Preoperative strength training for patients undergoing high tibial osteotomy: a prospective cohort study with historical controls.

STUDY DESIGN: Prospective cohort with historical controls. OBJECTIVE: To examine the effects of a 12-week preoperative high-intensity resistance training program on postoperative outcomes. BACKGROUND: The primary goals of high tibial osteotomy (HTO) are to decrease pain and improve overall function during activities of daily living and participation in sport and recreation in relatively young, active individuals with knee osteoarthritis. However, the postoperative recovery typically requires a considerable period of protected weight-bearing that can result in substantial deficits in muscular strength. METHODS: Fourteen patients (mean ± SD, 48.0 ± 7.8 years; 13 males, 1 females), scheduled for medial opening wedge HTO, completed a 12-week preoperative high-intensity isokinetic resistance training program focusing on quadriceps and hamstrings strength. These patients were matched to baseline clinical and demographic characteristics of 14 patients who previously received a medial opening wedge HTO without preoperative training. All outcomes were measured before and 6 months after surgery. The sport and recreation subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) was the primary outcome of interest. Secondary outcomes included the other KOOS subscales, scores on the Lower Extremity Functional Scale, and selected kinematic and kinetic variables obtained from 3-dimensional gait analysis. RESULTS: The patients in the preoperative training group achieved significantly greater scores on the KOOS sport and recreation (mean ± SD, 58.6 ± 16.6 versus 42.1 ± 20.4; mean difference, 16.4; 95% CI: 2.0, 30.9) and activities of daily living (mean ± SD, 85.3 ± 9.3 versus 76.9 ± 12.0; mean difference, 8.4; 95% CI: 0.1, 16.8) subscales. There were no significant differences between groups on other outcomes. CONCLUSION: The present findings suggest preoperative high-intensity resistance training of the quadriceps and hamstrings before HTO improves postoperative functioning in sport, recreation, and activities of daily living. LEVEL OF EVIDENCE: Therapy, level 2b.

Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation.

BACKGROUND: To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In all but one study, the limb was immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone. METHODS: Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupture rate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength. Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury. RESULTS: A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were 118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group. CONCLUSIONS: This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. All measured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.

Moments and muscle activity after high tibial osteotomy and anterior cruciate ligament reconstruction.

PURPOSES: To evaluate the effects of simultaneous high tibial osteotomy (HTO) and anterior cruciate ligament (ACL) reconstruction on 1) the external knee adduction moment, 2) the external knee flexion and extension moments, and 3) the quadriceps, hamstrings, and gastrocnemius muscle activity during walking. METHODS: Twenty-one patients with varus malalignment of the lower limb, medial compartment knee osteoarthritis, and concomitant anterior cruciate ligament (ACL) deficiency were tested before and 1 yr after undergoing simultaneous medial opening wedge high tibial osteotomy (HTO) and ACL reconstruction during a single operation. Three-dimensional kinetic and kinematic data were used to calculate external coronal and sagittal moments about the knee. EMG data from the quadriceps, hamstrings, and gastrocnemius were used to determine coactivation ratio and activation patterns. RESULTS: Neutral alignment and knee stability were achieved in all patients after surgery. The peak knee adduction moment decreased from 2.88 +/- 0.57 to 1.71 +/- 0.56%BW x Ht (P < 0.001). The early stance knee flexion moment decreased from 1.95 +/- 1.89 to 0.88 +/- 1.17%BW x Ht (P < 0.01). The late stance knee extension moment increased from 1.83 +/- 1.53 to 2.76 +/- 1.22%BW x Ht (P < 0.001). There were no significant differences in muscle coactivation or muscle activation patterns (P > 0.05). CONCLUSIONS: Improving lower limb alignment and knee stability significantly alters the coronal and the sagittal moments about the knee during walking, without apparent changes in muscle activation patterns.