Reduced Intratendinous Sliding in Achilles Tendinopathy During Active Plantarflexion Regardless of Horizontal Foot Position.

PURPOSE: The Achilles tendon consists of three subtendons with the ability to slide relative to each other. As optimal intratendinous sliding is thought to reduce the overall stress in the tendon, alterations in sliding behavior could potentially play a role in the development of Achilles tendinopathy. The aims of this study were to investigate the difference in intratendinous sliding within the Achilles tendon during isometric contractions between asymptomatic controls and patients with Achilles tendinopathy and the effect of changing the horizontal foot position on intratendinous sliding in both groups. METHODS: Twenty-nine participants (13 Achilles tendinopathy and 16 controls) performed isometric plantarflexion contractions at 60% of their maximal voluntary contraction (MVC), in toes-neutral, and at 30% MVC in toes-neutral, toes-in, and toes-out positions during which ultrasound images were recorded. Intratendinous sliding was estimated as the superficial-to-middle and middle-to-deep relative displacement. RESULTS: Patients with Achilles tendinopathy present lower intratendinous sliding than asymptomatic controls. Regarding the horizontal foot position in both groups, the toes-out foot position resulted in increased sliding compared with both toes-neutral and toes-out foot position. CONCLUSION: We provided evidence that patients with Achilles tendinopathy show lower intratendinous sliding than asymptomatic controls. Since intratendinous sliding is a physiological feature of the Achilles tendon, the external foot position holds promise to increase sliding in patients with Achilles tendinopathy and promote healthy tendon behavior. Future research should investigate if implementing this external foot position in rehabilitation programs stimulates sliding within the Achilles tendon and improves clinical outcome.

How reliable are femoropelvic kinematics during deep squats? The influence of subject-specific skeletal modelling on measurement variability.

BACKGROUND: Biplanar radiography displays promising results in the production of subject-specific (S.specific) biomechanical models. However, the focus has predominantly centred on methodological investigations in gait analysis. Exploring the influence of such models on the analysis of high range of motion tasks linked to hip pathologies is warranted. The aim of this study is to investigate the effect of S.Specific modelling techniques on the reliability of deep squats kinematics in comparison to generic modelling. METHODS: 8 able-bodied male participants attended 5 motion capture sessions conducted by 3 observers and performed 5 deep squats in each. Prior to each session a biplanar scan was acquired with the reflective-markers attached. Inverse kinematics of pelvis and thigh segments were calculated based on S.specific and Generic model definition. Agreement between the two models femoropelvic orientation in standing was assessed with Bland-Altman plots and paired t- tests. Inter-trial, inter-session, inter-observer variability and observer/trial difference and ratio were calculated for squat kinematic data derived from the two modelling approaches. RESULTS: Compared to the Generic model, the S.Specific model produced a calibration trial that is significantly offset into more posterior pelvis tilt (-2.8±2.7), hip extension (-2.2±3.8), hip abduction (-1.2±3.6) and external rotation (-13.8±11.4). The S.specific model produced significantly different squat kinematics in the sagittal plane of the pelvis (entire squat cycle) and hip (between 40 % and 60 % of the squat cycle). Variability analysis indicated that the error magnitude between the two models was comparable (difference<2°). The S.specific model exhibited a lower variability in the observer/trial ratio in the sagittal pelvis and hip, the frontal hip, but showed a higher variability in the transverse hip. SIGNIFICANCE: S.specific modelling appears to introduce a calibration offset that primarily translates into an effect in the sagittal plane kinematics. However, the clinical added value of S.specific modelling in terms of reducing experimental sources of kinematic variability was limited.

Correlation between tibial and femoral bone and cartilage changes in end-stage knee osteoarthritis.

Knee osteoarthritis is a whole joint disease highlighting the coupling of cartilage and bone adaptations. However, the structural properties of the subchondral bone plate (SBP) and underlying subchondral trabecular bone (STB) in the femoral compartment have received less attention compared to the tibial side. Furthermore, how the properties in the femoral compartment relate to those in the corresponding tibial site is unknown. Therefore, this study aimed to quantify the structural bone and cartilage morphology in the femoral compartment and investigate its association with those of the tibial plateau. Specifically, tibial plateaus and femoral condyles were retrieved from 28 patients with end-stage knee-osteoarthritis (OA) and varus deformity. The medial condyle of tibial plateaus and the distal part of the medial femoral condyles were micro-CT scanned (20.1 µm/voxel). Cartilage thickness (Cart.Th), SBP, and STB microarchitecture were quantified. Significant (P < <.001; 0.79 ≤ r ≤ 0.97) correlations with a relative difference within 10% were found between the medial side of the femoral and tibial compartments. The highest correlations were found for SBP porosity (r = 0.97, mean absolute difference of 0.50%, and mean relative difference of 9.41%) and Cart.Th (r = 0.96, mean absolute difference of 0.18 mm, and relative difference of 7.08%). The lowest correlation was found for trabecular thickness (r = 0.79, mean absolute difference of 21.07 µm, and mean relative difference of 5.17%) and trabecular number (r = 0.79, mean absolute difference of 0.18 mm-1, and relative difference of 5.02%). These findings suggest that the distal femur is affected by OA in a similar way as the proximal tibia. Given that bone adaptation is a response to local mechanical forces, our results suggest that varus deformity similarly affects the stress distribution of the medial tibial plateau and the medial distal femur.

Covariations between scapular shape and bone density in B-glenoids: A statistical shape and density modeling-approach.

B-type glenoids are characterized by posterior humeral head migration and/or bony-erosion-induced glenoid retroversion. Patients with this type of osteoarthritic glenoids are known to be at increased risk of glenoid component loosening after anatomic total shoulder arthroplasty (aTSA). One of the main challenges in B glenoid surgical planning is to find a balance between correcting the bony shape and maintaining the quality of the bone support. This study aims to systematically quantify variabilities in terms of scapular morphology and bone mineral density in patients with B glenoids and to identify patterns of covariation between these two features. Using computed tomography scan images of 62 patients, three-dimensional scapular surface models were constructed. Rigid and nonrigid surface registration of the scapular surfaces, followed by volumetric registration and material mapping, enabled us to develop statistical shape model (SSM) and statistical density model (SDM). Partial least square correlation (PLSC) was used to identify patterns of covariation. The developed SSM and SDM represented 85.9% and 56.6% of variabilities in terms of scapular morphology and bone density, respectively. PLSC identified four modes of covariation, explaining 66.0% of the correlation between these two variations. Covariation of posterior-inferior glenoid erosion with posterior sclerotic bone formation in association with reduction of bone density in the anterior and central part of the glenoid was detected as the primary mode of covariation. Identification of these asymmetrical distribution of bone density can inform us about possible reasons behind glenoid component loosening in B glenoids and surgical guidelines in terms of the compromise between bony shape correction and bone support quality.

Sensitivity of Model-Based Predictions of Post-TKA Kinematic Behavior to Residual Errors in Ultrasound-Based Knee Collateral Ligament Strain Assessment.

Ultrasound-based ligament strain estimation shows promise in non-invasively assessing knee joint collateral ligament behavior and improving ligament balancing procedures. However, the impact of ultrasound-based strain estimation residual errors on in-silico arthroplasty predictions remains unexplored. We investigated the sensitivity of post-arthroplasty kinematic predictions to ultrasound-based strain estimation errors compared to clinical inaccuracies in implant positioning.Two cadaveric legs were submitted to active squatting, and specimen-specific rigid computer models were formulated. Mechanical properties of the ligament model were optimized to reproduce experimentally obtained tibiofemoral kinematics and loads with minimal error. Resulting remaining errors were comparable to the current state-of-the-art. Ultrasound-derived strain residual errors were then introduced by perturbing lateral collateral ligament (LCL) and medial collateral ligament (MCL) stiffness. Afterwards, the implant position was perturbed to match with the current clinical inaccuracies reported in the literature. Finally, the impact on simulated post-arthroplasty tibiofemoral kinematics was compared for both perturbation scenarios. Ultrasound-based errors minimally affected kinematic outcomes (mean differences < 0.73° in rotations, 0.1 mm in translations). Greatest differences occurred in external tibial rotations (-0.61° to 0.73° for MCL, -0.28° to 0.27° for LCL). Comparatively, changes in implant position had larger effects, with mean differences up to 1.95° in external tibial rotation and 0.7 mm in mediolateral translation. In conclusion, our study demonstrated that the ultrasound-based assessment of collateral ligament strains has the potential to enhance current computer-based pre-operative knee arthroplasty planning.

Calibration of Holzapfel-Gasser-Ogden collateral ligament properties in a hybrid post-arthroplasty knee joint model for laxity testing.

Knee collateral ligaments play a vital role in providing frontal-plane stability in post-total knee arthroplasty (TKA) knees. Finite element models can utilize computationally efficient one-dimensional springs or more physiologically accurate three-dimensional continuum elements like the Holzapfel-Gasser-Ogden (HGO) formulation. However, there is limited literature defining subject-specific mechanical properties, particularly for the HGO model. In this study, we propose a co-simulation framework to obtain subject-specific material parameters for an HGO-based finite element ligament model integrated into a rigid-body model of the post-TKA knee. Our approach achieves comparable accuracy to spring formulations while significantly reducing coefficient calibration time and demonstrating improved correlation with reference knee kinematics and ligament strains throughout the tested loading range.

Three- instead of two-dimensional evaluation of key parameters alters the choice of the lowest instrumented vertebra in Lenke 1 and 2 AIS patients.

PURPOSE: Treatment of AIS, a three-dimensional spinal (3D) deformity, is guided by a two-dimensional (2D) evaluation. Novel 3D approaches that address the 2D limitations have not been adopted in AIS care due to their lengthy and complex 3D reconstruction procedures. This study aims to introduce a simple 3D method that translates the 2D key parameters (Stable vertebra (SV), Lenke lumbar modifier, Neutral vertebra (NV)) into 3D and to quantitively compare these 3D corrected parameters to the 2D assessment. METHODS: The key parameters of 79 surgically treated Lenke 1 and 2 patients were measured in 2D by two experienced spine surgeons. Next, these key parameters were measured in 3D by indicating relevant landmarks on biplanar radiographs and using the 'true' 3D CSVL which was perpendicular to the pelvic plane. Differences between the 2D and 3D analysis were examined. RESULTS: A 2D-3D mismatch was identified in 33/79 patients (41.8%) for at least one of the key parameters. More specifically, a 2D-3D mismatch was identified in 35.4% of patients for the Sag SV, 22.5% of patients for the SV and 17.7% of patients for the lumbar modifier. No differences in L4 tilt and NV rotation were found. CONCLUSION: The findings highlight that a 3D evaluation alters the choice of the LIV in Lenke 1 and 2 AIS patients. Although, the true impact of this more precise 3D measurement on preventing poor radiographic outcome needs further investigation, the results are a first step toward establishing a basis for 3D assessments in daily practice.

The effect of weight-bearing positions on coronal lower limb alignment: A systematic review.

BACKGROUND: The coronal alignment of the lower limb is generally accepted as a major determinant of surgical outcome in total knee arthroplasty (TKA). To achieve the ideal post-operative alignment, surgeons need to be aware of the influence that weight-bearing positions have on the final knee alignment. Therefore, this review aims to define the effect of varying weight-bearing positions on the coronal alignment of the lower limb. We hypothesized that a coronal alignment deformity increases with loading. METHODS: The PubMed, Medline and google scholar databases were searched systematically in June 2022. Only studies which compared coronal alignment with a standardized radiographic protocol in the single leg, double leg and supine positions were included. To obtain pooled estimates of the effect of different weight-bearing positions, random-effect analysis were fitted using SAS. RESULTS: Compared to the supine position, double leg weight-bearing positions were found to be associated with a more pronounced varus deformity (mean difference in HKA is 1,76° (95% CI 1,32: 2,21), p < 0.0001)). The mean difference in HKA between double leg and single leg weight-bearing conditions was 1.43° (95% CI (-0,042;2,90), p = 0.0528). CONCLUSION: The overall knee alignment was found to be influenced by the weight-bearing position. An average difference of 1.76° in HKA-angle was found between a double leg-stance and supine position, tending to increased varus in the former weight-bearing position. It is therefore possible that the deformity could increase by 1.76° if knee surgeons only follow a pre-op planning based on double-leg stance full length radiographs.

In Silico Biomarkers of Motor Function to Inform Musculoskeletal Rehabilitation and Orthopedic Treatment.

In this review, we elaborate on how musculoskeletal (MSK) modeling combined with dynamic movement simulation is gradually evolving from a research tool to a promising in silico tool to assist medical doctors and physical therapists in decision making by providing parameters relating to dynamic MSK function and loading. This review primarily focuses on our own and related work to illustrate the framework and the interpretation of MSK model-based parameters in patients with 3 different conditions, that is, degenerative joint disease, cerebral palsy, and adult spinal deformities. By selecting these 3 clinical applications, we also aim to demonstrate the differing levels of clinical readiness of the different simulation frameworks introducing in silico model-based biomarkers of motor function to inform MSK rehabilitation and treatment, with the application for adult spinal deformities being the most recent of the 3. Based on these applications, barriers to clinical integration and positioning of these in silico technologies within standard clinical practice are discussed in the light of specific challenges related to model assumptions, required level of complexity and personalization, and clinical implementation.

Characterizing the viscoelastic properties of the anterolateral ligament and grafts commonly used in its reconstruction.

BACKGROUND: Current anatomic anterolateral ligament reconstruction is typically performed using either a gracilis tendon or an iliotibial band graft based on their quasi-static behavior. However, there is limited knowledge about their viscoelastic behaviors. This study aimed to characterize the viscoelastic properties of the anterolateral ligament, distal iliotibial band, distal gracilis tendon and proximal gracilis tendon for graft material choice in anterolateral ligament reconstruction. METHODS: All the tissues were harvested from thirteen fresh-frozen cadaveric knees and subjected to preconditioning (3-6 MPa), sinusoidal cycle (1.2-12 MPa), dwell at constant load (12 MPa), and load to failure (3%/s). The quasi-static and viscoelastic properties of the soft tissues were computed and compared using a linear mixed model (p < 0.05). FINDINGS: The hysteresis of anterolateral ligament (mean:0.4 Nm) was comparable with gracilis halves (p > 0.85) but iliotibial band (6 Nm) was significantly higher (p < 0.001,ES = 6.5). In contrast, the dynamic creep of anterolateral ligament (0.5 mm) was similar to iliotibial band (0.7 mm, p > 0.82) whereas both gracilis halves were significantly lower (p < 0.007,ES > 1.4). The elastic modulus of anterolateral ligament (181.4 MPa, p < 0.001,ES > 2.1) was the lowest compared to the grafts materials (distal gracilis tendon:835 MPa, distal gracilis tendon:726 MPa, iliotibial band:910 MPa). Additionally, the failure load of the anterolateral ligament (124.5 N, p < 0.001,ES > 2.9) was also the lowest. INTERPRETATION: The mechanical properties of the gracilis halves and iliotibial band were significantly different from anterolateral ligament, except for hysteresis and dynamic creep, respectively. Our findings showed that the gracilis halves may be a more appropriate graft choice for anterolateral ligament reconstruction due to its low energy dissipation and permanent deformation under dynamic loads.

Quantitative statistical shape model-based analysis of humeral head migration, Part 2: Shoulder osteoarthritis.

We wanted to investigate the quantitative characteristics of humeral head migration (HHM) in shoulder osteoarthritis (OA) and their possible associations with scapular morphology. We quantified CT-scan-based-HHM in 122 patients with a combination of automated 3D scapulohumeral migration (=HHM with respect to the scapula) and glenohumeral migration (=HHM with respect to the glenoid) measurements. We divided OA patients in Group 1 (without HHM), Group 2a (anterior HHM) and Group 2b (posterior HHM). We reconstructed and measured the prearthropathy scapular anatomy with a statistical shape model technique. HHM primarily occurs in the axial plane in shoulder OA. We found "not-perfect" correlation between subluxation distance AP and scapulohumeral migration values (rs = 0.8, p < 0.001). Group 2b patients had a more expressed prearthropathy glenoid retroversion (13° vs. 7°, p < 0.001) and posterior glenoid translation (4 mm vs. 6 mm, p = 0.003) in comparison to Group 1. Binary logistic regression analysis indicated prearthropathy glenoid version as a significant predictor of HHM (χ² = 27, p < 0.001). Multivariate regression analysis showed that the pathologic version could explain 56% of subluxation distance-AP variance and 75% of the scapulohumeral migration variance (all p < 0.001). Herewith, every degree increase in pathologic glenoid retroversion was associated with an increase of 1% subluxation distance-AP, and scapulohumeral migration. The occurrence of posterior HHM is associated with prearthropathy glenoid retroversion and more posterior glenoid translation. The reported regression values of HHM in the function of the pathologic glenoid version could form a basis toward a more patient-specific correction of HHM.

Advanced quantitative 3D imaging improves the reliability of the classification of acetabular defects.

INTRODUCTION: Classifying complex acetabular defects in revision total hip arthroplasty (THA) by means of conventional radiographs comes with significant limitations. Statistical shape modelling allows the virtual reconstruction of the native pelvic morphology, hereby enabling an analytic acetabular defect assessment. Our objective was to evaluate the effect of advanced imaging augmented with analytic representations of the defect on (1) intra- and inter-rater reliability, and (2) up- or downscaling of classification scores when evaluating acetabular defects in patients undergoing revision THA. MATERIALS AND METHODS: The acetabular defects of 50 patients undergoing revision THA were evaluated by three independent, fellowship-trained orthopaedic surgeons. Defects were classified according to the acetabular defect classification (ADC) using four different imaging-based representations, namely, standard radiographs, CT imaging, a virtual three-dimensional (3D) model and a quantitative analytic representation of the defect based on a statistical shape model reconstruction. Intra- and inter-rater reliabilities were quantified using Fleiss' and Cohen's kappa scores, respectively. Up- and downscaling of classification scores were compared for each of the imaging-based representations and differences were tested. RESULTS: Overall inter-rater agreement across all imaging-based representations for the classification was fair (κ 0.29 95% CI 0.28-0.30). Inter-rater agreement was lowest for radiographs (κ 0.21 95% CI 0.19-0.22) and increased for other representations with agreement being highest when using analytic defect models (κ 0.46 95% CI 0.43-0.48). Overall intra-rater agreement was moderate (κ 0.51 95% CI 0.42-0.60). Intra-rater agreement was lowest for radiographs (κ 0.40 95% CI 0.23-0.57), and highest for ratings including analytic defect models (κ 0.64:95% CI 0.46-0.82). Virtual 3D models with quantitative analytic defect representations upscaled acetabular defect scores in comparison to standard radiographs. CONCLUSIONS: Using 3D CT imaging with statistical shape models doubles the intra- and inter-rater reliability and results in upscaling of acetabular defect classification when compared to standard radiographs. This method of evaluating defects will aid in planning surgical reconstruction and stimulate the development of new classification systems based on advanced imaging techniques.

Impact of increasing total knee replacement constraint within a single implant line on coronal stability: an ex vivo investigation.

INTRODUCTION: Despite the existence of diverse total knee implant designs, few data is available on the relationship between the level of implant constraint and the postoperative joint stability in the frontal plane and strain in the collateral ligaments. The current study aimed to document this relation in an ex vivo setting. MATERIALS AND METHODS: Six fresh-frozen lower limbs underwent imaging for preparation of specimen-specific surgical guides. Specimens were dissected and assessed for joint laxity using the varus-valgus stress tests at fixed knee flexion angles. A handheld dynamometer applied tensile loads at the ankle, thereby resulting in a knee abduction-adduction moment of 10 Nm. Tibiofemoral kinematics were calculated using an optical motion capture system, while extensometers attached to medial collateral (MCL) and lateral collateral ligament (LCL) measured strain. Native joint testing was followed by four TKA designs from a single implant line-cruciate retaining, posterior stabilised, varus-valgus constrained and hinged knee (HK)-and subsequent testing after each implantation. Repeated measures linear mixed-models (p < 0.05) were used to compare preoperative vs. postoperative data on frontal plane laxity and collateral ligament strain. RESULTS: Increasing implant constraint reduced frontal plane laxity across knee flexion, especially in deep flexion (r2 > 0.76), and MCL strain in extension; however, LCL strain reduction was not consistent. Frontal plane laxity increased with knee flexion angle, but similar trends were inconclusive for ligament strain. HK reduced joint laxity and ligament strain as compared to the native condition consistently across knee flexion angle, with significant reductions in flexion (p < 0.024) and extension (p < 0.001), respectively, thereby elucidating the implant design-induced joint stability. Ligament strain exhibited a strong positive correlation with varus-valgus alignment (r2 = 0.96), notwithstanding knee flexion angle or TKA implant design. CONCLUSION: The study demonstrated that increasing the constraint of a TKA resulted in lower frontal plane laxity of the knee. With implant features impacting laxity in the coronal plane, consequentially affecting strain in collateral ligaments, surgeons must consider these factors when deciding a TKA implant, especially for primary TKA. LEVEL OF EVIDENCE: V.

Applying the ICF model in adult spinal deformity: disability in terms of participation should be incorporated in the care pathway.

PURPOSE: To investigate the participation restriction of adult spinal deformity (ASD) patients, and its relation with the impairments in body structure and function, and activity limitation, as this important information regarding the individual's perspective on the social impact of the disease on their life is presently not captured. METHODS: Forty-three ASD patients participated in the study and completed the impact on participation and autonomy (IPA) questionnaire to assess the level of participation. Activity limitations and impairments were measured with the Balance Evaluation Systems Test (BESTest) and Scoliosis Research Society-22r (SRS-22). Also, age, body height, body weight, BMI, Mini-mental state examination and Cumulative Illness Rating Scale were assessed. A univariate linear regression analysis was conducted to investigate the relationship between the IPA and the independent variables, whereas a multivariate analysis identified the significant predictive variables for the IPA questionnaire. RESULTS: The univariate analysis identified performance on the BESTest and SRS-22 as significantly (p < 0.001) related to the IPA questionnaire. The multiple regression analysis revealed that the performance on BESTest (p = 0.073) and SRS-22 (p < 0.001) independently predicted the IPA questionnaire, explaining 73.5% of its variance. CONCLUSION: To fully understand the impact of ASD on the individual's functioning, disability and health-status, it is suggested that questionnaires on participation to society should be considered, together with clinical postural tests (e.g. the BESTest) and questionnaires related to HRQOL (e.g. the SRS-22), in the ASD care path. This additional information should allow the surgeon to make a more informed selection of surgical patients.

External rotation of the foot position during plantarflexion increases non-uniform motions of the Achilles tendon.

The medial (GM) and lateral gastrocnemius (GL) muscles enroll to different subparts of the Achilles tendon to form their respective subtendons. The relative gastrocnemii activations during submaximal plantarflexion contraction depend on the position of the foot in the horizontal plane: with toes-in, GL activation increases and GM activation decreases, compared to toes-out. The aim of the current study was to investigate whether horizontal foot position during submaximal isometric plantarflexion contraction differently affects the subtendons within the Achilles tendon in terms of their (i) length at rest, and (ii) elongations and distal motions. Twenty healthy subjects (12 females/8 males) participated in the study. Three-dimensional ultrasound images were taken to capture subtendon lengths at rest and during isometric contraction. Ultrasound images were recorded at the distal end of Achilles tendon (sagittal plane) during ramped contractions and analyzed using a speckle tracking algorithm. All tasks were conducted twice, ones with toes-in and ones with toes-out. At rest, subtendons were shorter with toes-out compared to toes-in. During contraction, the GM subtendon lengthened more in toes-out, compared to the GL, and vice versa (all p <.01). The relative motions within the Achilles tendon (middle minus top layers displacements) were smaller in toes-in compared to toes-out (p =.05) for higher contraction intensity. Our results demonstrated that the horizontal foot position during plantarflexion contraction impacts Achilles tendon motions. Such findings may be relevant in a clinical context, for example in pathologies affecting Achilles tendon motions such as Achilles tendinopathy.

The different subtalar ligaments show significant differences in their mechanical properties.

BACKGROUND: Today, the relative contribution of each ligamentous structure in the stability of the subtalar joint is still unclear. The purpose of this study is to assess the material properties of the different ligamentous structures of the subtalar joint. METHODS: Eighteen paired fresh-frozen cadaveric feet were used to obtain bone-ligament-bone complexes of the calcaneofibular ligament (CFL), the cervical ligament (CL) and the anterior capsular ligament-interosseous talocalcaneal ligament complex (ACaL-ITCL). The samples were subjected to uniaxial testing to calculate their respective stiffness and failure load. RESULTS: The stiffness of ACaL-ITCL complex (mean: 150 ± 51 N/mm, 95% confidence interval (CI): 125.0-176.6 N/mm) was significantly higher than both CFL (mean: 55.8 ± 23.0 N/mm, CI: 43.8-67.7 N/mm) and CL (mean: 63.9 ± 38.0 N/mm, CI: 44.4-83.3 N/mm). The failure load of both the ACaL-ITCL complex (mean:382.5 ± 158 N, CI: 304.1-460.8 N) and the CFL (mean:320.4 ± 122.0 N, CI: 257.5-383.2 N) were significantly higher than that of the CL (mean:163.5 ± 58.0 N, CI: 131.3-195.7 N). The injury pattern demonstrated a partial rupture in all CFL and ACaL-ITCL specimens and in 60% of the CL specimens. CONCLUSION: The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment.

Assessment of in vivo bone activity patterns in medial mobile-bearing unicompartmental knee arthroplasty : a prospective SPECT/CT study.

AIMS: Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs. METHODS: In total, 34 patients (13 female, 21 male; mean age 62 years (41 to 79); BMI 29.7 kg/m2 (23.6 to 42.1)) with 38 medial Oxford partial UKAs (20 left, 18 right; 19 cementless, 14 cemented, and five hybrid) were prospectively followed with sequential 99mTc-hydroxymethane diphosphonate single photon emission CT (SPECT)/CT preoperatively, and at one and two years postoperatively. Changes in mean osteoblastic activity were investigated using a tracer localization scheme with volumes of interest (VOIs), reported by normalized mean tracer values. A SPECT/CT registration platform additionally explored cortical tracer evolution in zones of interest identified by previous experimental research. RESULTS: Significant reduction of tracer activity from the preoperative situation was found in femoral and anteromedial tibial VOIs adjacent to the UKA components. Temporarily increased osteoblastic bone activity was observed in VOIs comprising the UKA keel structure at one year postoperatively compared to the preoperative activity. Persistent higher tracer uptake was found in the posterior tibial cortex at final follow-up. Multivariate analysis showed no statistical difference in osteoblastic bone activity underneath cemented or cementless components. CONCLUSION: Well-functioning medial mobile-bearing UKAs showed distinct changes in patterns of normalized bone tracer activity in the different VOIs adjacent to the prosthetic components, regardless of their type of fixation. Compared to the preoperative situation, persistent high bone activity was found underneath the keel and the posterior tibial cortex at final follow-up, with significant reduced activity only being identified in femoral and anteromedial tibial VOIs. Cite this article: Bone Joint J 2022;104-B(1):34-44.

Variability drivers of treatment costs in hospitals: A systematic review.

OBJECTIVES: Studies on variability drivers of treatment costs in hospitals can provide the necessary information for policymakers and healthcare providers seeking to redesign reimbursement schemes and improve the outcomes-over-cost ratio, respectively. This systematic literature review, focusing on the hospital perspective, provides an overview of studies focusing on variability in treatment cost, an outline of their study characteristics and cost drivers, and suggestions on future research methodology. METHODS: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Handbook for Systematic Reviews of Interventions. We searched PubMED/MEDLINE, Web of Science, EMBASE, Scopus, CINAHL, Science direct, OvidSP and Cochrane library. Two investigators extracted and appraised data for citation until October 2020. RESULTS: 90 eligible articles were included. Patient, treatment and disease characteristics and, to a lesser extent, outcome and institutional characteristics were identified as significant variables explaining cost variability. In one-third of the studies, the costing method was classified as unclear due to the limited explanation provided by the authors. CONCLUSION: Various patient, treatment and disease characteristics were identified to explain hospital cost variability. The limited transparency on how hospital costs are defined is a remarkable observation for studies wherein cost variability is the main focus. Recommendations relating to variables, costs, and statistical methods to consider when designing and conducting cost variability studies were provided.

The Function Assessment Scale for Spinal Deformity: Validity and Reliability of a New Clinical Scale.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim of this study was to develop and validate the Function Assessment scale for Spinal Deformity (FASD). SUMMARY OF BACKGROUND DATA: Spinal malalignment impacts daily functioning. Standard evaluation of adult spinal deformity (ASD) is based on static radiography and patient-reported scores, which fail to assess functional impairments. A clinical scale, quantifying function and balance of patients with ASD, could increase our insights on the impact of ASD on functioning. METHODS: To develop the FASD, 70 ASD patients and 20 controls were measured to identify the most discriminating items of the Balance Evaluation Systems Test and Trunk Control Measurement Scale. Discussions between experts on the clinical relevance of selected items led to further item reduction. The FASD's discriminative ability was established between 43 patients and 19 controls, as well as between three deformity subgroups. For its responsiveness to treatment, 10 patients were reevaluated 6 months postoperatively. Concurrent validity was assessed through correlation analysis with radiographic parameters (pelvic tilt; sagittal vertical axis [SVA]; pelvic incidence minus lumbar lordosis [PI-LL]; coronal vertical axis) and patient-reported scores [Oswestry Disability Index]; Scoliosis Research Society outcome questionnaire; Falls Efficacy Scale-International). Test-retest and interrater reliability were tested on two groups of ten patients using intraclass correlation coefficients (ICC). RESULTS: Patients with ASD, mainly with sagittal malalignment, scored worse compared to controls on FASD (P < 0.001) and its subscales. No significant improvement was observed 6 months postoperatively (P = 0.758). FASD correlated significantly to all patient-reported scores and to SVA and PI-LL. Reliability between sessions (ICC = 0.97) and raters (ICC = 0.93) was excellent. Subscales also showed good to excellent reliability, except FASD 1 on "spinal mobility and balance" between sessions (ICC = 0.71). CONCLUSION: FASD proved to be a valid and reliable clinical scale for evaluation of functional impairments in ASD. Objective information on function and balance might ultimately guide physiotherapeutic treatment toward improved functioning.Level of Evidence: 2.