± 6.4°, p = 0.017). Functional KSS showed no differences between groups during follow-up.

CONCLUSION

Showing knee ROM photographs seemed to result in significant improvement of knee flexion and clinical KSS in the first 6 weeks post-TKA and may be recommended as part of post-TKA rehabilitation.

The STAK tool: evaluation of a new device to treat arthrofibrosis and poor range of movement following total knee arthroplasty and major knee surgery

Aims

This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis.

Methods

35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions.

Results

Compared to the control group, the STAK intervention group made significant gains in mean ROM (30° versus 8°, p < 0.0005), WOMAC (19 points versus 3, p < 0.0005), and OKS (8 points versus 3, p < 0.0005). The improvements in the STAK group were maintained at long-term follow-up. No patients suffered any complications relating to the STAK, and 96% of patients found the STAK tool ‘perfectly acceptable’.

Conclusion

The STAK tool is effective in increasing ROM and reducing pain and stiffness. Patients find it acceptable and adherence to treatment was high. This study indicates that the STAK tool would be of benefit in clinical practice and may offer a new, cost-effective treatment for arthrofibrosis.

Cite this article: Bone Joint Open 2020;1-8:465–473.

Development of a Patient-Based Goniometric System for the Assessment of Contracture Conditions in Dupuytren's Disease

BACKGROUND

Treatment outcomes of Dupuytren's disease depend largely on degree of contracture and biological severity. Longitudinal assessment of each is crucial for effective care and long-term outcome assessment. Ideally, each Dupuytren's patient should have ongoing interval evaluations. Because of the large number of Dupuytren's patients, it would be impractical and costly for health care professionals to examine every patient in person on a regular basis. Patient-based evaluations might provide a useful and cost-effective alternative to office-based examination.

METHODS

Finger goniometry is the standard metric for office-based evaluation of Dupuytren's disease. This study's goal was to develop a new patient-reported goniometric system. The authors developed a completely Web-based goniometric software for patients to use without supervision and without undue effort or cost. They then evaluated the validity and precision of the core measurement system and the reliability of its patient-based application.

RESULTS

With a correlation of 0.992 (p < 0.01), a mean deviation of -0.25 degree, and a standard deviation of 2.74 degrees in patient-based application, the authors found their goniometric software to be comparable to practitioner-based, conventional goniometry. The authors believe patient-based goniometry to be a sufficiently accurate, valid, and reliable approach for longitudinal clinical assessment of Dupuytren's disease.

CONCLUSIONS

Patient-based goniometric approaches have great potential for inexpensive, accurate, and accessible longitudinal assessment of the large population of Dupuytren's patients. Such approaches could help to substantially improve overall care of Dupuytren's disease through early diagnosis and timely treatment. In addition, being able to collect reliable patient data on a regular basis and on a larger scale could help improve understanding of the natural history of Dupuytren's disease.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

Concurrent Validity of 2D and Inertial Goniometer Motion Assessment

Context: The validity and reliability of manual goniometry is highly dependent on the examiner’s expertise. Technological advances can overcome these problems to some extent. Inertial goniometry, for instance, could bridge the gap between 2D and manual goniometry, but its validity remains to be studied. Participants: 40 healthy individuals (mean ± SD: 31 men, age = 23.9 ± 4.1 years, 184 ± 6 cm, 80.7 ± 10.0 kg; 9 women, age = 23.6 ± 3.6 years, 170 ± 4 cm, 60.6 ± 5.1 kg). Measurements: 2D and inertial goniometry by mobee med™ were used to measure active and passive single straight-leg raise mobility performance. Intracorrelation coefficients (ICCs) and typical error of the estimate (TEE) inform the reliability and quality of the measurement by the rater. Results: The relationship of the inertial goniometry for active and passive mobility of the single straight-leg raise was practically perfect (r = .95–.98). Based on the Bland-Altman plots, the means of the difference between the 2D and inertial based goniometry were small (2–3°). Conclusion: Due to its high concurrent validity, ease of use, and efficiency with regard to time and personnel requirements, this inertial goniometer device is an effective and efficient approach to measuring range of motion. However, additional validity and reliability studies should investigate joints with more degrees of freedom.

The effect of a six-week plyometric training on dynamic balance and knee proprioception in female badminton players

OBJECTIVE

Non-contact anterior cruciate ligament (ACL) injury is one of the most common severe injuries among female badminton players. Dynamic balance (DB) and knee proprioception (KP) are critical in preventing this injury. The purpose of this study was to investigate the effect of a six-week plyometric training (PT) program on DB and KP in female badminton players.

METHODS

Twenty-two healthy beginner female badminton players were randomly assigned to either control (CG) or experimental group (ExG). The ExG went through PT for six weeks. Pre- and post-intervention Y balance and photography tests were used to assess DB and KP, respectively.

RESULTS

There was no difference between groups prior to PT in DB (p=0.804) and KP (at 45°, p=0.085 and at 60°, p=0.472 angles; p>0.05). However, after the PT only ExG improved significantly in DB (p=0.003) and KP (at 45°, p=0.004 and at 60°, p=0.010 angles; p<0.05).

CONCLUSION

Female badminton players' dynamic balance and knee proprioception improved significantly after plyometric training (PT). These results may be important in preventing non-contact anterior cruciate ligament (ACL) injury, which requires further investigation.

Does soft tissue balancing using intraoperative pressure sensors improve clinical outcomes in total knee arthroplasty? A protocol of a multicentre randomised controlled trial

INTRODUCTION

Soft tissue imbalance is considered to be a major surgical cause of dissatisfaction following total knee arthroplasty (TKA). Surgeon-determined manual assessment of ligament tension has been shown to be a poor determinant of the true knee balance state. The recent introduction of intraoperative sensors, however, allows surgeons to precisely quantify knee compartment pressures and tibiofemoral kinematics, thereby optimising coronal and sagittal plane soft tissue balance. The primary hypothesis of this study is that achieving knee balance with use of sensors in TKA will improve patient-reported outcomes when compared with manual balancing.

METHODS AND ANALYSIS

A multicentred, randomised controlled trial will compare patient-reported outcomes in 222 patients undergoing TKA using sensor-guided balancing versus manual balancing. The sensor will be used in both arms for purposes of data collection; however, surgeons will be blinded to the pressure data in patients randomised to manual balancing. The primary outcome will be the change from baseline to 1 year postoperatively in the mean of the four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS₄) that are most specific to TKA recovery: pain, symptoms, function and knee-related quality of life. Secondary outcomes will include the surgeon's capacity to determine knee balance, radiographic and functional measures and additional patient-reported outcomes. Normality of data will be assessed, and a Student's t-test and equivalent non-parametric tests will be used to compare differences in means among the two groups.

ETHICS AND DISSEMINATION

Ethics approval was obtained from South Eastern Sydney Local Health District, Approval (HREC/18/POWH/320). Results of the trial will be presented at orthopaedic surgical meetings and submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ACTRN#12618000817246.

Can stretch sensors measure knee range of motion in healthy adults?

Study aim: There are currently limited methods available to access dynamic knee range of motion (ROM) during free-living activities. This type of method would be valuable for monitoring and progressing knee rehabilitation. Therefore, the aim of this study was to evaluate the functioning of stretch sensors for the measurement of knee ROM and to assess the level of the measurement error. Material and methods: Nine healthy participants were included in the study. Three stretch sensors (StretchSense™, Auckland, NZ) were attached on the participants’ right knees by Kinesiotape®. A Cybex dynamometer was used to standardise movement speed of the knee joint. Data was recorded through the StretchSense™ BLE application. Knee angles were obtained from the video clips recorded during the testing and were analysed by MaxTraq® 2D motion analysis software. The knee angles were then synchronised with the sensor capacitance through R programme. Results: Seven out of the nine participants presented with high coefficient of determination (R2) (>0.98) and low root mean square error (RMSE) (<5°) between the sensor capacitance and knee angle. Two participants did not confirm good relationship between capacitance and knee angle as they presented high RMSE (>5°). The equations generated from these 7 participants’ data were used individually to predict knee angles. Conclusions: The stretch sensors can be used to measure knee ROM in healthy adults during a passive, non-weight-bearing movement with a clinically acceptable level of error. Further research is needed to establish the validity and reliability of the methodology under different conditions before considered within a clinical setting.

Measurement of knee joint range of motion with a digital goniometer: A reliability study

OBJECTIVES

Measurements of joint range of motion (ROM) are part of a physical therapist's daily work. Activities of daily living and exercises can be complicated to perform when ROM is limited, and depending on the demands in daily living, the knee joint requires different ROM. In sports, a few degrees in ROM may make the difference between getting injured or not. The goals for physical therapists are to help the patients to regain full ROM, mobility, strength, and function after sustaining an injury. To measure joints with the manual universal goniometer is considered time-consuming and difficult with respect to repeated measurements. Recently, a new digital instrument for measuring ROM was developed-EasyAngle. A first objective of the study was to investigate the reliability of EA for measuring knee joint angles, considering intrarater and interrater reliability. A second objective was to investigate if there were any differences in the intrarater reliability between a novice and an experienced assessor.

METHOD

Passive knee angles were measured in fixed positions for 40 knee joints (20 subjects). Two registered physical therapists, one novice and one experienced, conducted the measurements. Both registered physical therapists were blinded to the measurements throughout the study.

RESULTS

The results showed very good intrarater (intraclass correlation coefficient [ICC] 0,997-0,998, standard error of mean 1.15-1.48, smallest detectable difference [SDD] 3.19-4.09, limits of agreement -3.36-3.04, -4.66-4.09) and interrater reliability (ICC 0.994, standard error of mean 2.11, SDD 5.85, limits of agreement -4.75-6.95) for measurements of knee joint ROM. No statistical difference between a novice and an experienced assessor was detected (p = 0.86).

CONCLUSION

The results of the present study showed very good ICC values for both intrarater and interrater reliability measuring knee joint ROM with EasyAngle. Relatively high SDD values were seen for both assessors and may indicate a problem monitoring small differences between measurements. Further studies are recommended to increase the generalizability of the results.

Validity and Reliability of Elbow Range of Motion Measurements Using Digital Photographs, Movies, and a Goniometry Smartphone Application

INTRODUCTION

Range of motion (ROM) is closely monitored before and after surgery for stiff elbow and during rehabilitation. Measurements in the home environment may be helpful to increase involvement and adherence of the patient. Therefore, our objective is to investigate the validity and inter- and intraobserver reliability of 3 alternative methods to assess the ROM by the patient in a home-based situation, in comparison to the universal goniometer (UG). We hypothesize that all 3 alternative methods will be valid alternatives and show a level of reliability equivalent to UG.

METHODS

Goniometric measurements of elbow flexion, extension, pronation and supination using photography, movie, and a smartphone application were obtained. The validity of these measurement methods was compared to UG. The interobserver and intraobserver reliability were calculated for all measurement methods.

RESULTS

Photography and movie based goniometry of the elbow showed good validity in flexion and extension. The interobserver and intraobserver reliability were found to be good to excellent for photo and movie but moderate to poor for UG and the smartphone application.

CONCLUSIONS

Photo or movie based goniometry seems to be a useful option for initial and follow-up measurement of the elbow ROM, both in the outpatient clinic and in a home environment. Based on our study, the smartphone application we used is not recommended.

The reliability and validity of goniometric elbow measurements in adults: A systematic review of the literature

BACKGROUND

The universal goniometer is a simple measuring tool. With this review we aimed to investigate the reliability and validity of the universal goniometer in measurements of the adults' elbow.

METHODS

Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed and our study protocol was published online at PROSPERO. A literature search was conducted on relevant studies. Methodological quality was assessed using the Quality Appraisal of Diagnostic Reliability (QAREL) scoring system.

RESULTS

Out of 697 studies yielded from our literature search, 12 were included. Six studies were rated as high quality. The intrarater reliability intraclass correlation coefficient ranged from 0.45 to 0.99, the interrater reliability ranged from intraclass correlation coefficient 0.53-0.97. One study providing instructions on goniometric alignment did not find a difference in expert versus non-expert examiners. Another study in which examiners were not instructed found a higher interrater reliability in expert examiners. One study investigating the validity of the goniometer in elbow measurements found a maximum standard error of the mean of 11.5° for total range of motion.

DISCUSSION

Overall, the studies showed high intra- and interrater reliability of the universal goniometer. The reliability of the universal goniometer in non-expert examiners can be increased by clear instructions on goniometric alignment.

Inter-rater reliability and validity of angle measurements using smartphone applications for weight-bearing ankle dorsiflexion range of motion measurements

OBJECTIVES

The purpose of this study was to examine the inter-rater reliability, validity, and error of angle measurements for ankle dorsiflexion range of motion while in the weight-bearing position using a smartphone application.

DESIGN

Reliability and validity study.

SETTING

Measurement positions were performed by one experienced examiner.

PARTICIPANTS

Eighteen volunteers participated in the study. Three examiners (examiner 1 and examiner 2 had completed the course to become qualified certified athletic trainers and examiner 3 did not belong to the course) performed smartphone application measurements.

MAIN OUTCOME MEASURES

Ankle dorsiflexion range of motion was measured in the lunge position. Radiographic measurements were performed using a bony landmark. The markerless method for application measurements was used, using a body part as a landmark.

RESULTS

Using the markerless method for application measurements, the intra-class correlation coefficients were 0.945. Using Pearson's correlation coefficient and intra-class correlation coefficients to compare the radiographic measurements and markerless method for application measurements, three examiners showed very high correlation (r > 0.9) and almost perfect (>0.81) intra-class correlation coefficient. Error values were less than 5° according to examiner 1 and examiner 2.

CONCLUSION

Smartphone application measurements using the markerless method of ankle dorsiflexion range of motion exhibited inter-rater reliability and high validity.

Smartphone technology: a reliable and valid measure of knee movement in knee replacement

Knee range of motion (ROM) following a knee arthroplasty is an important clinical outcome that directly relates to the patient's physical function. Smartphone technology has led to the creation of applications that can measure ROM. The aim was to determine the concurrent reliability and validity of the photo-based application 'Dr Goniometer' (DrG) compared with a universal goniometer performed by a clinician. A smartphone camera was used to take photographs of the knee in full flexion and full extension, and the images were sent by participants to a study phone. Participants then rated the ease of participation. To assess validity, the patient's knee was measured by a clinician using a goniometer. To examine reliability, four clinicians assessed each image using DrG on four separate occasions spaced 1 week apart. A total of 60 images of knee ROM for 30 unicondylar or total knee arthroplasty were assessed. The goniometer and DrG showed strong correlations for flexion (r=0.94) and extension (r=0.90). DrG showed good intrarater reliability and excellent inter-rater reliability for flexion (intraclass correlation coefficient=0.990 and 0.990) and good reliability for extension (intraclass correlation coefficient=0.897 and 0.899). All participants found the process easy. DrG was proven to be a valid and reliable tool in measuring knee ROM following arthroplasty. Smartphone technology, in conjunction with patient-reported outcomes, offers an accurate and practical way to remotely monitor patients. Benefit may be found in differentiating those who need face-to-face clinical consult to those who do not.

Viability of Hand and Wrist Photogoniometry

BACKGROUND

No goniometric technique is both maximally convenient and completely accurate, although photogoniometry (ie, picture taking to facilitate digital angle measurement) shows promise in this regard. Our purpose was to test the feasibility and reliability of a photogoniometric protocol designed to measure wrist and digit range of motion in general.

METHODS

Two independent observers examined a sample of joints in both normal and abnormal hands according to a photogoniometric protocol. Interrater and intrarater correlation were calculated, and these measurements were compared with measurements made by a third independent examiner with a manual goniometer.

RESULTS

The photo-based measurements were reliable within and between observers; however, only a minority of these measurements were in agreement with manually collected values.

CONCLUSIONS

At present, photogoniometry is not an acceptable alternative to manual goniometry for determining wrist and digit range of motion in general. Joint-specific photogoniometry should be the subject of future study, as should relevant imaging and software technology.

How Does Level and Type of Experience Affect Measurement of Joint Range of Motion?

OBJECTIVES

Comparison of range of motion measurements by 3 types of investigators with different levels and types of training using three different measurement techniques. The study hypothesis was that the accuracy and precision of range of motion measurements would vary based on (1) the level and type of experience of the investigator and (2) the measurement technique used.

DESIGN/SETTING

Descriptive laboratory study.

PARTICIPANTS

Ten fresh frozen cadavers (20 upper and 20 lower extremities).

INTERVENTIONS

Shoulder, elbow, hip, and knee motion were measured using 3 different measurement techniques (digital photography, goniometry, and visual estimation) by 3 groups of investigators (attending orthopedic surgeons, physical therapists, and residents). Accuracy was defined by the difference from the reference standard (motion capture analysis), whereas precision was defined by the proportion of measurements within either 5° or 10° of the reference standard. Analysis of variance, t-tests, and chi-squared tests were used.

RESULTS

Statistically significant (p < 0.05) differences in accuracy were found for hip flexion, abduction, internal rotation, external rotation, and knee flexion. However, none of these differences met the authors' defined clinical significance (maximum difference 3°). Precision was significantly (p < 0.05) different for elbow extension, hip flexion, abduction, internal rotation, external rotation, and knee flexion.

CONCLUSION

This study found that clinically accurate measurements of shoulder, elbow, hip, and knee motion are obtained regardless of technique used or the investigators' level and type of experience. Precision was equivalent for all shoulder motions, elbow flexion, and knee extension, but varied by as much as 7% to 28% between groups for all other motions.

Is digital photography an accurate and precise method for measuring range of motion of the shoulder and elbow?

BACKGROUND

Accurate measurements of shoulder and elbow motion are required for the management of musculoskeletal pathology. The purpose of this investigation was to compare three techniques for measuring motion. The authors hypothesized that digital photography would be equivalent in accuracy and show higher precision compared to the other two techniques.

METHODS

Using infrared motion capture analysis as the reference standard, shoulder flexion/abduction/internal rotation/external rotation and elbow flexion/extension were measured using visual estimation, goniometry, and digital photography on 10 fresh frozen cadavers. These measurements were performed by three physical therapists and three orthopaedic surgeons. Accuracy was defined by the difference from the reference standard (motion capture analysis), while precision was defined by the proportion of measurements within the authors' definition of clinical significance (10° for all motions except for elbow extension where 5° was used). Analysis of variance (ANOVA), t-tests, and chi-squared tests were used.

RESULTS

Although statistically significant differences were found in measurement accuracy between the three techniques, none of these differences met the authors' definition of clinical significance. Precision of the measurements was significantly higher for both digital photography (shoulder abduction [93% vs. 74%, p < 0.001], shoulder internal rotation [97% vs. 83%, p = 0.001], and elbow flexion [93% vs. 65%, p < 0.001]) and goniometry (shoulder abduction [92% vs. 74%, p < 0.001] and shoulder internal rotation [94% vs. 83%, p = 0.008]) than visual estimation. Digital photography was more precise than goniometry for measurements of elbow flexion only [93% vs. 76%, p < 0.001].

CONCLUSIONS

There was no clinically significant difference in measurement accuracy between the three techniques for shoulder and elbow motion. Digital photography showed higher measurement precision compared to visual estimation for shoulder abduction, shoulder internal rotation, and elbow flexion. However, digital photography was only more precise than goniometry for measurements of elbow flexion. Overall digital photography shows equivalent accuracy to visual estimation and goniometry, but with higher precision than visual estimation.

Smartphone photography utilized to measure wrist range of motion

The purpose was to determine if smartphone photography is a reliable tool in measuring wrist movement. Smartphones were used to take digital photos of both wrists in 32 normal participants (64 wrists) at extremes of wrist motion. The smartphone measurements were compared with clinical goniometry measurements. There was a very high correlation between the clinical goniometry and smartphone measurements, as the concordance coefficients were high for radial deviation, ulnar deviation, wrist extension and wrist flexion. The Pearson coefficients also demonstrated the high precision of the smartphone measurements. The Bland-Altman plots demonstrated 29-31 of 32 smartphone measurements were within the 95% confidence interval of the clinical measurements for all positions of the wrists. There was high reliability between the photography taken by the volunteer and researcher, as well as high inter-observer reliability. Smartphone digital photography is a reliable and accurate tool for measuring wrist range of motion.

LEVEL OF EVIDENCE

II.

Smartphone-based accelerometry is a valid tool for measuring dynamic changes in knee extension range of motion

INTRODUCTION

Measurement of static joint range of motion is used extensively in orthopaedic and rehabilitative communities to benchmark treatment efficacy. Static measures are, however, insufficient in providing detailed information about patient impairments. Dynamic range of motion measures could provide more detailed information about patient impairments thus leading to better clinical assessments. Reliable and valid methods are available, but due to limitations in the present technology, dynamic measures are seldom performed in clinical settings. The objective of this study was to determine the validity of smartphone-based accelerometry measuring the dynamic range of motion of the knee joint during a passively executed extension movement.

MATERIALS AND METHODS

Dynamic knee extension range of motion was examined three consecutive times in twenty-one healthy male subjects utilising an isokinetic dynamometer to generate passively the extension motion. Measurements of joint angles in dynamic knee extension were performed using two methods: (i) isokinetic dynamometer (gold-standard method, Biodex System 4 Pro) and (ii) smartphone (iPhone 6, attached to the tibia) accelerometry data.

RESULTS

Tests of validity showed excellent correlation (rs=0.899) between methods, with a low standard error of measurement of 0.62deg. and limits of agreement ranging from -9.1 to 8.8deg. Interclass correlation coefficients showed excellent between-measures reliability (ICC>0.862) for both methods.

CONCLUSIONS

Smartphone-based accelerometry is a valid tool for measuring the range of motion at the knee joint during dynamic extension movements. This method enables the clinician to carry out simple, low cost, and valid clinical measurements of dynamic knee extension range of motion.

At Home Photography-Based Method for Measuring Wrist Range of Motion

Purpose  To determine the reliability of wrist range of motion (WROM) measurements based on digital photographs taken by patients at home compared with traditional measurements done in the office with a goniometer. Methods  Sixty-nine postoperative patients were enrolled in this study at least 3 months postoperatively. Active and passive wrist flexion/extension and radial/ulnar deviation were recorded by one of the two attending surgeons with a 1-degree resolution goniometer at the last postoperative office visit. Patients were provided an illustrated instruction sheet detailing how to take digital photographic images at home in six wrist positions (active and passive flexion/extension, and radial/ulnar deviation). Wrist position was measured from digital images by both the attending surgeons in a randomized, blinded fashion on two separate occasions greater than 2 weeks apart using the same goniometer. Reliability analysis was performed using the intraclass correlation coefficient to assess agreement between clinical and photography-based goniometry, as well as intra- and interobserver agreement. Results  Out of 69 enrolled patients, 30 (43%) patients sent digital images. Of the 180 digital photographs, only 9 (5%) were missing or deemed inadequate for WROM measurements. Agreement between clinical and photography-based measurements was "almost perfect" for passive wrist flexion/extension and "substantial" for active wrist flexion/extension and radial/ulnar deviation. Inter- and intraobserver agreement for the attending surgeons was "almost perfect" for all measurements. Discussion  This study validates a photography-based goniometry protocol allowing accurate and reliable WROM measurements without direct physician contact. Passive WROM was more accurately measured from photographs than active WROM. This study builds on previous photography-based goniometry literature by validating a protocol in which patients or their families take and submit their own photographs. Clinical Relevance  Patient-performed photography-based goniometry represents an alternative to traditional clinical goniometry that could enable longer-term follow-up, overcome travel-related impediments to office visits, improve convenience, and reduce costs for patients.

Reliability and validity of angle measurements using radiograph and smartphone applications: experimental research on protractor

[Purpose] The present study aimed to demonstrate the following by using measurements for the definite angles provided by the digital protractor: inter-rater reliability and validity in radiograph measurements and smartphone application measurements. [Subjects and Methods] The subject angles were 26 angles between 15° and 180° that were selected randomly using a computer. Three examiners measured the angles using the radiograph and smartphone application. The radiograph was obtained at a position 250 cm from the chest shooting cassette holder. The smartphone photograph was obtained at positions 50, 100, 150, 200, and 250 cm from the holder. [Results] Under all conditions, intra-class correlation coefficients showed 0.999. The correlation coefficient was 0.999 for all conditions. The mean absolute difference to the protractor was ≤0.28° for all conditions. [Conclusion] In comparison with the protractor, radiograph measurements and smartphone application measurements, the results of the present study showed high inter-rater reliability, validity, and small error. The results indicated that radiograph and smartphone application measurements could be used as criteria of validity in angle measurements. It supported the legitimacy of high-quality previous studies that used radiograph measurements as a criterion for validity.

Is digital photography an accurate and precise method for measuring range of motion of the hip and knee?

BACKGROUND

Accurate measurements of knee and hip motion are required for management of musculoskeletal pathology. The purpose of this investigation was to compare three techniques for measuring motion at the hip and knee. The authors hypothesized that digital photography would be equivalent in accuracy and show higher precision compared to the other two techniques.

METHODS

Using infrared motion capture analysis as the reference standard, hip flexion/abduction/internal rotation/external rotation and knee flexion/extension were measured using visual estimation, goniometry, and photography on 10 fresh frozen cadavers. These measurements were performed by three physical therapists and three orthopaedic surgeons. Accuracy was defined by the difference from the reference standard, while precision was defined by the proportion of measurements within either 5° or 10°. Analysis of variance (ANOVA), t-tests, and chi-squared tests were used.

RESULTS

Although two statistically significant differences were found in measurement accuracy between the three techniques, neither of these differences met clinical significance (difference of 1.4° for hip abduction and 1.7° for the knee extension). Precision of measurements was significantly higher for digital photography than: (i) visual estimation for hip abduction and knee extension, and (ii) goniometry for knee extension only.

CONCLUSIONS

There was no clinically significant difference in measurement accuracy between the three techniques for hip and knee motion. Digital photography only showed higher precision for two joint motions (hip abduction and knee extension). Overall digital photography shows equivalent accuracy and near-equivalent precision to visual estimation and goniometry.

Measurement of the knee flexion angle with smartphone applications: Which technology is better?

PURPOSE

The range of motion of the knee is a critical element of clinical assessment. The tested hypothesis was that the measurement of the knee flexion angle measured with two specific smartphone applications using either inclinometer or camera technology was different from the reference measurement with a navigation system designed for total knee arthroplasty (TKA).

METHODS

Ten consecutive patients were selected for navigation-assisted TKA. Five navigated, five inclinometer and five camera measurements of knee flexion angle were obtained for each patient throughout the complete range of motion. The difference, the correlation and the coherence between all measurements and all paired sub-groups were analysed.

RESULTS

There was a strong correlation and a good coherence between the three techniques of measurements, but the knee flexion angle reported by the inclinometer differed substantially from the camera- and navigation-based measurements. The camera-based measurement was clinically identical to the navigated data, with a mean difference of <1° and only 1/50 difference >3°.

CONCLUSION

Camera-based smartphone measurement of the knee range of motion is fit for purpose in a routine clinical setting. The accuracy may be higher than other conventional measurement techniques, allowing a more precise rating of the clinical outcomes after TKA.

LEVEL OF EVIDENCE

II.

Validity and reliability of arm abduction angle measured on smartphone: a cross-sectional study

BACKGROUND

Measuring range of movement is important in clinical shoulder assessment. Over the years, different techniques have been used to analyze upper limbs mobility. Smartphone image-based goniometer offers a noninvasive easy-to-use method of measuring arm abduction angle. However, the validity of this method has not been previously established. The purpose of this study was to investigate the validity and reliability of an Internet and image-based app (mROM) regarding arm abduction angle in both healthy subjects and patients suffering from shoulder damage.

METHODS

Twenty three subjects with shoulder pathology (14 female, 9 male) and 14 healthy subjects (8 female, 6 male) were examined (37 shoulders). mROM app was used to measure arm abduction angle. Two examiners measured 37 shoulders on 3 separate occasions over 2 days: 2 measurements on the first day and a third one the following day. Descriptive statistics were calculated for descriptive and anthropometric variables, as well as for the first measure of arm abduction angle by photographs and inertial sensors. Reliability was investigated by intraclass correlation coefficients and p values, and validity by Pearson correlation and P.

RESULTS

Intra-rater and inter-rater reliability were high (intraclass correlation coefficients 0.998 and 0.984 respectively) for the total sample, although, for the healthy group, intrareliability was lower and interreliability was no reliable. Measurements from photographs and intertial sensors were highly correlated (Pearson r = 0.964) for the total sample. However, it was no significant for the healthy group.

CONCLUSION

Smartphone photographs are a reliable and valid method to measure arm abduction angle, supporting the use of photography obtained through app for measuring joint ROM. This method provides a convenient and precise tool in assessment of arm motion.

Comparison of self-reported and measured range of motion in total knee arthroplasty patients

Total knee arthroplasty (TKA) is an established method used in the treatment of end-stage knee osteoarthritis. Range of motion (ROM) and relief from pain show success of TKA. One of the most important aims of this treatment is to achieve an adequate ROM. Numerous outcome instruments and patient-reported questionnaires are in use to evaluate of TKA patients. For this purpose, disease-specific questionnaires and self-reported ROM and function evaluation tools are also being developed. The most important criteria in musculoskeletal care is assessing the joint mobility of the patient's. Joint mobility can be measured with visual estimates, universal goniometer, X-ray radiography, digital gravity goniometers and applications found in smart phones. Apart from the reliability and validity of the method, obtaining the same results from different examiners is very important. The clinical follow-up of patients is an important part of postoperative care after TKA. The follow-up interval and duration remain dependent on the physician's anticipation of the clinical progress of the individual patient. Long-term surveillance of joint arthroplasty is necessary, but it has also become increasingly burdensome as greater numbers of TKAs are performed, and in younger populations. Patient self-reported questionnaires and self-goniometric measurement are used by many investigators to decrease this burden on the surgeon or staff, and in combination with telemedicine radiographs might be a reasonable option to routine clinic visits. They could reasonably be expected to lower the burden on both the patient and the clinician without eliminating contact and thus sacrificing quality of care. At the same time, it would reduce the financial burden too. Self-reported measured ROM can use in the routine follow-ups to reduce surgeons, physiotherapist and other staff.

A Non-Contact Measurement System for the Range of Motion of the Hand

An accurate and standardised tool to measure the active range of motion (ROM) of the hand is essential to any progressive assessment scenario in hand therapy practice. Goniometers are widely used in clinical settings for measuring the ROM of the hand. However, such measurements have limitations with regard to inter-rater and intra-rater reliability and involve direct physical contact with the hand, possibly increasing the risk of transmitting infections. The system proposed in this paper is the first non-contact measurement system utilising Intel Perceptual Technology and a Senz3D Camera for measuring phalangeal joint angles. To enhance the accuracy of the system, we developed a new approach to achieve the total active movement without measuring three joint angles individually. An equation between the actual spacial position and measurement value of the proximal inter-phalangeal joint was established through the measurement values of the total active movement, so that its actual position can be inferred. Verified by computer simulations, experimental results demonstrated a significant improvement in the calculation of the total active movement and successfully recovered the actual position of the proximal inter-phalangeal joint angles. A trial that was conducted to examine the clinical applicability of the system involving 40 healthy subjects confirmed the practicability and consistency in the proposed system. The time efficiency conveyed a stronger argument for this system to replace the current practice of using goniometers.

Comparative analysis of photograph-based clinical goniometry to standard techniques

BACKGROUND

Assessment of joint range of motion (ROM) is an accepted evaluation of disability as well as an indicator of recovery from musculoskeletal injuries. Many goniometric techniques have been described to measure ROM, with variable validity due to inter-rater reliability. In this report, we assessed the validity of photograph-based goniometry in measurement of ROM and its inter-rater reliability and compared it to two other commonly used techniques.

METHODS

We examined three methods for measuring ROM in the upper extremity: manual goniometry (MG), visual estimations (VE), and photograph-based goniometry (PBG). Eight motions of the upper extremity were measured in 69 participants at an academic medical center.

RESULTS

We found visual estimations and photograph-based goniometry to be clinically valid when tested against manual goniometry (r avg. 0.58, range 0.28 to 0.87). Photograph-based measurements afforded a satisfactory degree of inter-rater reliability (ICC avg. 0.77, range 0.28 to 0.96).

CONCLUSIONS

Our study supports photograph-based goniometry as the new standard goniometric technique, as it has been clinically validated, is performed with greater consistency and better inter-rater reliability when compared with manual goniometry. It also allows for better documentation of measurements and potential incorporation into medical records in direct contrast to visual estimation.

The effects of laser treatment in tendinopathy: a systematic review

Tendons have as main function transmit forces from the muscle to the bones. Tendinopathy is an inflammatory process that occurs in and around the tendon, when these are affected by some injury. Low level laser therapy consists in a local application of a monochromatic, coherent and short wavelength light. Its use began in 60's and since then several benefits for tendon injuries have been reported. The objective of this study is to collect the most recent studies about the use of laser on the tendinopathy treatment. We performed searches on the following electronic databases PubMed, Medline, CAPES journals portal and LILACS. After the analysis, we selected three articles that showed that the use of low-level laser therapy, compared to placebo, is effective in treatment of tendinopathy. Despite the need for more studies about this theme, the low-level laser therapy demonstrates consistent results in the treatment of tendinopathy.

Is there a difference in sagittal alignment of Blount's disease between radiographic and clinical evaluation?

BACKGROUND

A procurvatum deformity of the proximal tibia often is seen in patients with Blount's disease. If left untreated, it can lead to progressive angulation in the sagittal plane and altered contact stresses across the knee.

QUESTIONS/PURPOSES

We asked the following questions: (1) Is the mean angle of procurvatum measured from full-length lateral radiographs of the tibia greater than that of procurvatum measured from clinical photographs of the affected lower extremity? (2) Is there a linear relationship between radiographically measured procurvatum and radiographically measured procurvatum?

METHODS

We treated 72 patients surgically for Blount's disease between 1997 and 2012; of those, 29 patients were excluded from this analysis because they did not have adequate photographs or radiographs, leaving 43 patients (60% of the patients treated surgically; 47 limbs total), mean age of 13 years (range, 6-25 years), who underwent surgical realignment for Blount's disease were retrospectively evaluated at a median of 97 months after surgery (range, 24-170 months). Genu procurvatum was measured from full-length lateral radiographs of the tibia and clinical photographs of the affected lower extremity. We then assessed the relationship between radiographically measured procurvatum and clinically measured procurvatum using linear regression analysis.

RESULTS

The mean preoperative radiographically measured procurvatum (12.3°; range -3.1° to 55.2°) was larger than the clinically measured procurvatum (6.0°; range, -1° to 45°; p = 0.024). The mean postoperative radiographically measured procurvatum (4.2°; range -4.8° to 30.3°) was larger than the clinically measured procurvatum (2.1°; range, -2° to 20°; p = 0.041). Preoperatively and postoperatively, radiographically measured procurvatum and clinically measured procurvatum were well correlated (linear regression p < 0.001). After surgical realignment, the mean improvement in radiographically measured procurvatum (8.2°) was larger than that measured for clinically measured procurvatum (3.8°) (p = 0.018).

CONCLUSIONS

In patients with Blount's disease, visual inspection of the extremity can underestimate the procurvatum deformity of the proximal tibia relative to the measurable deformity on radiographs. Furthermore, surgical correction of proximal tibial procurvatum does not lead to clinical hyperextension of the knee.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial

BACKGROUND

The aim of this study was to determine whether center-based, one-to-one physical therapy provides superior outcomes compared with group-based therapy or a simple monitored home-based program in terms of functional and physical recovery and health-related quality of life after total knee arthroplasty.

METHODS

Patients awaiting primary total knee arthroplasty at two Sydney metropolitan hospitals were enrolled into this prospective, randomized, superiority trial preoperatively. At two weeks postoperatively, participants were randomly allocated to one of three six-week treatment programs (twelve one-to-one therapy sessions, twelve group-based therapy sessions, or a monitored home program) with use of a computer-generated sequence. Self-reported outcomes (Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index pain and function subscales, and Medical Outcomes Study 12-Item Short-Form Survey) and performance-based functional outcomes were measured over twelve months postoperatively by a blinded assessor. The primary outcome was knee pain and function measured with use of the Oxford Knee Score at ten weeks postoperatively. Intention-to-treat analysis was conducted.

RESULTS

Two hundred and forty-nine patients (eighty-five who had one-to-one therapy, eighty-four who had group-based therapy, and eighty who were in the monitored home program) were randomized and 233 were available for their one-year follow-up assessment. Participants who received one-to-one therapy did not have a superior Oxford Knee Score at week ten compared with those who received the alternative interventions; the median score was 32 points for the one-to-one therapy group, 36 points for the group-based therapy group, and 34 points for the monitored home program group (p = 0.20). Furthermore, one-to-one therapy was not superior compared with group-based therapy or monitored home program in improving any of the secondary outcomes across the first postoperative year. No adverse events were associated with any of the treatment arms.

CONCLUSIONS

One-to-one therapy does not provide superior self-reported or performance-based outcomes compared with group-based therapy or a monitored home program, in the short term and the long term after total knee arthroplasty.

LEVEL OF EVIDENCE

Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Measurement of the knee flexion angle with a Smartphone-application is precise and accurate

We hypothesized that the measurement of the knee flexion angle measured with a specific Smartphone application was different from the reference measurement with a navigation system designed for total knee arthroplasty (TKA). Ten consecutive patients operated on for navigation assisted TKA were selected. Six navigated and 6 Smartphone measurements of knee flexion angle were obtained for each patient. The paired difference between measurements and their correlation were analyzed. The mean paired difference between navigated and Smartphone measurements was -1.1° ± 6.8° (n.s.). There was a significant correlation between both measurements. The coherence between both measurements was good. The intra-observer and inter-observer reproducibility were good. The Smartphone application used may be considered as precise and accurate. The accuracy may be higher than other conventional measurement techniques.

Difference in knee joint position sense in athletes with and without patellofemoral pain syndrome

PURPOSE

The purpose of this study was to evaluate knee joint position sense (JPS) in athletes with patellofemoral pain syndrome (PFPS) and compare it with healthy participants under non-weight bearing (sitting) and weight bearing (standing) conditions.

METHODS

Twenty patients and 20 healthy athletes participated in this study. JPS was evaluated by active replication of knee angles with visual cues eliminated. Two target angles in sitting and one in standing were tested. Each test and replication was repeated three times. By subtracting the test angle from the replicated angle, the absolute error was calculated as a dependent variable.

RESULTS

No significant difference in knee JPS was found between groups either in the sitting or in the standing tests.

CONCLUSION

It seems that PFPS does not affect the knee JPS in athletes. The lack of deficiency in patients could possibly be attributed to their severity of knee pathology, pain intensity and their physical activity level.

LEVEL OF EVIDENCE

Case-control study, Level III.

Menstrual cycle and knee joint position sense in healthy female athletes

PURPOSE

The aim of this study was to investigate the effect of menstrual cycle on knee joint position sense (JPS) in healthy female athletes.

METHODS

Sixteen healthy female athletes participated in this study. Serum estrogen and progesterone levels were collected during the three phases of menstrual cycle. The knee JPS was also measured during the same phases using a system comprise of skin markers, digital photography, and AutoCAD software. Absolute angular errors were calculated as well as changes in hormone levels between the three phases.

RESULTS

Serum estrogen concentration was significantly higher during the mid-luteal (179.5 Pg/ml) and mid-follicular (125.6 Pg/ml) phases as compared with the early-follicular (menses) (22.8 Pg/ml) phase (P = 0.0001). Also serum progesterone concentration was significantly higher during the mid-luteal phase (7.35 Ng/ml) as compared with the menses (0.58 Ng/ml) and mid-follicular (0.5 Ng/ml) phases (P = 0.0001). The greatest amount of mean (SD) value of absolute error was at menses (4.2°), and the least amount of it was at mid-luteal (2.5°) phase. Also, a significant difference was observed within three phases of menstrual cycle (P = 0.025).

CONCLUSION

The result of this study suggests that healthy female athletes have different levels of knee JPS across a menstrual cycle. JPS accuracy decreases in menses, when circulating sex-hormones levels are low. Therefore, female athletes are at higher risk of injury at menses and improving their awareness regarding the knee injury risk factors can be a fundamental step toward preventing injuries.

LEVEL OF EVIDENCE

Case series, Level IV.

Improvements in knee range and symptomatic and functional behavior after knee arthroplasty based on preoperative restriction in range

Recovery of knee range and Oxford Knee Score post knee arthroplasty based on preoperative knee range is described. A total of 191 patients recruited across 5 hospitals were assessed preoperatively, at 8 weeks postoperatively and 1 year. Preoperative knee range was categorized into "low" (≤ 109), "moderate" (> 109 to ≤ 120), and "high" (> 120°) flexion and "normal" (± -5) and "restricted" (> +5°) terminal extension. Recovery was analyzed using MIXED modeling procedures. The low-flexion group gained flexion across time. The moderate-flexion and high-flexion groups lost flexion initially then recovered, but 1-year flexion remained lower than preoperative values. The restricted terminal extension group gained extension across time. The normal terminal extension group lost extension initially then recovered to preoperative values at 1 year. Recovery in Oxford score was independent of preoperative knee range limitation. Improvement in knee range postoperatively, but not self-reported behavior, is highly dependent on the initial restriction in range.