Asia-Pacific Journal of Sport Medicine Arthroscopy Rehabilitation and Technology最新文献

Objectives

While there is a consensus against bracing after anterior cruciate ligament (ACL) reconstruction, the question of its potential benefits, especially in cases involving meniscus repair, as well as its routine use by the majority of clinicians, remains a topic of debate. This study aims to assess the effectiveness of bracing in relation to clinical scores after ACL reconstruction, regardless of meniscus surgery.

Methods

This randomised controlled study involved patients aged 15–55 years who underwent arthroscopic ACL reconstruction surgery. All eligible patients were assigned into two groups: one group received an adjustable frame with a four-point fixation knee brace for a four-week period, while the other did not.

A single experienced surgeon performed standard anatomical single-bundle ACL reconstruction. All patients, irrespective of whether they underwent meniscus repair, followed the same rehabilitation protocol. Knee functional questionnaires, including the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner Activity Scale, Visual Analogue Scale (VAS), and examinations, were collected preoperatively, at six months, one year, and two years postoperatively. The study employed an intention-to-treat analysis and multilevel mixed-effects generalised linear models to compare continuous outcomes between the groups, adjusting for the times of follow-up.

Results

A total of 84 patients (42 patients per group) comprised of 75 males (89 %) and average age of 30 ± 9.4 years old. Patient-reported function, physical examination findings, and surgical characteristics were comparable between the two groups. (P-value >0.05) Both groups demonstrated significant improvement in IKDC and Lysholm scores at the end of the two-year follow-up period. (P-value <0.0001) In multivariate analysis, bracing was significantly associated with lower Tegner activity scale than the non-brace group after adjustment for VAS and time (coefficient −0.49, 95 % confidence interval −0.87, −0.10, P-value = 0.013). None of the graft ruptures were reported, and there was no significant difference of return to sports between the groups at the end of the follow-up.

Conclusion

The study suggests that knee bracing after ACL reconstruction, regardless of any additional meniscus procedures, fails to enhance subjective or objective outcomes and could potentially have a negative impact on the Tegner activity scale, although the difference is not clinically significant. The routine use of a postoperative brace should be discontinued.

Level of evidence

Level I, Randomised controlled trial with no negative criteria.

Objective

Initial tension at graft fixation is one of key factors for good outcomes in anterior cruciate ligament (ACL) reconstruction. Identifying the pre-operative factors that influence postoperative knee laxity under the anterior tibial load is useful in determining the initial tension at graft fixation. Thus, the purpose of this study was to clarify the pre-operative factors affecting the side-to-side difference in anterior laxity immediately after the anatomic double-bundle ACL reconstruction with a constant initial tension.

Methods

Fifty-five patients underwent the anatomic double-bundle ACL reconstruction with hamstring tendon grafts. Anterior tibial displacement (ATD) was measured on both knees using KT-2000 Knee Arthrometer under anterior drawer load of 67 N, 89 N, 134 N and manual maximum load at 30° of flexion before ACL reconstruction under anesthesia, and was also measured on the operated knees under 89 N immediately after ACL reconstruction under anesthesia. Then, side-to-side difference (SSD) before and immediately after ACL reconstruction was calculated. Correlative relation between the SSD immediately after ACL reconstruction and the ATD/the SSD in each condition was analyzed.

Results

The side-to-side difference of ATD immediately after surgery was −3.8 ± 1.7 mm (0 to -8mm) in response of 89 N of anterior load. There was correlation between the SSD immediately after ACL reconstruction and all ATD on both knees except for the ATD under manual maximum load on the injured knee, while little correlation between the SSD immediately after ACL reconstruction and that before ACL reconstruction was found. Especially, ATD under 89 N on the opposite knees and ATD under 134 N on the injured knees showed selective correlation with the SSD immediately after surgery in the step-wise multiple regression analysis.

Conclusion

As the anterior tibial displacements under 89 N on the contra-lateral knee and under 134 N on the injured knee had a significant correlation with the SSD immediately after ACL reconstruction, those values may be helpful in determining the increase or decrease in initial tension at graft fixation.

Background

Arthroscopic rotator cuff repair (ARCR) is a minimally invasive surgical technique. However, it is challenging to control postoperative pain. This study aimed to investigate the difference between a single-shot interscalene block and a combined continuous block for ARCR.

Methods

Ninety-four patients who underwent ARCR were included in this study. In the preceding period, 43 patients received a single-shot interscalene block and continuous postoperative intravenous opioid infusion (Single group). In the posterior period, 51 patients received a single-shot interscalene block preoperatively and a continuous block postoperatively (Continuous group). Their mean age at surgery was 64.9 years (range, 43–83 years). The mean follow-up period was 25.4 months (range, 24–54 months). The numerical rating scale (NRS) of pain was evaluated immediately after the surgery, at rest, and at night for 1–4 days after the surgery. One day postoperatively, the amount of food taken was assessed from 0 % (no food intake) to 100 % (all food taken). The University of California at Los Angeles (UCLA) shoulder score, range of motion (ROM), and isometric shoulder strength were evaluated.

Results

NRS at rest in the Continuous group on the day of surgery was 3.7 ± 2.5. This was significantly lower than in the Single group (5.2 ± 1.8) (P = 0.002). NRS at rest in the Continuous group on the second day after surgery was 3.0 ± 2.1, significantly lower than in the Single group (3.9 ± 1.8) (P = 0.04). The amount of food taken in the morning in the Continuous group was 61 % ± 37 %, which was significantly greater than in the Single group (35 % ± 41 %) (P = 0.004). The ROM of extension at 6 months postoperatively in the Continuous group was 47 ± 7°, which was significantly greater than in the Single group (43 ± 6°) (P = 0.02). The postoperative strength of the external rotator at 6 months in the Continuous group was 95 ± 33 N, significantly greater than in the Single group (78 ± 28 N) (P = 0.01). There was no significant difference in UCLA score at any time.

Conclusion

The continuous interscalene block with ultrasound guidance in ARCR effectively relieved pain. The recovery of ROM for extension and the strength of the external rotator was better in the Continuous group.

Background/Objective

Normal knee kinematics during flexion and extension activities over the whole range of motion remains unknown. This study aimed to clarify in vivo kinematics during knee flexion and extension activities of normal knees by comparing continuous flexion and extension activities up to a high flexion angle.

Methods

Twenty knees of 10 Japanese volunteers were enrolled in this study. Each volunteer performed a continuous squatting motion under fluoroscopy, and a two- or three-dimensional registration technique was used. Rotation and anteroposterior translation of the medial and lateral sides of the femur relative to the tibia at each flexion angle were evaluated.

Results

Femoral external rotation was significantly smaller from 10° to 40° flexion during extension activities than during flexion activities. However, the femoral external rotation was larger from 120° to 130° flexion during extension activities than during flexion activities. From 10° to 60° of flexion, the medial side was significantly more posteriorly located during extension activities than during flexion activities. Furthermore, the lateral side was significantly more posteriorly located at 130° of flexion during extension activities than during flexion activities.

Conclusion

In vivo kinematics of normal knees during extension activities differ from those during flexion activities in early and high flexion.

Background

Chronic ankle instability (CAI) has been considered a neurophysiological disease, having as symptoms dysfunction in somatosensory and motor system excitability. Rehabilitation has been considered an effective treatment for CAI. However, few studies have explored the effects of rehabilitation on neuroplasticity in the CAI population.

Objective

The purpose of this study was to investigate the effects of rehabilitation on cortical activities for postural control in CAI patients and to find the correlation between the change in cortical activities and patient-reported outcomes (PROs).

Methods

Thirteen participants with CAI (6 female, 7 male, age = 33.8 ± 7.7 years, BMI = 24.7 ± 4.9 kg/m²) received a home exercise program for about 40 min per day, four days per week and six weeks, including ankle range-of-motion exercise, muscle strengthening, and balance activities. Cortical activation, PROs and Y-balance test outcomes were assessed and compared before and after rehabilitation. Cortical activation was detected via Functional near-infrared spectroscopy (fNIRS) while the participants performed single-leg stance tasks.

Results

The participants had better PROs and Y balance test outcomes after rehabilitation. Greater cortical activation was observed in the primary somatosensory cortex (S1, d = 0.66, p = 0.035), the superior temporal gyrus (STG, d = 1.06, p = 0.002) and the middle temporal gyrus (MTG, d = 0.66, p = 0.035) in CAI patients after rehabilitation. Moreover, significant positive correlations were observed between the recovery of ankle symptoms and the change of cortical activation in S1 (r = 0.74, p = 0.005) and STG (r = 0.72, p = 0.007) respectively.

Conclusion

The current study reveals that six weeks of rehabilitation can cause greater cortical activation in S1, STG and MTG. This increase in cortical activation suggested a better ability to perceive somatosensory stimuli and may have a compensatory role in function improvement.

Background

This study aimed to investigate the correlations of serum vitamin D insufficiency with quadriceps neuromuscular function in patients with anterior cruciate ligament (ACL) injury.

Methods

A cross-sectional study was conducted. Eighteen patients with a primary, unilateral ACL injury who had insufficient serum vitamin D concentrations (<30 ng/ml) were recruited for the study. Bilateral quadriceps neuromuscular function, including maximal strength, the speed of rapid contraction, and inhibition, were measured on an isokinetic dynamometer with the hip and the knee joint flexion at 90° and 45°, respectively. Quadriceps strength was measured by maximal voluntary isometric contractions (MVIC); the speed of rapid contraction was quantified by the rate of torque development (RTD), which was divided into the early (RTD_0-50) and the late phase (RTD_100-200); quadriceps inhibition was quantified by the central activation ratio (CAR). Serum vitamin D concentration was quantitatively determined by serum 25(OH)D concentration measured by the 25(OH)D ELISA kit. The Spearman rank correlation analysis was used to examine the correlation between the vitamin D concentration and bilateral quadriceps MVIC, RTD_0-50, RTD_100-200, and CAR, respectively.

Results

The results of Spearman rank correlation analyses showed that the serum 25(OH)D concentration was significantly correlated with bilateral quadriceps MVIC (injured: r = 0.574, p = 0.013; uninjured: r = 0.650, p = 0.003) and RTD_0-50 (r = 0.651, p = 0.003), and CAR (r = 0.662, p = 0.003) on the uninjured limb. However, no significant correlations were found between the serum 25(OH)D concentration and the other outcomes.

Conclusions

The serum vitamin D concentration correlates with quadriceps neuromuscular function in patients with ACL injury who had vitamin D insufficiency.

Background

The purpose of this study was to investigate the positional effect of guide pins used in the transtibial pullout repair of medial meniscus posterior root tears on the popliteal artery.

Methods

We used eight cadaveric knees. Two 2.4-mm guide pins were inserted into the posterior root of the medial meniscus at 50° to the articular surface from the medial edge of the tibial tuberosity (anteromedial group) and the anterior edge of the medial collateral ligament (posteromedial group) using an aiming guide placed at the posterior root attachment of the medial meniscus from the anteromedial portal. The posterior capsule was dissected, and the popliteal artery was identified. The positional effect of the guide pins on the popliteal artery was photographed arthroscopically at 0°, 30°, 60°, and 90° knee flexion angles. The popliteal artery diameter and the minimum distance between the popliteal artery center and the guide pin tip were measured.

Results

At 90° knee flexion, most of the guide pins in the anteromedial (6 knees; 75 %) and posteromedial groups (7 knees; 87.5 %) collided with the femoral intercondylar wall. The rate of collision was significantly higher at the 90° knee flexion position than that at other angles (p = 0.02). The average shortest distance between the popliteal artery center and the guide pin tip at 0° knee flexion in the posteromedial group (5.4 mm ± 3.4 mm) was significantly greater than that at other knee flexion angles, although the mean distance in the posteromedial group was so negligible that the guide pin could penetrate the popliteal artery.

Conclusions

Knee flexion at 90° causes less damage to the popliteal artery during the transtibial pullout repair of medial meniscus posterior root tears.

Background

This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years.

Methods

Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60–73 years). The mean time from injury to surgery was 80.5 months (range, 1–480 months), and the mean follow-up time was 26.2 months (range, 24–42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren–Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up.

Results

The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2–8 mm) to 0.9 mm (range, 0–2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74–116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren–Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients.

Conclusions

Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years.

Level of evidence

A retrospective study, case series (IV).

Background/Objective

The purpose of this study was to find factors indicating the occurrence of the Segond fracture, a specific type of anterolateral ligament injury.

Methods

From January 2015 to December 2017, we retrospectively reviewed the medical records of patients diagnosed with acute anterior cruciate ligament (ACL) injury who underwent reconstruction within 90 days of injury. Diagnosis of the Segond fracture was determined either by magnetic resonance imaging or plain radiographs. Factors examined were: age at surgery, sex, body mass index (kg/m²), status of menisci, and activities led to ACL injury. After univariate screening, multivariate logistic regression analyses were performed. Patients were divided into four groups based on the presence of lateral meniscal (LM) and/or medial meniscal (MM) injuries and compared with respect to the occurrence of Segond fractures.

Results

A total of 375 patients were included (163 males, 212 females), with mean age 25.8 years old. Among them, 22 of 375 (5.9 %) had a Segond fracture. We identified injured lateral menisci (adjusted odds ratio (aOR), 3.029; 95 % Confidence Interval (CI), 1.206–7.609; P = 0.018), intact medial menisci (aOR, 0.229; 95 % CI, 0.065–0.810; P = 0.022), and higher body mass index (aOR, 1.102; 95 % CI, 1.008–1.205; P = 0.034) as factors indicative of the occurrence of Segond fracture. LM injury without MM injury suggested the existence of a Segond fracture.

Conclusion

LM injury without a MM injury indicated the occurrence of a Segond fracture. Higher body mass index also increased the risk for Segond fracture occurrence.

Surgical repair or reconstruction of the lateral ligaments for patients with chronic ankle instability (CAI) could, logically, restore the proprioception of ankle through retensing receptors. To validate this hypothesis, seven databases were systematically searched, and thirteen studies comprising a total of 347 patients with CAI were included. Although five studies reported improved proprioceptive outcomes after surgeries, the other five studies with between-limb/group comparisons reported residual deficits at final follow-up, which does not consistently support proprioceptive recovery after existing surgical restabilization for CAI. More controlled studies are needed to provide evidence-based protocols to improve proprioceptive recovery after ankle restabilization for CAI.