The combination of tibial anterior translation and axial rotation into a single biomechanical factor improves the prediction of patient satisfaction over each factor alone in patients with ACL reconstructed knees.

PURPOSE: The purpose of this study was to identify biomechanical factors, in both reconstructed and healthy knees, that correlate with patient satisfaction after ACL reconstruction. METHODS: Seventeen patients who had undergone unilateral ACL reconstruction were reviewed 9 years post-op. Patients completed subjective questionnaires and underwent manual knee laxity testing (Lachman-Trillat, KT-1000, and pivot shift) and automated laxity testing. During automated testing, both legs were rotated into external rotation and then internal rotation until peak rotational torque reached 5.65 Nm. Load-deformation curves were generated from torque and rotation data. Features of the curves were extracted for analysis. Total leg rotation and anterior laxity during KT-1000 testing were combined into a single factor (Joint Play Envelope or JPE). Patients were divided into groups based on patient satisfaction scores (Group 1: Higher Satisfaction, Group 2: Lower Satisfaction, Group 3: Unsatisfied). Load-deformation curve features and manual laxity testing results were compared between groups 1 and 2 to determine which biomechanical factors could distinguish between the groups. Diagnostic screening values were calculated for KT-1000 testing, the pivot shift test, total leg rotation and JPE. RESULTS: During manual testing, no significant differences in biomechanical factors were found when comparing reconstructed knees in group 1 and group 2. When comparing the reconstructed and healthy knees within group 2, the reconstructed knees had a significantly higher displacement during the KT-1000 manual maximum test (p < 0.002). When considering the reconstructed knees alone, neither the result of the pivot shift test nor KT-1000 testing could distinguish between group 1 and group 2. During automated testing, there were no significant differences between the groups when comparing the reconstructed lower limbs. The healthy lower limbs in group 2 had more maximum external rotation (p < 0.02) and decreased stiffness at maximum external rotation (p < 0.02) when compared to the healthy lower limbs in group 1. Total leg rotation was unable to distinguish between group 1 and group 2. JPE could distinguish between group 1 and group 2 when considering the reconstructed limb alone (p < 0.02). All four diagnostic screening values for JPE were equal or higher than in the other criteria. JPE also showed the most significant correlation with patient satisfaction. CONCLUSIONS: Joint Play Envelope is an objective measure that demonstrated improved predictive value as compared to other tests when used as a measure of satisfaction in patients with ACL reconstructed knees.

Diagnostic findings caused by cutting of the iliotibial tract and anterolateral ligament in an ACL intact knee using a standardized and automated clinical knee examination.

PURPOSE: The purpose of this study was to evaluate the separate contribution of the two definitions of the anterolateral ligament (ALL), the mid-third lateral capsular ligament (MTLCL) and deep capsule-osseous layer of the iliotibial tract (dcITT) in addition to the superficial iliotibial tract (sITT) to the control of tibial motion with respect to the femur during the application of force/torque seen during the three tests of the standard clinical knee examination (AP Lachman test, tibial axial rotation test and varus-valgus stress test). METHODS: Six pelvis-to-toe cadaveric specimens were examined using an automated testing device that carried out the three components of the clinical knee examination. Internal/external rotation torque, anteroposterior load and adduction/abduction torque were applied, while torque/force and positional measurements were recorded. Sequential sectioning of the structures followed the same order for each knee, sITT, dcITT and MTLCL. Testing was repeated after release of each structure. RESULTS: During the tibial axial rotation test, releasing the sITT caused an increase in internal rotation of 2.6° (1.4-4.1°, p < 0.0005), while release of the dcITT increased internal rotation an additional 0.8° (0.4-1.1°, p < 0.0015). Changes in secondary motions of the tibia after sITT release demonstrated an increase in anterior translation of 1.2 mm (0.6-2.0 mm, p < 0.0005) during internal rotation, while release of the dcITT increased the same motion an additional 0.4 mm (0.2-0.5 mm, p < 0.0005). During the AP Lachman test, release of the sITT caused the tibia to move more anteriorly by 0.7 mm (0.4-1.1 mm, p < 0.0005) and increased internal rotation by 2.7° (0.9-5.2°, p < 0.004). The additional release of the dcITT resulted in more anterior translation by 0.3 mm (0.1-0.4 mm, p < 0.002) and internal rotation by 0.9° (0.2-1.7°, p < 0.005). During the varus-valgus stress test, release of the sITT permitted 0.9° (0.4-1.4°, p < 0.0005) more adduction of the tibia, while the additional release of the dcITT significantly increased adduction by 0.4° (0.2°-0.5°, p < 0.001). Release of the MTLCL had a nominal but significant increase in internal rotation, 0.6° (0.1-1.1°, p < 0.0068) and external rotation, -0.1° (-0.1° to -0.2°, p < 0.0025) during the tibial axial rotation test, anterior translation of 0.2 mm (0.0-0.4 mm, p < 0.021) only during the AP Lachman test, and adduction rotation, 0.2° (0.0-0.3°, p < 0.034) only during the varus-valgus stress test. CONCLUSION: The presence of increased adduction during an automated knee examination provides unique information identifying the release of the sITT, dcITT and the MTLCL in this cadaveric study. While their sequential release caused similar pattern changes in the three components of the automated knee examination, the extent of change due to release of the MTLCL was markedly less than after release of the dcITT which was markedly less than after release of the sITT.

Anatomical "C"-shaped double-bundle versus single-bundle anterior cruciate ligament reconstruction in pre-adolescent children with open growth plates.

PURPOSE: To analyse the clinical, rotational and radiological (MRI) results of paediatric anatomical "C-shaped" double-bundle (DB) anterior cruciate ligament (ACL) reconstruction with anteromedial and posteromedial bundle compared to single-bundle (SB) ACL reconstruction. METHODS: Between 2008 and 2014, 57 consecutive patients received a paediatric ACL reconstruction with open physis and were allocated into two groups, according to the surgical procedure. Transepiphyseal SB technique was used until 2012 and DB consecutively thereafter. Follow-up consisted of a clinical evaluation with assessment of the International Knee Documentation Committee (IKDC) form, the Lysholm knee score, Tegner activity score, KT-1000 arthrometer evaluation, VAS Scores for satisfaction, MRI and testing of rotational stability using a robotic system. RESULTS: The mean time from ACL reconstruction to follow-up was 48.1 ± 15.8 in the SB group (n = 17) and 23.1 ± 13.2 in the DB group (n = 16; p < 0.001). No differences were found in the subjective scores. Biomechanically, there were significant differences identified in the KT-1000 (p < 0.03) and total tibial axial rotation (p < 0.04) when evaluating the reconstructed knee only. Ten of 17 (59%) of the SB patients had a Joint Play Area within the acceptable range of the median healthy knee value compared to 100 % in the DB group. Decreased patient satisfaction was associated with increased total tibial axial rotation. No growth disturbance was observed. Overall, 98% of patients were reached and either examined or interviewed. Re-rupture rate was 3 of 21 (14.3%) for DB and 9 of 35 (25.7%) for SB. All but one re-ruptures (92%) happened in the first 16 postoperative months independent of technique. CONCLUSIONS: The re-rupture rate after pre-adolescent ACL reconstruction is too high both historically and in this mixed cohort. Anatomical transepiphyseal DB ACL reconstruction with open physis may result in a reduction in this re-rupture rate, which may be related to a tighter control of the Joint Play Area. While subjective clinical results were similar between SB and DB, decreased patient satisfaction was associated with increased total tibial axial rotation in the entire cohort. Despite the need for two transepiphyseal tunnels in the DB technique, there did not appear to be an increased risk in growth plate disturbance. Transepiphyseal DB ACL reconstruction appears to be a reasonable alternative to current techniques in pre-adolescent children with an ACL rupture. LEVEL OF EVIDENCE: IV.

Efficacy of non-operative treatment of patients with knee arthrofibrosis using high-intensity home mechanical therapy: a retrospective review of 11,000+ patients.

BACKGROUND: Recovery from knee surgery or injury can be hindered by knee arthrofibrosis, which can lead to motion limitations, pain and delayed recovery. Surgery or prolonged physical therapy are often treatment options for arthrofibrosis, but they can result in increased costs and decreased quality of life. A treatment option that can regain lost motion without surgery would help minimize risks and costs for the patient. The purpose of this study was to determine treatment efficacy of high-intensity home mechanical stretch therapy in patients with knee arthrofibrosis. METHODS: Records were reviewed for 11,000+ patients who were prescribed a high-intensity stretch device to regain knee flexion. Initial and last recorded knee flexion and days between measurements were available for 9842 patients (Dataset 1). Dataset 2 was a subset of 966 patients from Dataset 1. These 966 patients had separate more rigorous measurements available from physical therapy notes (Dataset 3) in addition to data from the internal database (Dataset 2). Within and between dataset statistics were calculated using t tests for comparison of means and Cohen's d for determination of effect size. RESULTS: All dataset showed significant gains in flexion (p < 0.01). Mean initial flexion, last recorded flexion and flexion gain were 79.5°, 108.4°, and 29.9°, respectively in Dataset 1. Differences between Datasets 2 and 3 had small effect sizes (Cohen's d < 0.17). The were no significant differences when comparing workers' compensation and non-workers' compensation patients. The average last recorded flexion for all datasets was above the level required to perform activities of daily living. Motion gains were recorded in under 60 days from device delivery. CONCLUSIONS: High-intensity home mechanical stretch therapy was effective in restoring knee flexion, generally in 2 months or less, and in avoiding additional surgery in severe motion loss patients regardless of sex, age, or workers' compensation status. We believe high-intensity stretching should be considered in any patient who is at risk for a secondary motion loss surgery, because in over 90% of these patients, the complications and costs associated with surgery can be avoided.

Instrumented examination of anterior cruciate ligament injuries: minimizing flaws of the manual clinical examination.

The clinical examination is a basic language of orthopaedics; it is how orthopaedic surgeons communicate with one another. However, each surgeon speaks a different dialect that has been influenced by where and with whom that surgeon trained, as well as that person's own experiences. Because of the inherent variability in the magnitude, direction, and rate of force application during the clinical examination, manual arthrometers were developed in an attempt to more consistently quantify the clinical examination. Instrumented manual devices, such as the KT-1000 (MEDmetric, San Diego, CA), were the first to provide objective numbers to surgeons and researchers evaluating anteroposterior (AP) knee joint laxity. Although these devices provide surgeons with feedback related to the amount of force applied, the rate at which the force is applied is uncontrolled, resulting in a lack of reliability similar to that of the clinical examination itself. In addition to potential errors in measuring AP laxity, rotational laxity has proven to be very difficult to quantify. Robotic systems that make use of computer-driven motors to perform laxity testing have recently been developed to control the magnitude, direction, and rate of force application and thus improve the accuracy and reliability of both AP and rotational laxity evaluation. This review discusses the evolution of instrumented clinical knee examination over the past 3 decades and highlights the advantages and disadvantages of the various testing systems, as well as how current and future developments in this area may improve the field of orthopaedics by minimizing the flaws of the manual clinical examination.

Mechanical therapy for loss of knee flexion.

We hypothesized that adding home mechanical therapy to traditional physical therapy by a physical therapist would significantly reduce the need for surgical management of loss of knee flexion after surgery or injury. From 1990 to 1999, we followed up on 34 patients who added home mechanical therapy after failure of physical therapy alone. Thirty-one (91.2%) of these patients regained functional flexion (defined as flexion to 115 degrees) after 6.7 weeks. After surgery, these patients had waited a mean of 23.6 weeks before starting home mechanical therapy. Over the course of this therapy, mean knee flexion progressed from 70.8 degrees to 130.6 degrees. Only 2 patients in this study required surgical manipulation. We conclude that a home mechanical therapy program will reduce the need for surgical management of loss of knee flexion.

Maximizing total end range time is safe and effective for the conservative treatment of frozen shoulder patients.

OBJECTIVE: The purpose of this retrospective cohort study was to compare range of motion, subjective outcomes, and the prevalence of reoperation in groups of frozen shoulder patients with either low or moderate/high irritability treated with the same total end range time-maximizing protocol. DESIGN: A total of 36 patients were treated with the total end range time-maximizing protocol (12 patients with low irritability and 24 patients with moderate/high irritability). American Shoulder and Elbow Society Standardized Shoulder Assessment Form (ASES) scores and external rotation and abduction were recorded before and after the rehabilitation protocol and were compared between the two groups. RESULTS: For both groups, external rotation and abduction of the involved shoulder significantly increased from pretreatment to posttreatment, and the posttreatment external rotation and abduction of the involved shoulder did not differ from those of the uninvolved shoulder. There were no differences between the groups in either external rotation (P = 0.71) or abduction (P = 0.46). ASES scores were significantly lower and pain scores were significantly higher for the moderate/high irritability group both before and after treatment than for the low irritability group; however, the moderate/high irritability group demonstrated significantly greater gains in both ASES and pain scores. One patient in the low irritability group underwent a lysis of adhesions. CONCLUSIONS: We conclude that a total end range time-maximizing rehabilitation protocol is a safe, effective treatment option for patients with frozen shoulder.

High-intensity mechanical therapy for loss of knee extension for worker's compensation and non-compensation patients.

BACKGROUND: Knee flexion contractures have been associated with increased pain and a reduced ability to perform activities of daily living. Contractures can be treated either surgically or conservatively, but these treatment options may not be as successful with worker's compensation patients. The purposes of retrospective review were to 1) determine the efficacy of using adjunctive high-intensity stretch (HIS) mechanical therapy to treat flexion contractures, and 2) compare the results between groups of worker's compensation and non-compensation patients. METHODS: Fifty-six patients (19 women, 37 men, age = 51.5 ± 17.0 years) with flexion contractures were treated with HIS mechanical therapy as an adjunct to outpatient physical therapy. Mechanical therapy was only prescribed for those patients whose motion had reached a plateau when treated with physical therapy alone. Patients were asked to perform six, 10-minute bouts of end-range stretching per day with the ERMI Knee Extensionater(r) (ERMI, Inc., Atlanta, GA). Passive knee extension was recorded during the postoperative visit that mechanical therapy was prescribed, 3 months after beginning mechanical therapy, and at the most recent follow-up. We used a mixed-model 2 × 3 ANOVA (group × time) to evaluate the change in passive knee extension between groups over time. RESULTS: Regardless of group, the use of adjunctive HIS mechanical therapy resulted in passive knee extension deficits that significantly improved from 10.5° ± 5.2° at the initial visit to 2.6° ± 3.5° at the 3 month visit (p < 0.001). The degree of extension was maintained at the most recent follow-up (2.0° ± 2.9°), which was significantly greater than the initial visit (p < 0.001), but did not differ from the 3 month visit (p = 0.23). The gains in knee extension did not differ between worker's compensation and non-compensation patients (p = 0.56). CONCLUSIONS: We conclude that the adjunctive use of HIS mechanical therapy is an effective treatment option for patients with knee flexion contractures, regardless of whether the patient is being treated as part of a worker's compensation claim or not.