Clinical and biomechanical outcomes following patellar tendon repair with suture tape augmentation.

PURPOSE: Patellar tendon ruptures (PTR) occur predominantly in middle-aged patients following indirect trauma. The aim of this study was to quantify the short-term results using a suture tape augmentation technique for the repair of PTR. METHODS: All consecutive patients with acute (< 6 weeks) PTR who underwent suture tape augmentation between 03/2014 and 11/2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Visual Analog Scale (VAS) for pain, Tegner Activity Scale (TAS) and return to sport rates, Lysholm score, International Knee Documentation Committee subjective knee form (IKDC) as well as Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, a standardized clinical examination and an isometric strength evaluation of knee extension and flexion were performed. It was hypothesized that high return to sport rates and good functional outcome would be observed and that the majority of patients would not present with a severe (> 20%) knee extension strength deficit when compared to the contralateral side. RESULTS: A total of 7 patients (mean age 37.0 ± SD 13.5 years; 6 male/1 female) were available for final assessment at a median follow-up of 17.0 (25-75% IQR 16.0-77.0) months. Three injuries occurred during ball sports, two injuries occurred during winter sports, and one injury each occurred during a motorcycling and skateboarding accident. The average time between trauma and surgery was 4.7 ± 2.6 days. At follow-up, patients reported little pain (VAS: 0 [0-0.4]). Return to sport was possible for all patients 8.9 ± 4.0 months postoperatively at a high level (TAS: 7.0 [6.0-7.0]). Five patients (71.4%) returned to the preinjury level of play, and 2 (28.6%) did not return to the preinjury level of play. Patient-reported outcome measures were moderate to good (Lysholm score: 80.4 ± 14.5; IKDC: 84.2 ± 10.6; KOOS subscales: pain 95.6 ± 6.0, symptoms 81.1 [64.9-89.1], activities of daily living 98.5 [94.1-100], sport and recreation function 82.9 ± 14.1 and knee-related quality of life 75.9 ± 16.3). All patients were very satisfied (57.1%) or satisfied (42.9%) with the postoperative result. No postoperative complications were reported. Strength measurements revealed a severe knee extension deficit in 3 patients (42.9%), but no significant deficit of isometric knee extension or flexion strength in comparison with the contralateral side was observed overall (p > 0.05). CONCLUSION: Suture tape augmentation in acute PTR repair leads to good functional outcome without major complications. Although a severe knee extension strength deficit may occur in some patients postoperatively, an excellent return to sports rate and high patient satisfaction can be expected nonetheless. LEVEL OF EVIDENCE: Retrospective cohort study; III.

Midterm outcome and strength assessment after quadriceps tendon refixation with suture anchors.

PURPOSE: Quadriceps tendon ruptures (QTR) occur predominantly in middle-aged patients through violent eccentric contraction that occurs either when trying to regain balance or during a fall on the hyperflexed knee. The aim of this study was to quantify midterm postoperative results, including strength potential measured via standardized strength tests following acute (< six weeks) quadriceps tendon refixation using suture anchors. METHODS: All consecutive patients with QTR who underwent surgical suture anchor refixation between 2012 and 2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Tegner Activity Scale (TAS), Lysholm score, International Knee Documentation Committee subjective knee form (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, return to work rates, and Visual Analog Scale (VAS) for pain. Additionally, a standardized clinical examination and an isometric strength assessment of knee extension and flexion were performed. RESULTS: A total of 17 patients (median age 61.0 [25-75% IQR 50.5-72.5]) were available for final assessment at a mean follow-up of 47.1 ± SD 25.4 months. The majority of patients were male (82.4%) and most injuries occurred due to a fall on the hyperflexed knee (76.5%). The average time interval between trauma and surgery was 12.7 ± 7.5 days. Patients achieved a moderate level of activity postoperatively with a median TAS of 4 (3-5.5) and reported good to excellent outcome scores (Lysholm score: 97 (86.5-100); IKDC: 80.7 ± 13.5; KOOS subscales: pain 97.2 (93.1-100), symptoms 92.9 (82.5-100), activities of daily living 97.1 (93.4-100), sport and recreation function 80 (40-97.5) and knee-related quality of life 87.5 (62.5-100). All patients were able to fully return to work and reported little pain [VAS: 0 (0-0)]. No postoperative complications were reported. Strength measurements revealed a significant deficit of knee extension strength in comparison to the contralateral side (p = 0.011). CONCLUSION: Suture anchor refixation of acute QTR leads to good functional results and high patient satisfaction without major complications. Isometric knee extension strength, however, may not be fully restored compared to the unaffected side.

Midterm outcome and strength assessment after proximal rectus femoris refixation in athletes.

PURPOSE: Proximal rectus femoris avulsions (PRFA) are relatively rare injuries that occur predominantly among young soccer players. The aim of this study was to evaluate midterm postoperative results including strength potential via standardized strength measurements after proximal rectus femoris tendon refixation. It was hypothesized that the majority of competitive athletes return to competition (RTC) after refixation of the rectus femoris tendon without significant strength or functional deficits compared to the contralateral side. METHODS: Patients with an acute (< 6 weeks) PRFA who underwent surgical refixation between 2012 and 2019 with a minimum follow-up of 12 months were evaluated. The outcome measures compiled were the median Tegner Activity Scale (TAS) and mean RTC time frames, Harris Hip Score (HHS), Hip and Groin Outcome Score (HAGOS) subscales, International Hip Outcome Tool-33 (iHOT-33), and Visual Analog Scale (VAS) for pain. In addition, a standardized isometric strength assessment of knee flexion, knee extension, and hip flexion was performed to evaluate the functional result of the injured limb in comparison to the uninjured side. RESULTS: Out of 20 patients, 16 (80%) patients were available for final assessment at a mean follow-up of 44.8 ± SD 28.9 months. All patients were male with 87.5% sustaining injuries while playing soccer. The average time interval between trauma and surgery was 18.4 ± 8.5 days. RTC was possible for 14 out of 15 previously competitive athletes (93.3%) at a mean 10.5 ± 3.4 months after trauma. Patients achieved a high level of activity postoperatively with a median (interquartile range) TAS of 9 (7-9) and reported good to excellent outcome scores (HHS: 100 (96-100); HAGOS: symptoms 94.6 (89.3-100), pain 97.5 (92.5-100), function in daily living 100 (95-100), function in sport and recreation 98.4 (87.5-100), participation in physical activities 100 (87.5-100), quality of life 83.1 ± 15.6; iHot-33: 95.1 (81.6-99.8)). No postoperative complications were reported. Range of motion, isometric knee flexion and extension, as well as hip flexion strength levels were not statistically different between the affected and contralateral legs. The majority of patients were "very satisfied" (56.3%) or "satisfied" (37.5%) with the postoperative result and reported little pain (VAS 0 (0-0.5)). CONCLUSION: Surgical treatment of acute PRFA yields excellent postoperative results in a young and highly active cohort. Hip flexion and knee extension strength was restored fully without major surgical complications. LEVEL OF EVIDENCE: Retrospective cohort study; III.

Association of paraspinal muscle water-fat MRI-based measurements with isometric strength measurements.

OBJECTIVES: Chemical shift encoding-based water-fat MRI derived proton density fat fraction (PDFF) of the paraspinal muscles has been emerging as a surrogate marker in subjects with sarcopenia, lower back pain, injuries and neuromuscular disorders. The present study investigates the performance of paraspinal muscle PDFF and cross-sectional area (CSA) in predicting isometric muscle strength. METHODS: Twenty-six healthy subjects (57.7% women; age: 30 ± 6 years) underwent 3T axial MRI of the lumbar spine using a six-echo 3D spoiled gradient echo sequence for chemical shift encoding-based water-fat separation. Erector spinae and psoas muscles were segmented bilaterally from L2 level to L5 level to determine CSA and PDFF. Muscle flexion and extension maximum isometric torque values [Nm] at the back were measured with an isokinetic dynamometer. RESULTS: Significant correlations between CSA and muscle strength measurements were observed for erector spinae muscle CSA (r = 0.40; p = 0.044) and psoas muscle CSA (r = 0.61; p = 0.001) with relative flexion strength. Erector spinae muscle PDFF correlated significantly with relative muscle strength (extension: r = -0.51; p = 0.008; flexion: r = -0.54; p = 0.005). Erector spinae muscle PDFF, but not CSA, remained a statistically significant (p < 0.05) predictor of relative extensor strength in multivariate regression models (R2adj = 0.34; p = 0.002). CONCLUSIONS: PDFF measurements improved the prediction of paraspinal muscle strength beyond CSA. Therefore, chemical shift encoding-based water-fat MRI may be used to detect subtle changes in the paraspinal muscle composition. KEY POINTS: • We investigated the association of paraspinal muscle fat fraction based on chemical shift encoding-based water-fat MRI with isometric strength measurements in healthy subjects. • Erector spinae muscle PDFF correlated significantly with relative muscle strength. • PDFF measurements improved prediction of paraspinal muscle strength beyond CSA.

Excellent balance skills despite active and inactive juvenile idiopathic arthritis - unexpected results of a cross-sectional study.

OBJECTIVES: Postural control (PC) is fundamental for human movements. Different factors, such as injuries or diseases, can adversely affect PC. The purpose of this study was to evaluate PC in juvenile idiopathic arthritis (JIA) patients with different disease activity levels in comparison to healthy peers. METHODS: JIA patients with active and inactive lower limb joints (n=36 each group) were examined. Both groups have been on medication and have had physiotherapy for at least 5 years. For comparison, an age- and gender-matched healthy control group (CG; n=36) participated. PC was measured bipedal on a balance-board (S3-Check, TST, Großhoeflein), with an instable tilting between left and right. The parameters of interest were the best results of Stability Index (STI), Sensorimotor Index (SMI) and Symmetry Index (SYI) out of 4 test trials as well as JIA disease-related variables. Data were analysed with descriptive statistics, comparison of averages, linear regression and correlations (p<0.05). RESULTS: The three groups showed no differences in anthropometric characteristics and SYI (p>0.05). In both JIA groups, STI and SMI were lower than indices of CG (p<0.05), indicating better stability and motor control. Balance indices did not differ between active and inactive JIA patients (p>0.05). CONCLUSIONS: JIA patients showed better PC than CG. Possible explanations are an increased body-awareness due to long-term physiotherapy and daily coordination training due to compensatory movements. The positive results highlight the success of individual, interdisciplinary treatment in JIA and can be used to promote recommendations for safe sport participation.

Cross-sectional study on exercise-related skin complaints among sports students at two German universities.

Sports activities can lead to exercise-related skin complaints. These include different symptoms (e.g. infections, mechanical injuries, contact dermatitis). Previous studies mostly focused only on skin infections and injuries in competitive athletes. The purpose of this study was to determine the frequency and characteristics of exercise-related skin complaints among sports students and to what extent these complaints influence physical fitness. We performed a self-administered online survey among 259 actively exercising sports students from two German universities. Descriptive analyses were conducted. The most common complaints were blistering (57.3%), dryness (56.7%), redness (44.7%), and chafing (34.0%). Hands and feet (78.0% each) were most frequently affected. Participants whose skin was particularly stressed (47.5%) had higher training duration (7.6 h/week, 95%-CI 6.8-8.3 h) than those without complaints (5.1 h/week, 95%-CI 5.5-6.7 h, p = 0.003). The students reported reduced intensity (34.7%) and frequency (22.7%) of training due to their skin complaints. A reduction in performance was reported by 32.0% of the students. Actively exercising sports students considered an intact skin as essential for their physical fitness. Reported impairments of the skin led to a reduced intensity and frequency of training. To enhance the awareness of exercise-related skin complaints, further research is necessary.

Physiological extremes of the human blood metabolome: A metabolomics analysis of highly glycolytic, oxidative, and anabolic athletes.

Human metabolism is highly variable. At one end of the spectrum, defects of enzymes, transporters, and metabolic regulation result in metabolic diseases such as diabetes mellitus or inborn errors of metabolism. At the other end of the spectrum, favorable genetics and years of training combine to result in physiologically extreme forms of metabolism in athletes. Here, we investigated how the highly glycolytic metabolism of sprinters, highly oxidative metabolism of endurance athletes, and highly anabolic metabolism of natural bodybuilders affect their serum metabolome at rest and after a bout of exercise to exhaustion. We used targeted mass spectrometry-based metabolomics to measure the serum concentrations of 151 metabolites and 43 metabolite ratios or sums in 15 competitive male athletes (6 endurance athletes, 5 sprinters, and 4 natural bodybuilders) and 4 untrained control subjects at fasted rest and 5 minutes after a maximum graded bicycle test to exhaustion. The analysis of all 194 metabolite concentrations, ratios and sums revealed that natural bodybuilders and endurance athletes had overall different metabolite profiles, whereas sprinters and untrained controls were more similar. Specifically, natural bodybuilders had 1.5 to 1.8-fold higher concentrations of specific phosphatidylcholines and lower levels of branched chain amino acids than all other subjects. Endurance athletes had 1.4-fold higher levels of a metabolite ratio showing the activity of carnitine-palmitoyl-transferase I and 1.4-fold lower levels of various alkyl-acyl-phosphatidylcholines. When we compared the effect of exercise between groups, endurance athletes showed 1.3-fold higher increases of hexose and of tetradecenoylcarnitine (C14:1). In summary, physiologically extreme metabolic capacities of endurance athletes and natural bodybuilders are associated with unique blood metabolite concentrations, ratios, and sums at rest and after exercise. Our results suggest that long-term specific training, along with genetics and other athlete-specific factors systematically change metabolite concentrations at rest and after exercise.

Correction to: Associations of thigh muscle fat infiltration with isometric strength measurements based on chemical shift encoding-based water-fat magnetic resonance imaging.

After publication of this article [1], it is noticed it contained some errors in the Methods section.

Associations of thigh muscle fat infiltration with isometric strength measurements based on chemical shift encoding-based water-fat magnetic resonance imaging.

BACKGROUND: Assessment of the thigh muscle fat composition using magnetic resonance imaging (MRI) can provide surrogate markers in subjects suffering from various musculoskeletal disorders including knee osteoarthritis or neuromuscular diseases. However, little is known about the relationship with muscle strength. Therefore, we investigated the associations of thigh muscle fat with isometric strength measurements. METHODS: Twenty healthy subjects (10 females; median age 27 years, range 22-41 years) underwent chemical shift encoding-based water-fat MRI, followed by bilateral extraction of the proton density fat fraction (PDFF) and calculation of relative cross-sectional area (relCSA) of quadriceps and ischiocrural muscles. Relative maximum voluntary isometric contraction (relMVIC) in knee extension and flexion was measured with a rotational dynamometer. Correlations between PDFF, relCSA, and relMVIC were evaluated, and multivariate regression was applied to identify significant predictors of muscle strength. RESULTS: Significant correlations between the PDFF and relMVIC were observed for quadriceps and ischiocrural muscles bilaterally (p = 0.001 to 0.049). PDFF, but not relCSA, was a statistically significant (p = 0.001 to 0.049) predictor of relMVIC in multivariate regression models, except for left-sided relMVIC in extension. In this case, PDFF (p = 0.005) and relCSA (p = 0.015) of quadriceps muscles significantly contributed to the statistical model with R2adj = 0.548. CONCLUSION: Chemical shift encoding-based water-fat MRI could detect changes in muscle composition by quantifying muscular fat that correlates well with both extensor and flexor relMVIC of the thigh. Our results help to initiate early, individualised treatments to maintain or improve muscle function in subjects who do not or not yet show pathological fatty muscle infiltration.

Pathophysiology of juvenile idiopathic arthritis induced pes planovalgus in static and walking condition: a functional view using 3D gait analysis.

BACKGROUND: Patients suffering from juvenile idiopathic arthritis (JIA) frequently have affected ankle joints, which can lead to foot deformities such as pes planovalgus (JIA-PPV). Usually, JIA-PPV is diagnosed by examining the foot in non-weightbearing or in weightbearing, static condition. However, functional limitations typically appear during dynamic use in daily activities such as walking. The aim of this study was to quantify the pathophysiology of JIA-PPV in both static and dynamic condition, i.e. in upright standing and during the stance phase of walking using three-dimensional (3d) gait analysis. METHODS: Eleven JIA patients (age = 12y) with at least one affected ankle joint and fixed pes planovalgus (≥5°) were compared to healthy controls (CG) (n = 14, age = 11y). Kinematic and kinetic data were obtained in barefoot standing and walking condition (1.1-1.3 m/s) with an 8-camera 3d motion analysis system including two force-plates and one pressure distribution plate. All participants were prepared using reflecting markers according to the Oxford Foot and Plug-in-Gait Model. Results were compared using the Mann-Whitney-U-test and Wilcoxon signed-rank test (p < 0.05). RESULTS: In comparison to CG, JIA-PPV had an excessive hindfoot/tibia eversion (p < 0.001) and a forefoot/hindfoot supination (p < 0.001) in both static and walking condition. JIA-PPV showed a greater hindfoot/tibia eversion during walking (midstance) compared to standing (p = 0.021) in contrast to CG. The arch index, measured by plantar pressure distribution, indicates a reduced arch height in JIA-PPV (p = 0.007). Patients had a lower maximum dorsiflexion of hindfoot/tibia (p = 0.001) and a lower plantarflexion of forefoot/hindfoot (p = 0.028), both when standing and walking. The kinetic results showed lower maximum ankle dorsiflexion moments (p < 0.037) as well as generated ankle power (p = 0.086) in JIA-PPV. CONCLUSIONS: The pathophysiology of JIA-PPV during walking indicated that excessive hindfoot eversion produces accessory symptoms such as a reduced arch height, increased forefoot supination and reduced propulsion effect of the ankle. Muscular and coordinative insufficiency caused by arthritis can lead to the observed increased hindfoot eversion from static to dynamic condition. Conventional static or passive foot examination techniques probably underestimate deformity in JIA pes planovalgus. 3d gait analysis might be helpful in early diagnosis of this condition, especially in JIA patients with affected ankle joints.

Clinical gait analysis: comparing explicit state duration HMMs using a reference-based index.

In clinical gait analysis, the gait of a patient is recorded with optical motion capture and compared with a healthy reference group. High-dimensional gait datasets are difficult to interpret; machine learning can provide guidance regarding the most relevant gait phases and joint angles for visual analysis and quantify the difference between healthy and pathological gait. We propose an explicit state duration hidden Markov model (HMM) modeling the timeseries data of a subject or a group and the use of a reference-based measure that compares the most likely observations in each state. Based on this stochastic framework, the similarity between healthy and pathological gait can be quantified for each state, each joint angle, and each subject. This concept also includes an overall gait index useful for group comparison or the assessment of an individual's gait. For visualization, joint angle timeseries can be generated from the explicit state duration HMM. The accuracy of the explicit state duration HMM and the performance of the reference-based measures are evaluated on a dataset including strides of healthy subjects and patients suffering from arthritis.

Force enhancement of quadriceps femoris in vivo and its dependence on stretch-induced muscle architectural changes.

The purpose of this study was to investigate if force enhancement (FE) in vivo is influenced by stretch-induced changes of muscle architecture. Therefore, 18 subjects performed maximum voluntary isometric (100 degree knee flexion angle) and isometric-eccentric-isometric stretch contractions (80 degrees-100 degrees; ω=60 degrees.s(-1)) whereby pennation angle and fascicle length of vastus lateralis was determined using ultrasonography. We found significant (2-way repeated ANOVA; α=0.05) enhanced torque of 5-10% after stretch as well as significant passive FE but no significant differences in muscle architecture between isometric and stretch contractions at final knee angle. Furthermore, EMG recordings during a follow-up study (n=10) did not show significant differences in activation and mean frequency of contraction conditions. These results indicate that FE in vivo is not influenced by muscle architectural changes due to stretch.