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

OBJECTIVE: To assess the presence of early degenerative changes on Magnetic Resonance Imaging (MRI) 24 months after a traumatic meniscal tear and to compare these changes in patients treated with arthroscopic partial meniscectomy or physical therapy plus optional delayed arthroscopic partial meniscectomy. DESIGN: We included patients aged 18-45 years with a recent onset, traumatic, MRI verified, isolated meniscal tear without radiographic osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with optional delayed arthroscopic partial meniscectomy. MRIs at baseline and 24 months were scored using the MRI Osteoarthritis Knee Score (MOAKS). We compared baseline MRIs to healthy controls aged 18-40 years. The outcome was the progression of bone marrow lesions (BMLs), cartilage defects and osteophytes after 24 months in patients. RESULTS: We included 99 patients and 50 controls. At baseline, grade 2 and 3 BMLs were present in 26% of the patients (n = 26), compared to 2% of the controls (n = 1) (between group difference 24% (95% CI 15% to 34%)). In patients, 35% (n = 35) had one or more cartilage defects grade 1 or higher, compared to 2% of controls (n = 1) (between group difference 33% (95% CI 23% to 44%)). At 24 months MRI was available for 40 patients randomized to arthroscopic partial meniscectomy and 41 patients randomized to physical therapy. At 24 months 30% (n = 12) of the patients randomized to arthroscopic partial meniscectomy showed BML worsening, compared to 22% (n = 9) of the patients randomized to physical therapy (between group difference 8% (95% CI -11% to 27%)). Worsening of cartilage defects was present in 40% (n = 16) of the arthroscopic partial meniscectomy group, compared to 22% (n = 9) of the physical therapy group (between group difference 18% (95% CI -2% to 38%)). Of the patients who had no cartilage defect at baseline, 33% of the arthroscopic partial meniscectomy group had a new cartilage defect at follow-up compared to 14% of the physical therapy group. Osteophyte worsening was present in 18% (n = 7) of the arthroscopic partial meniscectomy group and 15% (n = 6) of the physical therapy group (between group difference 3% (95% CI -13% to 19%)). CONCLUSIONS: Our results might suggest more worsening of BMLs and cartilage defects with arthroscopic partial meniscectomy compared to physical therapy with optional delayed arthroscopic partial meniscectomy at 24-month follow-up in young patients with isolated traumatic meniscal tears without radiographic OA.

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

PURPOSE: This study aims to develop and externally validate a treatment algorithm to predict nonoperative treatment success or failure in patients with anterior cruciate ligament (ACL) rupture. METHODS: Data were used from two completed studies of adult patients with ACL ruptures: the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation study (development cohort) and the KNee osteoArthritis anterior cruciate Ligament Lesion study (validation cohort). The primary outcome variable is nonoperative treatment success or failure. Potential predictor variables were collected, entered into the univariable logistic regression model and then incorporated into the multivariable logistic regression model for constructing the treatment algorithm. Finally, predictive performance and goodness-of-fit were assessed and externally validated by discrimination and calibration measures. RESULTS: In the univariable logistic regression model, a stable knee measured with the pivot shift test and a posttrauma International Knee Documentation Committee (IKDC) score <50 were predictive of needing an ACL reconstruction. Age >30 years and a body mass index > 30 kg/m2 were predictive for not needing an ACL reconstruction. Age, pretrauma Tegner score, the outcome of the pivot shift test and the posttrauma IKDC score are entered into the treatment algorithm. The predictability of needing an ACL reconstruction after nonoperative treatment (discrimination) is acceptable in both the development and the validation cohort: area under the curve = resp. 0.69 (95% confidence interval [CI]: 0.58-0.81) and 0.68 (95% CI: 0.58-0.78). CONCLUSION: This study shows that the treatment algorithm can acceptably predict whether an ACL injury patient will have a(n) (un)successful nonoperative treatment (discrimination). Calibration of the treatment algorithm suggests a systematical underestimation of the need for ACL reconstruction. Given the limitations regarding the sample size of this study, larger data sets must be constructed to improve the treatment algorithm further. LEVEL OF EVIDENCE: Level II.

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

OBJECTIVE: To assess whether initial non-operative treatment of anterior cruciate ligament (ACL) ruptures with optional delayed ACL reconstruction leads to more meniscal procedures compared with early ACL reconstruction during the 2-year follow-up. METHODS: We compared the number of meniscal procedures of 167 patients with an ACL rupture, who either received early ACL reconstruction (n=85) or rehabilitation therapy plus optional delayed ACL reconstruction (n=82), participating in the Conservative vs Operative Methods for Patients with ACL Rupture Evaluation trial. Patients were aged 18 to 65 years (mean 31.3, SD 10.5), 60% male sex (n=100). We evaluated the presence and location of meniscal tears by baseline MRI. We analysed and compared how many patients per randomisation group had a meniscal procedure during follow-up in the ACL injured knee, adjusted for sex, body mass index, age group and orthopaedic surgeon. RESULTS: At baseline, 41% of the entire study population (69/167 patients) had a meniscal tear on MRI. During the 2-year follow-up, 25 patients randomised to early ACL reconstruction (29%, 25/85 patients) had a meniscal procedure, compared with 17 patients randomised to rehabilitation plus optional delayed reconstruction (21%, 17/82 patients) (risk ratio 0.67 with 95% CI 0.40 to 1.12, p=0.12). Of these patients who received early ACL reconstruction (n=82) and patients that received delayed ACL reconstruction (n=41), 5% of the patients had an additional isolated meniscal procedure after ACL reconstruction. In patients who received no ACL reconstruction (n=41), 10% (n=4) had an isolated surgical procedure for a meniscal tear during the 2-year follow-up period. CONCLUSION: Initial non-surgical treatment of ACL ruptures followed by optional delayed ACL reconstruction does not lead to a higher number of meniscal procedures compared with early ACL reconstruction over a 2-year follow-up period. TRIAL REGISTRATION NUMBER: NL 2618.

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

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a very common knee injury in the sport active population. There is much debate on which treatment (operative or non-operative) is best for the individual patient. In order to give a more personalized recommendation we aim to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture. METHODS: The ROTATE-trial is a multicenter, open-labeled cluster randomized controlled trial with superiority design. Randomization will take place on hospital level (n = 10). Patients must meet all the following criteria: aged 18 year or older, with a complete primary ACL rupture (confirmed by MRI and physical examination) and maximum of 6 weeks of non-operative treatment. Exclusion criteria consists of multi ligament trauma indicated for surgical intervention, presence of another disorder that affects the activity level of the lower limb, pregnancy, and insufficient command of the Dutch language. The intervention to be investigated will be an adjusted treatment decision strategy, including an advice from our treatment algorithm. Patient reported outcomes will be conducted at baseline, 3, 6, 12 and 24 months. Physical examination of the knee at baseline, 12 and 24 months. Primary outcome will be function of the knee measured by the International Knee Documentation Committee (IKDC) questionnaire. Secondary outcomes are, among others, the Tegner activity score, the Knee injury and Osteoarthritis Outcome Score (KOOS) and the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Healthcare use, productivity and satisfaction with ((non-)operative) care are also measured by means of questionnaires. In total 230 patients will be included, resulting in 23 patients per hospital. DISCUSSION: The ROTATE study aims to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture compared to current used treatment strategy. Using a treatment algorithm might give the much-wanted personalized treatment recommendation. TRIAL REGISTRATION: This study is approved by the Medical Research Ethics Committee of Erasmus Medical Center in Rotterdam and prospectively registered at the Dutch Trial Registry on May 13th, 2020. Registration number: NL8637.

ACL reconstruction for all is not cost-effective after acute ACL rupture.

OBJECTIVES: To conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator). METHODS: Patients aged between 18 and 65 years of age with a recent ACL rupture (<2 months) were randomised between either an early ACL reconstruction (index) or a rehabilitation plus an optional reconstruction in case of persistent instability (comparator) after 3 months of rehabilitation. A cost-utility analysis was performed to compare both treatments over a 2-year follow-up. Cost-effectiveness was calculated as incremental costs per quality-adjusted life year (QALY) gained, using two perspectives: the healthcare system perspective and societal perspective. The uncertainty for costs and health effects was assessed by means of non-parametric bootstrapping. RESULTS: A total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective. CONCLUSION: Routine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.

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

OBJECTIVE: To compare outcomes from arthroscopic partial meniscectomy versus physical therapy in young patients with traumatic meniscal tears. METHODS: We conducted a multicentre, open-labelled, randomised controlled trial in patients aged 18-45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomised to arthroscopic partial meniscectomy or standardised physical therapy with an optional delayed arthroscopic partial meniscectomy after 3-month follow-up. The primary outcome was the International Knee Documentation Committee (IKDC) score (best 100, worst 0) at 24 months, which measures patients' perception of symptoms, knee function and ability to participate in sports activities. RESULTS: Between 2014 and 2018, 100 patients were included (mean age 35.1 (SD 8.1), 76% male, 34 competitive or elite athletes). Forty-nine were randomised to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during the follow-up period. In both groups, improvement in IKDC scores was clinically relevant during follow-up compared with baseline scores. At 24 months mean (95% CI) IKDC scores were 78 (71 to 84) out of 100 points in the arthroscopic partial meniscectomy group and 78 (71 to 84) in the physical therapy group with a between group difference of 0.1 (95% CI -7.6 to 7.7) points out of 100. CONCLUSIONS: In this trial involving young patients with isolated traumatic meniscal tears, early arthroscopic partial meniscectomy was not superior to a strategy of physical therapy with optional delayed arthroscopic partial meniscectomy at 24-month follow-up. TRIAL REGISTRATION: https://www.trialregister.nl/trials.

Posteriorly positioned femoral grafts decrease long-term failure in anterior cruciate ligament reconstruction, femoral and tibial graft positions did not affect long-term reported outcome.

PURPOSE: To investigate the effect that femoral and tibial tunnel positions have on long-term reported and clinical outcome and to identify a safe zone based on favourable outcome. METHODS: Seventy-eight patients from a previous randomised controlled trial were included and were followed with a mean follow-up of 11.4 years. All patients had primary trans-tibial anterior cruciate ligament reconstruction performed. The femoral and tibial tunnel positions were visualised and translated in percentages with three-dimensional computed tomography post-operatively. There were 3 separate outcome variables: patient-reported outcome measured with the IKDC Subjective Knee Form, overall failure, and radiographic osteoarthritis. The correlation between tunnel aperture positions and outcome was determined with multivariate regression. The area with best outcome was defined as the safe zone and was determined with Youden's index in conjunction with receiver operating characteristics. RESULTS: No significant relationship was found between tunnel aperture positions and IKDC Subjective Knee Form at 10-year follow-up. The posterior-to-anterior femoral tunnel aperture position parallel to Blumensaat line showed a significant relationship (p = 0.03) to overall failure at 10-year follow-up. The mean posterior-to-anterior tunnel position of the group that did not fail was 37.7% compared to 44.1% in the overall failure group. Femoral tunnel apertures placed further anteriorly had more overall failures at long-term. The cut-off point lies at 35.0% from posterior-to-anterior parallel to Blumensaat. Of the 16 overall failures, 15 (93.8%) were placed further anteriorly than the cut-off point. No significant relationship was found between tunnel aperture positions and radiographic osteoarthritis. CONCLUSION: Femoral and tibial tunnel positions were not associated with long-term patient-reported outcome and radiographic osteoarthritis. Long-term overall failure was more frequently seen in patients with a more anteriorly placed femoral tunnel. This study identified a safe zone located at the most posterior 35% of the femoral condyle parallel to Blumensaat. This knowledge offers guidance to surgeons to operate more precisely and accurately and reconstruct a long-lasting graft. LEVEL OF EVIDENCE: Level III.

Effects of eccentric exercises on improving ankle dorsiflexion in soccer players.

PURPOSE: The purpose of this study was to determine the effect of targeted eccentric calf muscle exercises compared to regular training on ankle dorsiflexion in healthy adolescent soccer players with a decreased ankle dorsiflexion. METHODS: Male adolescent players (aged 14-21 years) from two professional soccer clubs were evaluated with the Weight Bearing Dorsiflexion Lunge Test (WBDLT) at baseline and after 12 weeks of this prospective controlled study. One club served as the control group and the other as the intervention group. Players with decreased ankle dorsiflexion (WBDLT) ≤ 10 cm) performed stretching and eccentric calf muscle exercises three times per week next to regular training in the intervention group, and performed only regular training in the control group. Primary outcome was the between-group difference in change in WBDLT between baseline and 12 weeks. RESULTS: Of 107 eligible players, 47(44 %) had a decreased ankle dorsiflexion. The WBDLT (± standard deviation) increased in the intervention group from 7.1 (± 1.8) to 7.4 (± 2.4) cm (95 % Confidence Interval (CI)[-0.493 to 1.108], p = 0.381) and in the control group from 6.1 (± 2.4) to 8.2 (± 2.9) cm (95 % CI [1.313 to 2.659], p < 0.001). The difference in change of WBDLT between both groups was statistically significant (95 % CI [-2.742 to -0.510], p = 0.005). CONCLUSIONS: Targeted eccentric calf muscle exercises do not increase ankle dorsiflexion in healthy adolescent soccer players. Compared to regular training, eccentric exercises even resulted in a decreased calf muscle flexibility. TRIAL REGISTRATION: This trial was registered retrospectively on the 7th of September 2016 in The Netherlands Trial Register (ID number: 6044).

Dutch multidisciplinary guideline on Achilles tendinopathy.

OBJECTIVE: To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients. DESIGN: Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase. DATA SOURCES: Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference. STUDY ELIGIBILITY CRITERIA: Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module. DATA EXTRACTION AND SYNTHESIS: To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations. PRIMARY OUTCOME MEASURE: The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions. RESULTS: Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy. SUMMARY/CONCLUSION: Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Quantitative DCE-MRI demonstrates increased blood perfusion in Hoffa's fat pad signal abnormalities in knee osteoarthritis, but not in patellofemoral pain.

OBJECTIVE: Infrapatellar fat pad (IPFP) fat-suppressed T2 (T2FS) hyperintense regions on MRI are an important imaging feature of knee osteoarthritis (OA) and are thought to represent inflammation. These regions are also common in non-OA subjects, and may not always be linked to inflammation. Our aim was to evaluate quantitative blood perfusion parameters, as surrogate measure of inflammation, within T2FS-hyperintense regions in patients with OA, with patellofemoral pain (PFP) (supposed OA precursor), and control subjects. METHODS: Twenty-two knee OA patients, 35 PFP patients and 43 healthy controls were included and underwent MRI, comprising T2 and DCE-MRI sequences. T2FS-hyperintense IPFP regions were delineated and a reference region was drawn in adjacent IPFP tissue with normal signal intensity. After fitting the extended Tofts pharmacokinetic model, quantitative DCE-MRI perfusion parameters were compared between the two regions within subjects in each subgroup, using a paired Wilcoxon signed-rank test. RESULTS: T2FS-hyperintense IPFP regions were present in 16 of 22 (73%) OA patients, 13 of 35 (37%) PFP patients, and 14 of 43 (33%) controls. DCE-MRI perfusion parameters were significantly different between regions with and without a T2FS-hyperintense signal in OA patients, demonstrating higher Ktrans compared to normal IFPF tissue (0.039 min-1 versus 0.025 min-1, p = 0.017) and higher Ve (0.157 versus 0.119, p = 0.010). For PFP patients and controls no significant differences were found. CONCLUSIONS: IPFP T2FS-hyperintense regions are associated with higher perfusion in knee OA patients in contrast to identically appearing regions in PFP patients and controls, pointing towards an inflammatory pathogenesis in OA only. KEY POINTS: • Morphologically identical appearing T2FS-hyperintense infrapatellar fat pad regions show different perfusion in healthy subjects, subjects with patellofemoral pain, and subjects with knee osteoarthritis. • Elevated DCE-MRI perfusion parameters within T2FS-hyperintense infrapatellar fat pad regions in patients with osteoarthritis suggest an inflammatory pathogenesis in osteoarthritis, but not in patellofemoral pain and healthy subjects.

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

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

T2 mapping of the meniscus is a biomarker for early osteoarthritis.

PURPOSE: To evaluate in vivo T2 mapping as quantitative, imaging-based biomarker for meniscal degeneration in humans, by studying the correlation between T2 relaxation time and degree of histological degeneration as reference standard. METHODS: In this prospective validation study, 13 menisci from seven patients with radiographic knee osteoarthritis (median age 67 years, three males) were included. Menisci were obtained during total knee replacement surgery. All patients underwent pre-operative magnetic resonance imaging using a 3-T MR scanner which included a T2 mapping pulse sequence with multiple echoes. Histological analysis of the collected menisci was performed using the Pauli score, involving surface integrity, cellularity, matrix organization, and staining intensity. Mean T2 relaxation times were calculated in meniscal regions of interest corresponding with the areas scored histologically, using a multi-slice multi-echo postprocessing algorithm. Correlation between T2 mapping and histology was assessed using a generalized least squares model fit by maximum likelihood. RESULTS: The mean T2 relaxation time was 22.4 ± 2.7 ms (range 18.5-27). The median histological score was 10, IQR 7-11 (range 4-13). A strong correlation between T2 relaxation time and histological score was found (rs = 0.84, CI 95% 0.64-0.93). CONCLUSION: In vivo T2 mapping of the human meniscus correlates strongly with histological degeneration, suggesting that T2 mapping enables the detection and quantification of early compositional changes of the meniscus in knee OA. KEY POINTS: • Prospective histology-based study showed that in vivo T 2 mapping of the human meniscus correlates strongly with histological degeneration. • Meniscal T 2 mapping allows detection and quantifying of compositional changes, without need for contrast or special MRI hardware. • Meniscal T 2 mapping provides a biomarker for early OA, potentially allowing early treatment strategies and prevention of OA progression.

To Improve Your Surgical Drilling Skills, Make Use of Your Index Fingers.

BACKGROUND: Surgery has greatly benefited from various technologic advancements over the past decades. Surgery remains, however, mostly manual labor performed by well-trained surgeons. Little research has focused on improving osseous drilling techniques. The objective of this study was to compare the accuracy and precision of different orthopaedic drilling techniques involving the use of both index fingers. QUESTIONS/PURPOSES: (1) Does the shooting grip technique and aiming at the contralateral index finger improve accuracy and precision in drilling? (2) Is the effect of drilling technique on accuracy and precision affected by the experience level of the performer? METHODS: This study included 36 participants from two Dutch training hospitals who were subdivided into three groups (N = 12 per group) based on their surgical experience (that is, no experience, residents, and surgeons). The participants had no further experience with drilling outside the hospital nor were there other potential confounding variables that could influence the test outcomes. Participants were instructed to drill toward a target exit point on a synthetic bone model. There were four conditions: (1) clenched grip without aiming; (2) shooting grip without aiming; (3) clenched grip with aiming at the contralateral index finger; and (4) shooting grip aiming at the contralateral index finger. Participants were only used to a clenched grip without aiming in clinical practice. Each participant had to drill five times per technique per test, and the test was repeated after 4 weeks. Accuracy was defined as the systematic error of all measurements and was calculated as the mean of the five distances between the five exit points and the target exit point, whereas precision was defined as the random error of all measurements and calculated as the SD of those five distances. Accuracy and precision were analyzed using mixed-design analyses of variance. RESULTS: Accuracy was highest when using a clenched grip with aiming at the index finger (mean 4.0 mm, SD 1.1) compared with a clenched grip without aiming (mean 5.0 mm, SD 1.2, p = 0.004) and a shooting grip without aiming (mean 4.9 mm, SD 1.4, p = 0.015). The shooting grip with aiming at the index finger (mean 4.1 mm, SD 1.2) was also more accurate than a clenched grip without aiming (p = 0.006) and a shooting grip without aiming (p = 0.014). Shooting grip with aiming at the opposite index finger (median 2.0 mm, interquartile range [IQR] 1.2) showed the best precision and outperformed a clenched grip without aiming (median 2.9 mm, IQR 1.1, p = 0.016), but was not different than the shooting grip without aiming (median 2.2 mm, IQR 1.4) or the clenched grip with aiming (median 2.4 mm, IQR 1.3). The accuracy of surgeons (mean 4.1 mm, SD 1.1) was higher than the inexperienced group (mean 5.0 mm, SD 1.1, p = 0.012). The same applied for precision (median 2.2 mm, IQR 1.0 versus median 2.8 mm, IQR 1.4, p = 0.008). CONCLUSIONS: A shooting grip combined with aiming toward the index finger of the opposite hand had better accuracy and precision compared with a clenched grip alone. Based on this study, experience does matter, because the orthopaedic surgeons outperformed the less experienced participants. Based on our study, we advise surgeons to aim at the index finger of the opposite hand when possible and to align the ipsilateral index finger to the drill bit. LEVEL OF EVIDENCE: Level II, therapeutic study.

Can we predict the clinical outcome of arthroscopic partial meniscectomy? A systematic review.

NHS-PROSPERO REGISTRATION NUMBER: 42016048592 OBJECTIVE: In order to make a more evidence-based selection of patients who would benefit the most from arthroscopic partial meniscectomy (APM), knowledge of prognostic factors is essential. We conducted a systematic review of predictors for the clinical outcome following APM. DESIGN: Systematic review DATA SOURCES: Medline, Embase, Cochrane Central Register, Web of Science, SPORTDiscus, PubMed Publisher, Google Scholar INCLUSION CRITERIA: Report an association between factor(s) and clinical outcome; validated questionnaire; follow-up >1 year. EXCLUSION CRITERIA: <20 subjects; anterior cruciate ligament-deficient patients; discoid menisci; meniscus repair, transplantation or implants; total or open meniscectomy. METHODS: One reviewer extracted the data, two reviewers assessed the risk of bias and performed a best-evidence synthesis. RESULTS: Finally, 32 studies met the inclusion criteria. Moderate evidence was found, that the presence of radiological knee osteoarthritis at baseline and longer duration of symptoms (>1 year) are associated with worse clinical outcome following APM. In addition, resecting >50% of meniscal tissue and leaving a non-intact meniscal rim after meniscectomy are intra-articular predictive factors for worse clinical outcome. Moderate evidence was found that sex, onset of symptoms (acute or chronic), tear type or preoperative sport level are not predictors for clinical outcome. Conflicting evidence was found for the prognostic value of age, perioperative chondral damage, body mass index and leg alignment. SUMMARY/CONCLUSION: Long duration of symptoms (>1 year), radiological knee osteoarthritis and resecting >50% of meniscus are associated with a worse clinical outcome following APM. These prognostic factors should be considered in clinical decision making for patients with meniscal tears.

Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review.

BACKGROUND: Anterior cruciate ligament (ACL) injury is an important risk factor for development of knee osteoarthritis (OA). To identify those ACL injured patients at increased risk for knee OA, it is necessary to understand risk factors for OA. AIM: To summarise the evidence for determinants of (1) tibiofemoral OA and (2) patellofemoral OA in ACL injured patients. METHODS: MEDLINE, EMBASE, Web of Science and CINAHL databases were searched up to 20 December 2013. Additionally, reference lists of eligible studies were manually and independently screened by two reviewers. 2348 studies were assessed for the following main inclusion criteria: ≥20 patients; ACL injured patients treated operatively or non-operatively; reporting OA as outcome; description of relationship between OA outcome and determinants; and a follow-up period ≥2 years. Two reviewers extracted the data, assessed the risk of bias and performed a best-evidence synthesis. RESULTS: Sixty-four publications were included and assessed for quality. Two studies were classified as low risk of bias. Medial meniscal injury/meniscectomy showed moderate evidence for influencing OA development (tibiofemoral OA and compartment unspecified). Lateral meniscal injury/meniscectomy showed moderate evidence for no relationship (compartment unspecified), as did time between injury and reconstruction (tibiofemoral and patellofemoral OA). CONCLUSIONS: Medial meniscal injury/meniscectomy after ACL rupture increased the risk of OA development. In contrast, it seems that lateral meniscal injury/meniscectomy has no relationship with OA development. Our results suggest that time between injury and reconstruction does not influence patellofemoral and tibiofemoral OA development. Many determinants showed conflicting and limited evidence and no determinant showed strong evidence.

Diagnostic value of medical history and physical examination of anterior cruciate ligament injury: comparison between primary care physician and orthopaedic surgeon.

PURPOSE: Well-designed validity studies on the clinical diagnosis of anterior cruciate ligament (ACL) injury are scarce. Our purpose is to assess the diagnostic value of ACL-specific medical history assessment and physical examination between primary and secondary care medical specialists. METHODS: Medical history assessment and physical examination were performed by both an orthopaedic surgeon and a primary care physician, both blinded to all clinical information, in a secondary care population. A knee arthroscopy was used as reference standard. A total of 60 participants were divided into an index group with an arthroscopically proven complete ACL rupture and a control group with an arthroscopically proven intact ACL. RESULTS: The orthopaedic surgeon recognized 94 % of the participants with an ACL rupture through a positive medical history combined with a positive physical examination; of the participants with an intact ACL, 16 % were misclassified by the orthopaedic surgeon. The primary care physician recognized 62 % of the participants with an ACL rupture and misclassified 23 % of the participants with an intact ACL. Physical examination appeared to have no additional value for the primary care physician. CONCLUSIONS: Combined medical history and physical examination have strong diagnostic value in ACL rupture diagnostics performed by an orthopaedic surgeon, whereas for the primary care physician, only medical history appeared to be of value. For current practice, this could mean that only orthopaedic surgeons can perform an ACL physical examination with accuracy. LEVEL OF EVIDENCE: III.

Computer-assisted surgery for knee ligament reconstruction.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011. OBJECTIVES: To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults. SEARCH METHODS: For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS. DATA COLLECTION AND ANALYSIS: Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI). MAIN RESULTS: The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes. AUTHORS' CONCLUSIONS: From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.

Computer-assisted surgery for knee ligament reconstruction.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011. OBJECTIVES: To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults. SEARCH METHODS: For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS. DATA COLLECTION AND ANALYSIS: Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI). MAIN RESULTS: The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes. AUTHORS' CONCLUSIONS: From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.

Hyaline fibromatosis of Hoffa's fat pad in a patient with a mild type of hyaline fibromatosis syndrome.

Hyaline fibromatosis syndrome (HFS) is a rare, homozygous, autosomal recessive disease, characterized by deposition of hyaline material in skin and other organs, resulting in esthetic problems, disability, and potential life-threatening complications. Most patients become clinically apparent in the first few years of life, and the disorder typically progresses with the appearance of new lesions. We describe a rare case of a 20-year-old patient with juvenile-onset mild HFS who presented with a history of progressive anterior knee pain. Detailed magnetic resonance (MR) imaging findings with histopathological correlation are presented of hyaline fibromatosis of Hoffa's fat pad, including differential diagnosis. The diagnosis of HFS is generally made on basis of clinical and histopathological findings. Imaging findings, however, may contribute to the correct diagnosis in patients who present with a less typical clinical course of HFS.

Are magnetic resonance imaging recovery and laxity improvement possible after anterior cruciate ligament rupture in nonoperative treatment?

PURPOSE: This study aimed to determine whether anterior cruciate ligament (ACL) features on magnetic resonance imaging (MRI) and knee laxity are improved 2 years after ACL rupture treated nonoperatively and to analyze the relation between changes in scores of ACL features and changes in laxity. METHODS: One hundred fifty-four eligible patients were included in a prospective multicenter cohort study with 2-year follow-up. Inclusion criteria were (1) ACL rupture diagnosed by physical examination and MRI, (2) MRI within 6 months after trauma, and (3) age 18 to 45 years. Laxity tests and MRI were performed at baseline and at 2-year follow-up. Fifty of 143 patients, for whom all MRI data was available, were treated nonoperatively and were included for this study. Nine ACL features were scored using MRI: fiber continuity, signal intensity, slope of ACL with respect to the Blumensaat line, distance between the Blumensaat line and the ACL, tension, thickness, clear boundaries, assessment of original insertions, and assessment of the intercondylar notch. A total score was determined by summing scores for each feature. RESULTS: Fiber continuity improved in 30 patients (60%), and the empty intercondylar notch resolved for 22 patients (44%). Improvement in other ACL features ranged from 4% to 28%. Sixteen patients (32%) improved on the Lachman test (change from soft to firm end points [n = 14]; decreased anterior translation [n = 2]), one patient (2%) showed improvement with the KT-1000 arthrometer (MEDmetric, San Diego, CA) and 4 patients (8%) improved on the pivot shift test. Improvement on the Lachman test was moderately negatively associated with the total score of ACL features at follow-up. Analyzing ACL features separately showed that only signal intensity improvement, clear boundaries, and intercondylar notch assessment were positively associated with improvement on the Lachman test. CONCLUSIONS: Two years after ACL rupture and nonoperative management, patients experienced partial recovery on MRI, and some knee laxity improvement was present. Improvement of ACL features on MRI correlates moderately with improved laxity. LEVEL OF EVIDENCE: Level II, Prospective comparative study.