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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level II.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III: retrospective.

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

Aims

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

Methods

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

Results

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

Conclusion

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

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

NTR7261 (Netherlands Trial Register).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

NL 2618.

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

PURPOSES

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Discussion

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

Trial registration

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

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

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Descriptive laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

Standardized pain mapping for diagnosing Achilles tendinopathy

OBJECTIVES

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

DESIGN

Cross-sectional study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Facial subcutaneous emphysema due to rectum injury after pelvic fracture

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

Effects of eccentric exercises on improving ankle dorsiflexion in soccer players

Purpose

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Predictive Factors for Hamstring Autograft Diameter in Anterior Cruciate Ligament Reconstruction

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Traumatic Meniscal Tears Are Associated With Meniscal Degeneration

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Descriptive laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

[Preventing anterior cruciate ligament injury in children is effective]

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

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).

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.

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 (T2_FS) 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 T2_FS-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. T2_FS-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

T2_FS-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 T2_FS-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 T2_FS-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 T2_FS-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 T2_FS-hyperintense infrapatellar fat pad regions in patients with osteoarthritis suggest an inflammatory pathogenesis in osteoarthritis, but not in patellofemoral pain and healthy subjects.

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.

Hamstring Tendon Regeneration After Harvesting: A Systematic Review

BACKGROUND

Hamstring tendons are often used as autografts for anterior cruciate ligament (ACL) reconstruction. However, no systematic review has been performed describing consequences such as hamstring tendon regeneration rate and determinants of hamstring tendon regeneration.

PURPOSE

To summarize the current literature regarding hamstring tendon rate regeneration, the time course of regeneration, and determinants of hamstring regeneration.

STUDY DESIGN

Systematic review.

METHODS

A search was performed in the Embase, Medline (OvidSP), Web of Science, Cochrane, PubMed, and Google Scholar databases up to June 2014 to identify relevant articles. A study was eligible if it met the following inclusion criteria: tendons were harvested, regeneration at harvest site was assessed, population size was at least 10 human subjects, full-text article was available, and the study design was either a randomized controlled trial, prospective cohort study, retrospective cohort study, or case control study. A risk of bias assessment of the eligible articles was determined. Data describing hamstring tendon regeneration rates were pooled per time period.

RESULTS

A total of 18 publications met the inclusion criteria. The mean regeneration rate for the semitendinosus and gracilis tendons was, in all cases, 70% or higher. More than 1 year after harvesting, 79% (median [IQR], 80 [75.5-90]) of the semitendinosus tendons and 72% (median [IQR], 80 [61-88.5]) of the gracilis tendons were regenerated. No significant differences in regeneration rate could be found considering patient sex, age, height, weight, or duration of immobilization. Results did not clearly show whether absence of regeneration disadvantages the subsequent hamstring function. Five studies measured the regeneration rate at different moments in time.

CONCLUSION

Hamstring tendons regenerated in the majority of patients after ACL reconstruction. The majority of the hamstring tendon regeneration was found to occur between 1 month and 1 year after harvest. No significant determinants for hamstring tendon regeneration could be identified because of a lack of research. The function and strength of the regenerated hamstring remained unclear.