Optimization of the "Perth CT" Protocol for Preoperative Planning and Postoperative Evaluation in Total Knee Arthroplasty.

Background and Objectives: Total knee arthroplasty (TKA) has become the treatment of choice for advanced osteoarthritis. The aim of this paper was to show the possibilities of optimizing the Perth CT protocol, which is highly effective for preoperative planning and postoperative assessment of alignment. Materials and Methods: The cross-sectional study comprised 16 patients for preoperative planning or postoperative evaluation of TKA. All patients were examined with the standard and optimized Perth CT protocol using advance techniques, including automatic exposure control (AEC), iterative image reconstruction (IR), as well as a single-energy projection-based metal artifact reduction algorithm for eliminating prosthesis artifacts. The effective radiation dose (E) was determined based on the dose report. Imaging quality is determined according to subjective and objective (values of signal to noise ratio (SdNR) and figure of merit (FOM)) criteria. Results: The effective radiation dose with the optimized protocol was significantly lower compared to the standard protocol (p < 0.001), while in patients with the knee prosthesis, E increased significantly less with the optimized protocol compared to the standard protocol. No significant difference was observed in the subjective evaluation of image quality between protocols (p > 0.05). Analyzing the objective criteria for image quality optimized protocols resulted in lower SdNR values and higher FOM values. No significant difference of image quality was determined using the SdNR and FOM as per the specified protocols and parts of extremities, and for the presence of prothesis. Conclusions: Retrospecting the ALARA ('As Low As Reasonably Achievable') principles, it is possible to optimize the Perth CT protocol by reducing the kV and mAs values and by changing the collimation and increasing the pitch factor. Advanced IR techniques were used in both protocols, and AEC was used in the optimized protocol. The effective dose of radiation can be reduced five times, and the image quality will be satisfactory.

The Influence of Platelet-Rich Fibrin on the Healing of Bone Defects after Harvesting Bone-Patellar Tendon-Bone Grafts.

Background and Objectives: A bone-patellar tendon-bone (BTB) autograft in anterior cruciate ligament reconstruction (ACLR) is still considered the gold standard among many orthopedic surgeons, despite anterior knee pain and kneeling pain being associated with bone defects at the harvest site. Bioregenerative products could be used to treat these defects, perhaps improving both the postoperative discomfort and the overall reconstruction. Materials and methods: During a year-long period, 40 patients were enrolled in a pilot study and divided into a study group, in which bone defects were filled with Vivostat® PRF (platelet-rich fibrin), and a standard group, in which bone defects were not filled. The main outcome was a decrease in the height and width of the bone defects, as determined by magnetic resonance imaging on the control exams during the one-year follow-up. The secondary outcomes included an evaluation of kneeling pain, measured with a visual analog scale (VAS), and an evaluation of the subjective knee scores. Results: The application of Vivostat® PRF resulted in a more statistically significant reduction in the width of the defect compared with that of the standard group, especially at 8 and 12 months post operation (p < 0.05). Eight months following the surgery, the study group's anterior knee pain intensity during kneeling was statistically considerably lower than that of the standard group (p < 0.05), and the statistical difference was even more obvious (p < 0.01) at the last follow-up. Each control examination saw a significant decrease in pain intensity in both the groups, with the values at each exam being lower than those from the prior exam (p < 0.01). A comparison of subjective functional test results 12 months post operation with the preoperative ones did not prove a statistically significant difference between the groups. Conclusions: The use of Vivostat® PRF reduces kneeling pain and accelerates the narrowing of bone defects after ACLR with a BTB graft, but without confirmation of its influence on the subjective knee score.

The Influence of the Q-Angle and Muscle Strength on Idiopathic Anterior Knee Pain in Adolescents.

Background and Objectives: Idiopathic anterior knee pain is a common condition in adolescents and is mostly of unknown cause. The aim of this study was to examine the influence of the Q-angle and muscle strength on idiopathic anterior knee pain. Materials and Methods: Seventy-one adolescents (41 females and 30 males) diagnosed with anterior knee pain were included in this prospective study. The extensor strength in the knee joint and the Q-angle were monitored. The healthy extremity was used as a control. The Student's paired sample t-test was applied for testing the difference. Statistical significance was set at 0.05. Results: There was no statistically significant difference in the Q-angle value between the idiopathic AKP and the healthy extremity (p > 0.05) within the entire sample. A statistically significant higher Q-angle of the idiopathic AKP knee (p < 0.05) was obtained in the female subgroup. No statistically significant difference (p > 0.05) was found in the male subgroup. Within the male subgroup, the strength of the extensors within the knee joint of the healthy extremity had statistically significant higher values than the strength of these muscles in the affected extremity (p < 0.05). Conclusion: A greater Q-angle is a risk factor linked to anterior knee pain within the female population. Decreased muscle strength of knee joint extensors is a risk factor linked to anterior knee pain in both sex subgroups.

Chronic post-surgical pain after knee arthroplasty: a role of peripheral nerve blocks.

Introduction: Peripheral nerve blocks are an efficient method of pain control after total knee arthroplasty (TKA), but there is no report of their impact on chronic post-surgical pain (CPSP). Methods: This prospective observational study aimed to assess adductor canal block (ACB) and IPACK block (blocks vs. no blocks) on opioid consumption, postoperative pain score, chronic post-surgical pain 2 years after TKA. Results: 166 patients (82 vs. 84) were analyzed. Opioid consumption was less in the group with blocks (9.74 ± 3.87 mg vs. 30.63 ± 11.52 mg) (p < 0.001). CPSP was present in 20.24% of patients in the group without blocks and 6.1% of patients with blocks (p = 0.011). Predictor variables of CPSP included pain before surgery (cut-off of 5.5), pain at rest (cut-off of 2.35), pain during active movement (cut-off: 2.5), and opioid consumption (cut-off: 8 mg). Conclusion: Peripheral nerve blocks provide adequate analgesia, significantly decrease opioid consumption, improve functional outcomes, and reduce CPSP 2 years after surgery.

Rifampicin-induced fever during treatment against staphylococcal biofilm in a patient with periprosthetic joint infection.

Periprosthetic joint infection (PJI) after total knee arthroplasty remains a challenging complication. The treatment options for PJI include different procedures; however, regardless of the strategy, antibiotics are required. The combination of different antibiotics increased the rates of PJI eradication. For almost 3 decades, rifampicin has been used as part of antibiotic therapy for PJI. Drug fever, a febrile response that coincides with the onset of drug administration and disappears after drug discontinuation in the absence of other underlying conditions that could cause fever, is frequently misdiagnosed. We present the case of a 72-year-old man with PJI 6 months after total knee arthroplasty. Two-stage revision surgery was followed by culture-directed antibiotic treatment (ciprofloxacin and rifampicin) against Staphylococcus aureus isolated from the periprosthetic tissue. On the fifth day of antibiotic treatment, the patient became febrile and, in the next 5 days, he had an intermittent fever of up to 40°C, although he showed clinical improvement. The patient was normotensive without a maculopapular rash, urticaria or clotting abnormalities. A drug fever was suspected, and rifampicin was discontinued. A re-challenge test was performed, and the fever recurred. Antibiotic treatment with ciprofloxacin was continued and, after 12 months of follow-up, the patient was doing well. Clinicians should be aware that fever could be a clinical presentation of drug fever. If it occurs during an infection, drug fever could necessitate additional diagnostic procedures for further evaluation, inadequate antibiotic therapy and prolonged hospitalisation.

The first case of septic arthritis of the knee caused by Eggerthia catenaformis.

Eggerthia catenaformis has been reported as a human pathogen. We present the first case of the primary knee infection caused by Eggerthia catenaformis in a 23-year-old male patient with a knee infection, after primary anterior cruciate ligament reconstruction. Eggerthia catenaformis was confirmed by MALDI-TOF mass spectrometry from synovial fluid. The dental focus was excluded. The isolated bacterial strain showed sensitivity to all of the tested antimicrobials. However, for successful management of knee infection, besides culture-directed antibiotics therapy, arthroscopic debridement and lavage were necessary.

Instrumental Activities of Daily Living-A Good Tool to Prospectively Assess Disability after a Second Contralateral Hip Fracture?

The aim of this study was to determine the outcome for patients who sustain a second hip fracture compared with those who sustain a first fracture, and to define the optimal measure to evaluate functional outcome after second hip fracture. METHODS: 343 patients with acute hip fractures who presented during a 12 month period were included in the study. Patients with a first (318 patients, 78.10 +/- 7.53 years) and second (25 patients, 78.96 +/- 6.02) hip fracture were compared regarding all baseline variables. Regression analysis was also performed to assess the independent relationship between the presence of a second hip fracture and observed outcome variables at discharge (physical disability, complications, length of stay, and mortality) and one-year after surgery (physical disability and mortality). RESULTS: Disability when performing instrumentalized activities of daily living (IADL) at one-year follow-up is independently related to the presence of a second hip fracture. There were no other statistically significant relationships between the presence of a second hip fracture and other observed outcome variables. CONCLUSIONS: Patients with a second hip fracture showed worse functional outcome at one-year follow-up when measured with the IADL scale. No increased short-nor long-term mortality rates were found in patients with a secondary hip fracture. IADL is a good tool to assess disability after a second hip fracture and could be thus a more reliable outcome measure when investigating differences in functional recovery in patients with a second hip fracture compared to conventionally used ADL scales.

The current state of bionic limbs from the surgeon's viewpoint.

Amputations have a devastating impact on patients' health with consequent psychological distress, economic loss, difficult reintegration into society, and often low embodiment of standard prosthetic replacement.The main characteristic of bionic limbs is that they establish an interface between the biological residuum and an electronic device, providing not only motor control of prosthesis but also sensitive feedback.Bionic limbs can be classified into three main groups, according to the type of the tissue interfaced: nerve-transferred muscle interfacing (targeted muscular reinnervation), direct muscle interfacing and direct nerve interfacing.Targeted muscular reinnervation (TMR) involves the transfer of the remaining nerves of the amputated stump to the available muscles.With direct muscle interfacing, direct intramuscular implants record muscular contractions which are then wirelessly captured through a coil integrated in the socket to actuate prosthesis movement.The third group is the direct interfacing of the residual nerves using implantable electrodes that enable reception of electric signals from the prosthetic sensors. This can improve sensation in the phantom limb.The surgical procedure for electrode implantation consists of targeting the proximal nerve area, competently introducing, placing, and fixing the electrodes and cables, while retaining movement of the arm/leg and nerve, and avoiding excessive neural damage.Advantages of bionic limbs are: the improvement of sensation, improved reintegration/embodiment of the artificial limb, and better controllability. Cite this article: EFORT Open Rev 2020;5:65-72. DOI: 10.1302/2058-5241.5.180038.

Length of the femoral tunnel in anatomic ACL reconstruction: comparison of three techniques.

PURPOSE: The aim of this paper was to determine whether the change in the position of the patient's leg as well as the use of flexible reamers may help in obtaining a longer femoral tunnel with minimal risk of perforating the posterior cortex. METHODS: One hundred and twenty-five patients who had undergone anatomic ACL reconstruction between 2010 and 2013 were included in this prospective cohort study. The first group was composed of patients whose femoral tunnel had been drilled with rigid reamers, while the leg being operated on was positioned on an arthroscopic leg holder (82 patients). In the second group of patients, the femoral tunnel was also drilled with rigid reamers, but the leg was positioned on the table (25 patients), while the third group was composed of patients whose femoral tunnel was drilled with flexible reamers, and the leg was positioned on a leg holder (18 patients). The length of the femoral tunnel was measured intraoperationally, while the site of femoral insertion and the position of the tunnel were read from native radiographic images. RESULTS: When the femoral tunnel was drilled on the medial aspect of the lateral condyle, the centre of the tunnel was located at 31.4 % from the most proximal point of the femoral condyle and 34.7 % from the Blumensaat line. The length of the tunnel drilled with rigid reamers on the operating table (36.1 mm) was statistically significantly greater (p < 0.05) than the length of the tunnel drilled with the same reamers, but with the leg positioned on the leg holder (32.5 mm). The length of the tunnel drilled with flexible reamers with the leg positioned on the leg holder (42.5 mm) was highly statistically significantly greater than the length of the tunnel drilled with rigid reamers (p < 0.01), and it was statistically significantly greater than the length of the tunnel drilled with rigid reamers with the leg placed on the operating table (p < 0.05). CONCLUSION: The drilling of the femoral tunnel during anatomic ACL reconstruction with the use of flexible reamers provides a longer femoral tunnel than when it is drilled with rigid reamers, without any danger of perforation of the posterior cortex. LEVEL OF EVIDENCE: III.

The effect of anterior cruciate ligament reconstruction on hamstring and quadriceps muscle function outcome ratios in male athletes.

INTRODUCTION: Maximal strength ratios such as the limb symmetry index (LSI) and hamstring-to-quadriceps ratio (HQ) may be considered the main outcome measures in the monitoring of recovery after anterior cruciate ligament (ACL) reconstruction. Although explosive strength is much more important than maximal strength, it is generally disregarded in the follow-up of muscle function recovery. OBJECTIVE: The purpose of this study was to compare ratios between maximal (Fmax) and explosive strength (rate of force development--RFD) in individuals with ACL reconstruction. METHODS: Fifteen male athletes were enrolled and had maximum voluntary isometric quadriceps and hamstring contractions tested (4.0 ± 0.1 months post reconstruction). In addition to Fmax RFD was estimated (RFDmax, as well as RFD at 50, 100, and 200 ms from onset of contraction) and LSI and HQ ratios were calculated. RESULTS: The involved leg demonstrated significant hamstring and quadriceps deficits compared to uninvolved leg (p < 0.01). Deficits were particularly significant in the involved quadriceps, causing higher HQ ratios (average 0.63), compared to the uninvolved leg (0.44). LSI was significantly lower for RFD variables (average 55%) than for Fmax (66%). CONCLUSION: The assessment of RFD may be considered an objective recovery parameter for one's readiness to return to sports and should be an integral part of standard follow-up protocol for athletes after ACL reconstruction. Moreover, the combination of indices derived from maximal and explosive strength may provide better insight in muscle strength balance, as well as a clear picture of functional implications.

Anatomic description of the anterolateral ligament of the knee.

PURPOSE: The anterolateral ligament, a structure that has been known for 130 years, has again attracted the attention both of orthopaedic doctors and anatomists. Since its initial description until now, this structure has had different names. Whether labelled as the mid-third lateral capsular ligament, the anterior oblique band of the fibular collateral ligament or the anterolateral ligament of the knee, this structure has been responsible for the so-called Segond avulsion fractures. The aim of this study was to determine the precise position and layer of the lateral knee compartment within which the anterolateral ligament is located, as well as its type. METHODS: In this study, the anatomical dissection of the lateral segment of 14 cadaveric knees (six male, eight female; seven right, seven left; average age of subjects: 78 years) was performed. The dissection was carried out in keeping with Seebacher, layer by layer. RESULTS: The anterolateral ligament was identified in seven out of 14 cadaveric knee joints (50 %). The length of the ligament was 41 ± 3 mm, while the width was 4 ± 1 mm and the thickness 1 mm (in the middle section). In 14 % of the cases, the anterior oblique band was identified as a part of the FCL. In all of the knee joints, a part of the fibres of the ITT with the same insertions and direction as the ALL was found, located, however, at a much more superficial level than the ALL. CONCLUSION: Analysis of the current scientific literature related to the anterolateral ligament and layer-by-layer dissection of the lateral region of 14 cadaveric knees has led to the conclusion that the anterolateral ligament is a thickening of the knee joint capsule located in the third layer of the lateral region of the knee (according to Seebacher) which is not always clearly morphologically differentiated from the remainder of the joint capsule. The anterolateral ligament is unequivocally a part of the joint capsule, which is why any damage to it should be treated in the same way as any other damage to the joint capsule.

Alternative method for direct measurement of tibial slope.

BACKGROUND/AIM: The tibial slope is one of the most frequently cited anatomical causes of anterior cruciate ligament trauma. The aim of this study was to determine the possibility of direct measuring of the tibial slope of the knee without prior soft tissue dissection in cadavers. METHODS: Measurement was performed on the two groups of samples: osteological and cadaveric. The osteological group consisted of 102 matured tibiae and measurement was performed: indirectly by sagittal photographing of the tibia, and directly by a set of parallel bars. The cadaveric group consisted of 50 cadaveric knees and measurement was performed directly by a set of parallel bars. The difference and correlation between indirect and the direct measurements were observed, which included also measuring of the difference and correlation of the tibial slope on the medial and lateral condyles. RESULTS: A statistically significant difference between the direct and indirect method of measuring (p < 0.01) of 1 degree was found for the tibial slope on the medial condyle, which is of no practical importance. Direct measurement of the osteological and cadaveric groups of samples did not show a statistically significant difference regarding the values of the tibial slope on the lateral condyle (p > 0.05). However, the slope on the medial condyle, as well as indirect measurement showed a statistically significant difference (p < 0.01). CONCLUSION: By the use of a set of parallel bars it is possible to measure the tibial slope directly without removal of the soft tissue. The results of indirect, photographic measurement did not statistically differ from the results of direct measurement of the tibial slope.

Evaluation of isokinetic and isometric strength measures for monitoring muscle function recovery after anterior cruciate ligament reconstruction.

Although various strength tests and their outcome measures have been proposed for anterior cruciate ligament (ACL) reconstruction (ACLR), their measurement properties still remain relatively underexplored. The aim of this study was to investigate the longitudinal construct validity of the standard isokinetic (IKT) and isometric test (IMT), and of the IMT of alternating consecutive maximal contractions (ACMC). In addition, the concurrent validity of ACMC was assessed and compared with the validity of IMT. The strength of quadriceps and hamstrings in 20 male athletes with an anterior cruciate ligament (ACL) injury were assessed before ACLR, 4 and 6 months after ACLR, by means of IMT, ACMC, and IKT performed at 60 and 180° · s(-1). Significant between-session differences in muscle strength variables were found in the involved quadriceps (F > 6.5; p ≤ 0.05), but not in the uninvolved leg (F < 2.5; p > 0.05). Coefficients of variations in the uninvolved leg (all below 13.5%) were lower than the involved leg (11.7-22.1%). Intraclass correlation coefficients were moderate-to-high for the uninvolved leg and low-to-high for quadriceps of the involved leg. The concurrent validity of ACMC with respect to the IKT (r = 0.57-0.92; p ≤ 0.05) was comparable with the validity of IMT (r = 0.52-0.87; p ≤ 0.05). We conclude that the explored longitudinal construct validity of most of the evaluated variables could be sufficiently sensitive to detect the effects of the applied rehabilitation procedures. In addition, the obtained sensitivity and concurrent validity and the potential advantages of ACMC over IMT, all suggest that ACMC could be a particularly promising method for routine testing of neuromuscular function after ACLR.

[The role of the posterior tibial slope on rupture of the anterior cruciate ligament].

BACKGROUND/AIM: Posterior tibial slope is one of the most citated factors wich cause rupture of the anterior cruciate ligament (ACL). The aim of this study was to determine the association of a greather posterior tibial slope on the lateral condyle, that is a lesser posterior tibial slope on the medial condyle, with ACL rupture. METHODS: The patients were divided into two groups. The study group included the patients with chronic instability of the knee besause of a previous rupture of ACL. The control group included the patients with knee lesion, but without ACL rupture. Posterior tibial slope measuring was performed by sagittal MR slices supported by lateral radiograph of the knee. We measured posterior tibial slope on lateral and medial condyles of the tibia. Using these values we calculated an average posterior tibial slope as well as the difference between slopes on lateral and medial condyles. RESULTS: Patients with ACL rupture have highly statistically significantly greather posterior tibial slope (p < 0.01) on lateral tibial condyle (7.1 degrees : 4.5 degrees) as well as statistically significantly lesser posterior tibial slope (p < 0.05) on medial tibial condyle (5.9 degrees : 6.6 degrees) than patients with intact ACL. CONCLUSION: Great posterior tibial slope on lateral tibial condyle associated with the small posterior tibial slope on the medial tibial condyle, that is a positive differentce between lateral and medial tibial condyles are factors wich may cause ACL rupture.

Alternating Consecutive Maximum Contraction as a Test of Muscle Function in Athletes Following ACL Reconstruction.

The novel test based on isometric alternating consecutive maximal contractions performed by two antagonistic muscles has been recently proposed as a test of muscle function in healthy subjects. The aim of this study was to evaluate reliability and sensitivity of a novel test as a test of knee muscles function in athletes recovering from anterior cruciate ligament reconstruction. Fifteen male athletes with recent ligament reconstruction (4.0 ± 0.1 months following the surgery) and 15 sport and physical education students participated in the study. Peak torques of the quadriceps and hamstring muscles assessed both through the alternating consecutive maximal contractions and standard isokinetic test performed at 60 º/s and 180 º/s served for calculation of the hamstrings-to-quadriceps ratio and the bilateral difference in strength. When applied on individuals recovering from anterior cruciate ligament reconstruction, the novel test revealed a high within-day reliability and sensitivity for detecting imbalances both between antagonistic and between contralateral muscles. The present findings suggest that alternating consecutive maximal contractions could be used as a test of muscle function that is either complementary or alternative to the isokinetic test, particularly in the laboratories where the isokinetic devices are not available. Potential advantages of the novel test could be both a brief testing procedure and a possibility to conduct it using relatively inexpensive devices such as custom made kits containing a single one-axis force transducer.