Tegner Activity Score Research Articles

Tibial tubercle transfer SurgeRy and physiothErapy Versus physIotherapy only for chronic paTellofemorAL paIn: study protocol for a randomiSed controllEd trial (REVITALISE)

BackgroundPatellofemoral pain (PFP) is a common musculoskeletal disorder resulting in anterior knee pain. Physiotherapy is the current standard treatment, while surgical intervention (tibial tubercle transfer [TTT]) is reserved for chronic cases when nonoperative treatment has failed. TTT can result in clinically meaningful improvement in patients with patellofemoral maltracking without instability. However, to date, no randomised controlled trials (RCT) have compared TTT combined with a physiotherapy (PT) programme to PT alone as the initial treatment for PFP.MethodsA single-centre nonblinded RCT in 40 patients with chronic PFP (> 1 year) and tibial tubercle-trochlear groove (TT-TG) > 15 mm will be randomised to either TTT followed by PT or to PT alone in a 1:1 ratio in a concealed manner. The primary outcome is knee pain at 18 weeks for the TTT group (6 weeks splint phase + 12 weeks PT) and at 12 weeks for the PT group, measured by the visual analog scale (VAS). Secondary outcomes include Patient-Reported Outcome Measures (PROMs) using the Kujala score, International Knee Documentation Committee (IKDC) ‘Subjective Knee Form’, Tegner Activity score and EuroQol 5D-5 L for quality of life. Range of motion (ROM) is measured using the decline step-down test (DSDT). Between-group differences will be analysed using multivariable linear regression analysis, while longitudinal differences will be assessed with linear mixed models for repeated measures. The difference in direct medical costs will also be assessed.DiscussionThe REVITALISE study is the first randomised study to compare surgical intervention (TTT) followed by PT to PT alone in patients with chronic PFP. This study will generate level-1 evidence on the most effective treatment for chronic PFP, which can be integrated into the national guideline to aid orthopaedic surgeons and physiotherapists in their decision-making and ultimately improve our care for patients with chronic PFP.Trial registrationStudy Identifier NCT06227806, registered on 26 Jan 2024 on ClinicalTrials.gov. The study underwent independent peer review and received approval from the ethical review board (number NL80956.091.22).

Comparison of Synovialization and Clinical Outcomes between Anterior Cruciate Ligament Anteromedial Bundle Augmentation and Double-Bundle Anterior Cruciate Ligament Reconstruction.

This study aimed to compare clinical outcomes and second-look arthroscopic findings between double-bundle anterior cruciate ligament (ACL) reconstruction for complete ACL rupture and anteromedial (AM) bundle augmentation with preservation of the posterolateral (PL) bundle in isolated AM bundle rupture. Between 2014 and 2021, we retrospectively analyzed 95 ACL reconstructions with at least 2 years of follow-up. Patients undergoing primary ACL reconstruction from January 2014 to June 2021 were included in the study. Double-bundle ACL reconstruction (group 1) was performed in the cases involving male patients, high activity levels, age below 40 years, or when there was a patient preference for double-bundle reconstruction. In contrast, for partial ACL ruptures with an intact PL bundle confirmed on preoperative magnetic resonance imaging, AM augmentation was performed (group 2). Preoperative and final follow-up clinical outcomes, along with synovial coverage during second-look arthroscopy, were compared between group 1 (65 cases) and group 2 (30 cases). Statistical analysis included correlation coefficients between the groups. The Lysholm score, Tegner activity scores, and International Knee Documentation Committee (IKDC) knee evaluation form score at final follow-up were 81.8 (±5.5), 7.2 (±0.9), and 79.4 (±6.7), respectively, in group 1, and they were 88.0 (±6.4, p = 0.038), 7.9 (±0.5, p = 0.042), and 86.2 (±5.4, p = 0.081), respectively, in group 2. For group 1, the Lachman test (p = 0.093) and the pivot shift test (p = 0.176) at the final follow-up showed no laxity in 57 and 59 knees, and there was plus one laxity in 8 and 6 knees. For group 2, there were no laxity in 27 and 28 knees, and plus one laxity in 3 and 2 knees. Synovial coverage area percentages of the grafted tendon were 74.3 (±10.7) and 86.9 (±7.3, p = 0.002) in groups and group 2, respectively, with superior synovial coverage observed in group 2. The AM bundle augmentation with preservation of the PL bundle in ACL injury yielded better synovial coverage and clinical scores compared with double-bundle ACL reconstruction for complete ACL rupture.

Neural structural alterations correlates of quadriceps muscle strength deficits in patients after anterior cruciate ligament reconstruction.

Persistent maladaptive changes of corticospinal tract (CST) and quadriceps strength deficits exist in patients with anterior cruciate ligament reconstruction (ACLR). This study aimed to investigate the relationships between the structural alterations of CST and quadriceps muscle strength deficits in patients with ACLR. Twenty-nine participants who had undergone unilateral ACLR (29 males; age=32.61±6.72 years) were enrolled in a cross-sectional investigation. We chose CST as a region of interest and performed diffusion tensor imaging (DTI) that measured the microstructure of white matter tracts. Maximal voluntary isometric quadriceps muscle strength was assessed using a hand-held dynamometer. Simple and partial correlation analyses were performed between the DTI outcomes and quadriceps muscle strength deficits in patients with ACLR before and after controlling for age, sex, BMI, Tegner activity score, and graft type. Sub-group analyses were also performed to investigate the relationships between the DTI outcomes of CST structure and quadriceps muscle strength deficits according to the graft type before and after controlling for age, sex, BMI, and Tegner activity score. Lower limb symmetry index (LSI) of quadriceps muscle strength was associated with a higher ratio of radial diffusivity (RD, r=-0.379, p=0.042) in corticospinal tracts of the injured hemisphere to those of the non-injured hemisphere in ACLR patients after controlling for age, BMI, Tegner activity score and graft type. In subgroup analyses of ACLR patients with hamstring autografts, we found that higher injured quadriceps muscle strength was associated with higher axial diffusivity (AD, r=0.616, p=0.033) of CST structure and lower LSI of quadriceps muscle strength was associated with higher ratio of mean diffusivity (MD, r=-0.682, p=0.014) and RD (r=-0.759, p=0.004) in corticospinal tracts of the injured hemisphere to those of the non-injured hemisphere in ACLR patients after controlling for age, BMI, Tegner activity score. Decreased integrity (higher ratio of RD) of CST microstructure in ACLR patients was significantly associated with lower quadriceps limb symmetry index, which hinted that quadriceps muscle strength deficits of injured side may be a demyelinating process of CST microstructure in ACLR.

Joint Effusion at 3 Months After Anterior Cruciate Ligament Reconstruction: Its Risk Factors and Association With Subsequent Muscle Strength and Graft Remodeling.

Joint effusion at 3 months after anterior cruciate ligament (ACL) reconstruction is a risk factor for ACL reinjury. However, factors associated with joint effusion at 3 months postoperatively and the effect of joint effusion on subsequent quadriceps muscle strength and graft remodeling remain unknown. To identify factors associated with joint effusion and investigate the association between joint effusion and quadriceps muscle strength and graft remodeling in the postoperative period. Case-control study; Level of evidence, 3. In this retrospective multicenter study, the medical records of patients who underwent single-bundle ACL reconstruction between 2015 and 2021 were reviewed. The study included the data of 174 patients (mean age, 23.5 ± 10.6 years). Demographic data, including sex, age at surgery, time from injury to surgery in months, body mass index, preinjury Tegner activity score, presence of meniscus, and chondral injuries, were collected. Magnetic resonance imaging was performed 3 months postoperatively. Joint effusion was defined as grade 3 (range of grades, 0-3) according to the ACL Osteoarthritis Score. Isokinetic strength testing was performed at 60 deg/s, while the limb symmetry index (LSI) of quadriceps strength was evaluated at 6 months postoperatively. Moreover, graft remodeling was evaluated using magnetic resonance imaging-derived signal intensity ratio (SIR) measures at 1 year postoperatively. The authors used multivariate logistic and linear regression analyses to identify the factors influencing joint effusion at 3 months and those associated with postoperative quadriceps strength LSI and SIR values, respectively. Greater preinjury Tegner activity scores (odds ratio, 1.59; 95% CI, 1.08 to 2.34; P = .02) increased the odds of joint effusion at 3 months postoperatively. Multivariable linear regression analysis revealed that joint effusion (β = -23.8; 95% CI, -36.0 to -11.7; P < .001) was an independent factor associated with LSI of the quadriceps. Furthermore, joint effusion (β = 1.33; 95% CI, 0.53 to 2.14; P = .001) was associated with a higher SIR value of the reconstructed graft. The preinjury Tegner activity score was a factor associated with joint effusion at 3 months postoperatively, and joint effusion was associated with subsequent muscle weakness and delayed graft remodeling.

Evaluating the Impact of Adjustable- and Fixed-Loop Femoral Endobuttons on Intraoperative Surgeon Satisfaction and Postoperative Patient Functional Outcomes in Anterior Cruciate Ligament (ACL) Reconstruction.

This study aims to evaluate the effects of adjustable- and fixed-loop femoral endobuttons on intraoperative surgeon satisfaction and postoperative patient functional outcomes in anterior cruciate ligament (ACL) reconstruction. The use of cortical suspensory devices, either fixed-loop or adjustable-loop, is common in ACL reconstruction surgeries for femoral tunnel fixation. Fixed-loop devices, although effective, often require additional tunnel drilling, potentially leading to tunnel widening. Adjustable-loop devices were introduced to mitigate this issue. However, there are concerns regarding the mechanical performance of adjustable loops, particularly under cyclical loading, which could affect long-term graft stability. This retrospective comparative study compares functional outcomes and intraoperative assessments of 140 patients who underwent ACL reconstruction between 2017 and 2021 with fixed-loop and adjustable-loop devices for the femoral side. Patients were evaluated at six weeks, six months, one year, and two years postoperatively using the Lysholm score, International Knee Document Committee score, Tegner activity scores, and knee stability tests, including Lachman and anterior drawer tests. Additionally, the study captured surgeon satisfaction intraoperatively and compared it with the final functional outcome. Both groups demonstrated significant improvements in knee stability, range of motion (ROM), and functional scores over time. At six weeks, the anterior drawer test showed 61 stable knees out of 70 in the adjustable-loop group and 57of 70 in the fixed-loop group, with stability maintained in 56 and 49 knees, respectively, at the final follow-up. The mean extension at two years was 0.5° ± 3.8° in the fixed-loop group and -1.3° ± 3.2° in the adjustable-loop group (p = 0.02). Although the adjustable-loop group showed trends toward better early knee stability and extension, these differences were not statistically significant at two years (p > 0.05). Surgeons' intraoperative satisfaction with graft firmness was higher in the adjustable-loop group. However, this did not correlate with long-term functional outcomes, as both groups had comparable scores at the final follow-up. Further research with larger sample sizes and extended follow-up periods is needed to confirm these findings. The limitations of this study include its retrospective design, the potential for selection bias, and the subjective nature of intraoperative assessments.

Comparison of Short-Term Clinical Effects of Minimally Invasive Anterior Talofibular Ligament Reconstruction versus Suture Anchor Repair for Chronic Lateral Ankle Instability

Objective: To compare the short-term clinical effects of minimally invasive anterior talofibular ligament (ATFL) reconstruction versus suture anchor repair in patients with chronic lateral ankle instability. Methods: A retrospective analysis was conducted on 68 patients at the 960th Hospital of the Chinese People’s Liberation Army Joint Logistics Support Force between January 2022 and June 2023, patients were divided into two groups based on surgical procedure: Group A (ATFL reconstruction, 35 cases) and Group B (suture anchor repair, 33 cases). Follow-up ranged from 1 to 12 months, assessing the American Orthopaedic Foot and Ankle Society (AOFAS) score, VAS pain score, Tegner activity score, and patient satisfaction, while noting any recurrence of ankle instability or complications such as numbness or infection. Results: In Group A, the AOFAS score improved from 74.46 ± 2.96 preoperatively to 90.91 ± 2.79 at final follow-up, Tegner score from 2.40 ± 0.50 to 5.69 ± 0.76, and VAS from 3.14 ± 0.85 to 1.60 ± 0.50; patient satisfaction was 8.31 ± 0.72. In Group B, AOFAS improved from 74.48 ± 2.29 to 90.55 ± 3.12, Tegner from 2.48 ± 0.51 to 5.76 ± 0.79, and VAS from 3.45 ± 0.83 to 1.73 ± 0.50, with patient satisfaction at 8.27 ± 0.63. No significant statistical difference was found between groups in any score (P &gt; 0.05), with both groups showing significant postoperative improvement (P &lt; 0.05) and no serious complications within 1-year follow-up. Conclusion: Both ATFL reconstruction and suture anchor repair yield favorable short-term outcomes in treating lateral ankle instability. Further research is needed to assess if anatomical reconstruction offers superior biomechanical benefits in scar healing over the suture anchor repair in long-term follow-up.

Clinical efficacy of arthroscopic single-bundle versus double-bundle reconstruction of the posterior cruciate ligament: a retrospective study.

To compare the functional and clinical outcomes of knee joints in patients over a 10-year period following posterior cruciate ligament (PCL) reconstruction with single-bundle versus double-bundle. Patients who underwent PCL reconstruction were retrospectively analyzed. Based on the surgical approach, they were divided into the single-bundle reconstruction group and the double-bundle reconstruction group. Preoperative and postoperative Lysholm score, International Knee Documentation Committee (IKCD) score, and Tegner activity score were evaluated, and the stability of the joints was assessed using KT-2000 arthrometer. Radiographs were taken at the final follow-up to evaluate the progression of osteoarthritis. A total of 61 patients were included in the analysis: 26 in the double-bundle group and 35 in the single-bundle group. Baseline data were comparable between the two groups (P > 0.05). There were no significant differences between the two groups in preoperative Lysholm, IKDC score, and Tegner activity score. Postoperatively, these scores were significantly higher at two and ten years follow-up (P < 0.05), with no significant difference between the groups (P > 0.05). There was no significant difference in side-to-side differences (SSD) at 30° and 90° of knee flexion preoperatively between the groups (P > 0.05). Postoperatively, SSD decreased significantly at the two year and ten year follow-up (P < 0.05), with no significant difference between the groups (P > 0.05). For osteoarthritis progression, there were four cases of Kellgren-Lawrence grade ≥ II in the single-bundle group and three cases in the double-bundle group, with no significant difference in the progression of osteoarthritis between the groups (P > 0.05). Both single-bundle and double-bundle reconstructions for PCL result in good joint stability and mobility, with similar progression of osteoarthritis in long-term follow-up. Level III.

MCL pie crusting for concomitant medial meniscal surgery does not appear to adversely influence primary ACL reconstruction functional outcomes

ObjectivesMedial collateral ligament “pie-crusting” (MCLPC), selective release of the superficial MCL, has been shown to improve the arthroscopic access to the posterior horn of the medial meniscus without adversely affecting the outcomes of isolated meniscal surgery. However, whether MCL PC, to address concomitant meniscal lesions during anterior cruciate ligament reconstruction (ACLR) surgery, adversely affects ACLR outcomes is unknown. The aim of this study was to assess whether patients who had undergone MCLPC at the time of ACLR had similar post outcomes to patients undergoing isolated ACLR. Methods55 consecutive patients (33 male and 22 female), with minimum 2-year follow-up, who had undergone MCLPC with concomitant primary ACLR (PC group) were retrospectively matched on the basis of age, sex and follow-up with 55 patients who underwent isolated primary ACLR. Post-operative outcome measures (PROMs) included the Knee injury and Osteoarthritis Outcome Score, the International Knee Documentation Committee score, Tegner activity score, the EuroQol five-dimension health questionnaire and EuroQol visual analogue scale. ResultsThe two groups’ median postoperative EQ 5D-VAS, EQ 5D-index and Tegner scores were similar. The difference between pre-operative and post-operative KOOS scores was similar for the two group for all subscales except the ADL subscale which was higher in the MCLPC group (24, IQR ​= ​6–32) than in the isolated ACLR group (5, IQR ​= ​0–9.74). The median post op IKDC score was 84 in the MCLPC group and compared with 90 in the isolated ACLR group. However, the difference between pre-operative and post-operative IKDC scores was higher in patients in the MCLPC group (40, IQR ​= ​25–49) than in the isolated ACLR group (32, IQR ​= ​19.6–46.8). ConclusionsMCLPC, performed at the time of ACLR does not appear to adversely affect the functional post-operative outcomes. Level of evidenceIV.

Outcomes of All-Inside Arthroscopic ACL Reconstruction with Lateral Extra-Articular Tenodesis (ACLR + LET).

Anatomic single-bundle ACL reconstruction (ACLR) produces good results when the graft and tunnel are positioned in the anatomic footprint on the femoral and tibial insertion sites in a more oblique orientation. The Anterolateral Complex of the knee and its biomechanical role in controlling rotational laxity, internal rotation, and pivot shift has led to adding adjunctive procedures like extra-articular augmentation and lateral extra-articular tenodesis (LET) to decrease rotational laxity. We prospectively analyzed young adults with rotational instability and generalized laxity undergoing an arthroscopic single bundle ACLR with an additional LET procedure. 42 patients, aged between 20 and 50, undergoing all-inside ACLR augmented with concomitant lateral extra-articular tenodesis between November 2020 and October 2021 were included. All patients were followed up for one year and functional assessment comprised of the International Knee Documentation Committee [IKDC] score, visual analogue score [VAS], and Lysholm Knee Scoring Scale at 6months and 1year. Return to activity was assessed using the Tegner Activity Score. The Lysholm score, IKDC score, and VAS showed significant improvements at 6months after ACLR + LET (p < 0.0001) and further improved significantly at 1year. The patients had a significant decline in the Tegner Activity Scale at 6months but returned to the near pre-injury level (5.98 ± 0.924) at 1year (5.67 ± 0.816) which was insignificant (p = 0.1067). Three patients sustained mild complications. 93% were satisfied with the surgery, 66% returned to sports and no patient underwent re-operation. Combination of LET with ACLR produces good functional outcomes, high rates of return to sports activities, and no graft failure in young patients at high risk of failure.

Evaluation of Return to Military Activities after Combining Anterior Cruciate Ligament Reconstruction with Modified Lateral Extra-articular Tenodesis Versus Anterior Cruciate Ligament Reconstruction Alone in Primary Anterior Cruciate Ligament Tear in Soldiers. A Randomized Comparative Study

Abstract Background: This study aimed to assess the clinical result, complications, failure rate, and return to resuming military duty of a single-stage anterior cruciate ligament reconstruction (ACLR) procedure utilizing quadrupled semitendinosus tendon graft joint with modified lateral extra-articular tenodesis (LET). This study evaluates the potential impact of combined modified LET with ACLR versus ACLR alone on the rate of return to high-impact military activities, which we call return to sports (RTSs), and the subsequent rate of the anterior cruciate ligament (ACL) graft failure. Materials and Methods: A total of 198 soldiers with primary ACL tears with a high-grade pivot test (grade 3) were included and randomized using the simple randomized method and divided into two groups. A consecutive cohort of military personnel with an isolated ACL tear undergoing ACLR with modified LET (group A, n = 116) and ACLR alone (group B, n = 82) were analyzed between 2016 and 2021. Both groups were followed up for a minimum of 2 years. Soldiers underwent a survey evaluating knee function (knee injury and osteoarthritis outcome score [KOOS]), RTS criteria (RTS type), symptoms (International Knee Documentation Committee [IKDC] subjective), activity level (Tegner score), and fear of movement (Tampa Scale of Kinesiophobia-11) to assess psychological readiness for sport participation. Results: Among these, a mean age of 32 ± 2.93 years underwent primary ACLR with modified LET (n = 116) or without LET (n = 82) procedure. A total of 31 soldiers (15.6%) experienced ACL graft failure, including 26 (31.7%) reconstructions without LET and 5 (4.3%) with LET. Combined with LET during primary ACLR, it lowered the risk of graft failure by 2.8 times. Multivariable analysis revealed a significant reduction in graft rupture risk (relative risk = 0.325, P = 0.029) associated with LET compared to ACLR alone after adjusting for age, anthropometric factors, and tibial slopes. 105 out of 113 (90.5%) soldiers were able to return to military duty in group A (combined ACLR with modified LET), whereas 51 of 81 (62.9%) of the soldiers who underwent ACLR alone (group B) returned to military duty (P = 0.05). Conclusion: At 24 months postoperatively, combined ACLR plus LET showed a significantly higher RTS rate than ACLR alone. The combined ACLR with the modified LET group also showed a lower failure rate than the ACLR alone group. No marked differences were observed in KOOS sub-scores, IKDCsubjective, and Tegner activity scores.

Medium- to Long-term Outcomes of Fasciotomy for Chronic Exertional Compartment Syndrome: A 6-Year Mean Follow-up Study.

Operative treatment of chronic exertional compartment syndrome (CECS) with fasciotomy is effective for symptomatic resolution, but outcomes at medium- to long-term follow-up are unclear. Patients will have favorable satisfaction at medium- to long-term follow-up and a high return to sport (RTS) rate after fasciotomy for treatment of CECS. Cross-sectional. Level 3. Retrospective review of patients who underwent fasciotomy for treatment of CECS from 2010 to 2021. Outcomes were assessed using Tegner Activity Scale, symptom resolution, patient satisfaction, return to activities, and EQ-5D-5L survey. Fifty patients (23 male and 27 female) were included. Mean age at time of surgery was 29.0 ± 11.6 years with mean follow-up 6.0 ± 2.3 years (range, 2.6-10.9). Tegner activity scores at final follow-up were improved compared with symptom onset (mean, 5.2 vs 3.3; P < 0.01). Increased preoperative symptom duration correlated with decreased RTS (β = -0.447; P = 0.01) and return to work (RTW) (β = -0.572; P = 0.01). Patients with a previous psychiatric diagnosis (n = 15) had lower rates of RTS (β = -0.358; P = 0.03) and RTW (β = -0.471, P = 0.02). Mean time to RTS was 5.5 ± 6.1 months. Mean visual analogue scale satisfaction rate was 74.4; 36 (72.0%) patients would be willing to have their fasciotomy again. Patients with fasciotomy of 1 to 2 compartments had higher Tegner score at final follow-up (P = 0.02) than those who had fasciotomy of >3 compartments; 19 (38.0%) patients reported experiencing paresthesia after their operation. No patients experienced major complications. Medium- to long-term outcomes of patients with CECS treated with fasciotomy demonstrated high satisfaction levels and high RTS rate. However, rate of minor complications including paresthesia, swelling, and cramping was high.

Proximal avulsion of the hamstring in young athlete patients: a case series and review of literature.

Hamstring injuries are a frequent occurrence of athletes, leading to a stop in practice and long-term alterations in sports performance. About 12% of these lesions involve avulsion at the level of the proximal insertion that can be complete (about 6%) or partial. Starting from an epidemiological and treatment evaluation of these lesions in literature, the aim of this study was to examine the functional outcomes and the rate of "return to play" in a population composed of athletes of various levels who have undergone surgery to reinsert the hamstring muscles at the ischial insertion, for a complete detachment of one or more tendon heads. Therefore, a retrospective study was carried out where 18 patients treated at the Orthopedics and Traumatology Unit of the I.R.C.C.S. San Matteo in Pavia (Italy) were identified in a time span ranging from March 2012 to August 2020. The sample was analysed taking into account age, sex and risk factors, as well as the pathophysiology and anatomy of the injury using the Wood classification, the time elapsed before surgery, the duration of the rehabilitation protocol and the possible return to sports activity, comparing the level of sports performance in the pre- and post-operative period using the Tegner Activity Score (TAS). Different post-operative outcome evaluation scores (Perth Hamstring Assessment Tool PHAT and Lower Extremity Functional ScaleLEFS) were also compared with each other in order to find a correlation with the real level of return to sporting activity. The mean age at surgery was 26.4 11.6 years. The population is composed of 14 males (77.8%) and 4 females (22.2%). All 18 patients returned to sports following surgery (100%). Of these patients, 17 (94%) maintained a level of sports performance equal to that before the injury. 100% of patients rated the outcome of the surgery as satisfactory. This study has shown that Hamstring reinsertion surgery is a correct indication in all athletes, allowing them a satisfactory return to sports practice.

Derotational distal femoral osteotomy yields better outcomes in patellar subluxation with proximal femoral torsion compared with distal femoral torsion: A retrospective comparative study.

Controversy exists regarding the origin of femoral torsion, and specific treatment rules regarding the optimal position of femoral osteotomy in patients with recurrent patellar subluxation and excessive femoral torsion are scarce. To establish a novel classification system for such patients, and to compare clinical and radiological outcomes after distal derotational femoral osteotomy (DDFO) between femoral torsion at proximal (neck and shaft) and distal levels. Between January 2014 and June 2019, patients who underwent DDFO were retrospectively reviewed. The segmental torsion analysis was performed to establish a novel classification system, and classify included patients into two groups: 35 patients in proximal torsion group and 38 patients in distal torsion group. These patients were followed-up for at least 3years. Clinical evaluations included functional outcomes, physical examinations, quality of life, activity level, satisfaction, and complications. Radiological outcomes included patellofemoral osteoarthritis, congruence, and alignment. Type I was defined as the proximal torsion. Type II was defined as the distal torsion. Proximal torsion group had lower postoperative femoral torsion (12.6 ± 2.6° vs. 14.8 ± 3.6°; P = .004) and higher surgical correction angle (21.6 ± 5.0° vs. 19.1 ± 3.0°; P = .009). All clinical and radiological outcomes improved significantly in both groups, but proximal torsion group had significantly higher quality of life (EQ-5D-5L: 0.96 ± 0.06 vs. 0.91 ± 0.07; P = .003. 92.0 ± 6.0 vs. 88.7 ± 5.8; P = .021) and Tegner activity score (5.2 ± 1.5 vs. 4.5 ± 1.4; P = .040), and fewer patellofemoral osteoarthritis (8.6% vs. 26.3%; P = .048). Two patients in the distal torsion group had subjective patellar instability. The percentage of patients with anterior knee pain was higher in the distal torsion group. A novel classification system for patients with recurrent patellar subluxation and excessive femoral torsion based on segmental femoral torsion analysis was established. DDFO was more appropriate for patients with proximal torsion, yielding higher surgical correction angle, and better clinical and radiological outcomes. Cohort study; Level of evidence, 3.

Efficacy of intra-articular injection of combined platelet-rich-plasma (PRP) and hyaluronic acid (HA) in knee degenerative joint disease: a prospective, randomized, double-blind clinical trial.

Intra-articular injections of hyaluronic acid (HA) and platelet-rich plasma (PRP) represent promising options in the conservative treatment of early stages of knee osteoarthritis (OA). Although the combined use of these two compounds seems to have a synergistic effect in pre-clinical studies, few clinical trials compared the association of PRP and HA with PRP and HA alone. The aim of study is toevaluate the efficacy of combined intra-articular injections of PRP and HA in the treatment of mild to moderate knee OA, compared to PRP and HA alone. One hundred and seventy-four patients were prospectively enrolled and randomized to undergo three intra-articular injections of either HA or PRP or the combination of PRP and HA with a two-week interval period. Patients were evaluated before treatment and after 3, 6, and 12months using Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective score, Visual Analogue Scale and TEGNER Activity Scores. All the treatments proved to be effective in reducing pain and improving joint function. The analysis of covariance did not show statistically significant differences among the three groups for any of the investigated outcome parameters after 6 and 12months (WOMAC: p = 0.45 and p = 0.64, respectively). No significant differences were found in terms of adverse events (p = 0.49) and painkiller use (p = 0.28 and p = 0.56, respectively) among the three groups. This multicenter, prospective, randomized, double-blind controlled trial revealed that intra-articular injections of PRP + HA, PRP, or HA represent a safe and viable treatment with comparable efficacy in terms of pain relief and functional outcomes in mild to moderate knee OA.

Survivorship and outcomes of intra- and perimeniscal corticosteroids injections with structured physiotherapy for degenerative medial meniscus tears

BackgroundDegenerative medial meniscus tears are a common pathology in the general population. Recent randomized trials demonstrated non-superiority of arthroscopic partial meniscectomy over conservative management. However, there is a paucity of information regarding the outcomes of combined conservative treatments. HypothesisIt was hypothesized that combined intra- and perimeniscal corticosteroid injections with structured physiotherapy, for degenerative medial meniscus tears, would result in high surgery-free and second injection-free survivorship. MethodsA retrospective review of 671 patients with symptomatic degenerative medial meniscus tears, who received intra- and perimeniscal corticosteroids injection combined with structured physiotherapy, was conducted. An ultrasound-guided injection of Triamcinolone Hexacetonide 20 mg/ml comprised; 1.5 ml intra-meniscal,1.5 ml in the meniscal wall, and 2 ml in the peri-meniscal space, was performed. Surgery free- and a second injection free-survivorship were analysed. Western Ontario and Macmaster University scores (WOMAC), Tegner activity scores, patient satisfaction, return-to-work status and average time to return to work were recorded. ResultsA total of 481 patients who met the inclusion criteria were included. The mean age was 51.1 ± 7.9 years. At five years post-procedure, surgery-free, and second injection-free survivorship of the ipsilateral knee was 83%, and 52%, respectively. A multivariate analysis adjusting survival on parametric risk factors identified that only effusion before steroid injection was an independent risk factor of treatment failure. At a mean follow-up of 4 ± 2 years, there was an improvement in WOMAC scores by 5.2 ± 4.9 for pain, by 2 ± 2 for stiffness, by 7.3 ± 7.4 for function, and by 12.4 ± 12.7 for the global scores. Additionally, there was significant improvement in the Tegner activity scores (All p < 0.001). Knee effusion and advanced osteoarthritis (Kellgren-Lawrence > III) were significantly associated with poorer outcomes; p < 0.003 and p < 0.0004, respectively. ConclusionA combination of intra- and perimeniscal corticosteroid injections and structured physiotherapy for degenerative medial meniscus tears, results in high surgery-free (83%) and second injection-free (52%) survivorship, as well as, effective clinical outcomes and satisfaction at 5 years. Level of evidenceIV; Retrospective Case Series.

Evaluation of healing after arthroscopic repair of lateral meniscal tears around the popliteal hiatus

BackgroundThe popliteal hiatus stabilizes the lateral meniscus (LM). Variable failure rates for LM repairs have been reported in knees with lateral meniscal tears (LMTs), which may be attributable to low vascularity around the popliteal hiatus. An effective repair method is essential to enhance the biological healing and stability of LMTs around the popliteal hiatus. HypothesisArthroscopic repair of LMTs, including the popliteus tendon around the popliteal hiatus, is expected to produce a low reoperation rate and effective treatment, both clinically and radiographically. Material and methodsFrom June 2011 to August 2020, 93 patients (mean age 27.9 ± 13.5 years) who underwent arthroscopic repair of LMTs including the popliteus tendon around the popliteal hiatus were enrolled. Patients with LMTs were divided into three groups: isolated LMTs, discoid LMTs, and LMTs with ACL injury. Patients had a minimum clinical follow-up of 2 years (mean 37.9 ± 19.3 months) and Tegner activity, Lysholm knee, and Hospital for Special Surgery (HSS) scores were evaluated for all patients. The widths of the popliteal hiatus and LM extrusion were measured on the sagittal and coronal planes using preoperative and postoperative magnetic resonance imaging (MRI). ResultsThe Tegner activity (2.6 ± 1.2–4.5 ± 1.3), Lysholm (67.9 ± 14.2–88.1 ± 6.4), and HSS scores (79.8 ± 11.5–93.7 ± 5.1) were significantly improved in all knees (p < 0.001). The width of the popliteal hiatus measured on MRI was significantly decreased, when comparing the preoperative and postoperative MRI for all knees (sagittal plane, 2.9 ± 1.4–1.5 ± 0.5 mm; coronal plane, 3.8 ± 2.5 to 1.9 ± 1.0 mm) (p < 0.05). The LM extrusion measured on the sagittal plane of postoperative MRI was also significantly reduced after arthroscopic repair (24.8 ± 3.1–23.7 ± 2.8 mm) (p = 0.001). Five reoperations (5/93, 5.3%) were performed, suggesting a clinical failure. ConclusionArthroscopic repair of isolated, discoid and post-traumatic LMTs including the popliteus tendon around the popliteal hiatus, is an effective surgical treatment for LM stabilization. Level of evidenceLevel IV, retrospective series.

The Effectiveness of the Modified Side-Locking Loop Suture Technique with Early Accelerated Rehabilitation for Acute Achilles Tendon Rupture in Athletes

Background/Objectives: An early accelerated rehabilitation is generally recommended after surgery for acute Achilles tendon ruptures (ATRs). The modified side-locking loop suture (MSLLS) is a surgical technique that provides high tensile strength to the repaired Achilles tendon and allows for a safe, early accelerated rehabilitation protocol without requiring postoperative immobilization. However, there are no reports investigating the clinical outcomes of the MSLLS technique with early accelerated rehabilitation for ATRs. To clarify the effectiveness of the MSLLS technique with an early accelerated rehabilitation protocol for ATR in athletes. Methods: We retrospectively analyzed 27 athletes (Tegner activity score ≥ 6) who underwent surgical treatment using the MSLLS technique for ATR between April 2017 and August 2022. All patients underwent an early accelerated rehabilitation protocol without immobilization. Outcome measures included the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score taken preoperatively and one year postoperatively, the time required to perform 20 continuous double-leg heel raises (DHR) and single-leg heel raises (SHR), the time to return to the original sport, and the presence of any complications. Results: The mean AOFAS score significantly improved from 37.2 ± 9.7 preoperatively to 96.3 ± 5.3 one year postoperatively. The mean time to be able to perform 20 continuous DHR and SHR was 7.7 ± 1.2 weeks and 11.3 ± 1.6 weeks, respectively. All patients were able to return to their original sport at their pre-injury level in an average of 22.7 ± 3.7 weeks without complication. Conclusions: The MSLLS technique in conjunction with an early accelerated rehabilitation protocol for ATR in athletes produced satisfactory results, with all patients able to return to their original sport at their preinjury level without complication.

Evaluation of a radiological grading system for the early detection of total knee arthroplasties at risk for revision surgery

IntroductionX-rays are regularly performed after primary total knee arthroplasty (TKA). While soft tissue management and ligament tension cannot be evaluated, important information, such as inadequate component positioning and loose cement location, as well as subsequent loosening, can be detected. The aim of this study was to correlate radiological findings, referring to the radiological grading system (previously published by the same study group, henceforth abbreviated as “RGS”), with long-term outcomes and implant survival.Materials and methodsA total of 266 patients who underwent titanium-coated TKA were included. In addition to implant survival, visual analogue scale score, Tegner activity score, knee society score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index, and short form-12 score as well as range of motion were evaluated. Clinical examination as well as anterior-posterior, lateral, full-length weight bearing, and patellar view radiographs were performed pre- and postoperatively, at the 3-, 6-, and 12-month postoperative follow-ups and at the final follow-up. The radiological grading system was evaluated and correlated with long-term outcome and survivorship.ResultsThe revision-free survival rate was 88.4% at a median follow-up of 9.8 years (IQR: 9.3–10.3 years; range: 0.1–11.8 years). Revision surgery was required in 31 TKAs (11.7%). The multivariate Cox regression model showed a significant association between an RGS score ≥ 3 deviation points (DP) and an increased risk for revision (hazard ratio: 2.092; 95% CI: 1.020–4.290; p = 0.044). Moreover, the KSS for pain was significantly worse in patients with a RGS score ≥ 3 DP (median, 85 [74–92] vs. 90 [80–94]; p = 0.007).ConclusionsThis is the first study indicating that deviation in component positioning, having an inadequate long leg axis, the presence of free cement or residual bony structures on postoperative X-rays significantly correlate with TKA outcome and implant survival. Therefore RGS can be of high predicable value for the survivorship of the prosthesis.Level of evidenceLevel IV – retrospective cohort study.

In non-elite athletes, women are more likely to return to sports after anterior cruciate ligament reconstruction: a retrospective cohort study

BackgroundThe desire to return to sports (RTS) and return to performance at preinjury level (RTSP) is a common motivator for athletes undergoing anterior cruciate ligament (ACL) reconstructive surgery. However, for non-elite athletes little is known about the patient and surgical variables influencing RTS/RTSP. Purpose was to determine which patient or surgical variables had an effect on RTS/RTSP in non-elite athletes. We also analyzed whether patients that RTS and RTSP have more confidence in the knee and less difficulty pivoting.MethodsA single-centre retrospective cohort study. All patients who had undergone primary hamstring ACL reconstruction within a 5-year period were included. Patients were asked about their pre- and postoperative sports participation using the Tegner Activity Score (TAS) as well as about their RTS/RTSP. Confidence in the knee and difficulty with pivoting were asked about. To determine the potential adverse effect of patient variables at the time of surgery (sex, age, height, weight, TAS preop) and surgical variables (graft diameter, surgical technique, concomitant injury) influencing RTS/RTSP, univariate and multivariate logistic regression analysis were used.Results370 ACL reconstructions were included. Average follow-up was 4.6 years (SD 1.4). RTS rate was 65% and RTSP 43%. Median preinjury TAS was 7 (Q1:6, Q3:8)), postoperative 6 (Q1:4, Q3:7). Multivariate analysis showed that women were more likely to RTS (OR 2.40, 1.16–4.97). A lower preinjury TAS (OR 0.80, 0.67–0.95) resulted in higher RTSP levels. None of the surgical variables had a significant influence on RTS or RTSP. Patients who returned to sports or to preinjury-level performance displayed significantly more confidence in the operated knee and less difficulty pivoting than non-returning patients.ConclusionOur study shows that 65% of non-elite athletes with an ACL reconstruction returned to sports, 43% at preinjury level. Women were over twice more likely to RTS than men. Preinjury TAS significantly influences RTSP, with a lower preinjury TAS leading to a higher percentage of RTSP. Patients returning to both scored better in their self-reported confidence in the knee and difficulty pivoting than non-returning patients.Level of evidenceRetrospective cohort III.

Preoperative Psychological Competitive Ability Is Associated With Emotional States Six Months After Anterior Cruciate Ligament Reconstruction With Hamstring Autograft: A Prospective Study.

Background Psychological state has been reported as one of the factors strongly related to a return to sports after anterior cruciate ligament (ACL) reconstruction. However, its relationship with the emotional state remains unclear. The aim of this study was to investigate whether patients who have undergone ACL reconstruction and have a higher preoperative psychological competitive ability have a better emotional status preoperatively and six months postoperatively. Methods Patients with a Tegner activity score of ≥6 who underwent ACL reconstruction between 2015 and 2020 were divided into two groups according to their grades on the Diagnostic Inventory of Psychological Competitive Ability for Athletes (DIPCA.3). The emotional states preoperatively and at six months postoperatively were assessed using the Profile of Mood States Second Edition (POMS2) and compared between the two groups. Furthermore, the possibility of returning to sports was compared between the groups based on participation in the entire practice at six months postoperatively. Results Eighty-four patients were included and divided into the high (DIPCA.3 grades ≥4, n = 23) and low (DIPCA.3 <4, n = 61) groups. Vigor-activity and friendliness were significantly higher in the high group than in the low group preoperatively. The difference was even greater at six months after ACL reconstruction. In addition, the high group showed significantly better results postoperatively for fatigue-inertia and total mood disturbance. Rates of return to sports did not differ significantly between the high and low groups (56.5% vs. 54.1%). Conclusions Those with a higher preoperative psychological competitive ability were in a positive emotional state preoperatively and six months after ACL reconstruction. However, the psychological competitive ability did not affect the rate of participation in the entire practice at six months postoperatively.